Faculty Conversation: Addressing Unacceptable Maternal Mortality Rates

Drs. May Sudhinaraset and Rebecca Delafield

The World Health Organization has stated that maternal mortality is “a critical barometer of the quality, accessibility, and equity of health systems,” as well as an indicator of the status of women’s rights. By that measure, we are failing. As recently as 2023, the United States was one of only seven countries to report a significant increase in maternal mortality since 2000. And although rates have declined since then, among high-income nations the U.S. has the highest rate of maternal deaths, according to the health policy organization KFF. These rates are fueled by wide and growing racial and ethnic disparities, with people of color having not only the highest rates of pregnancy-related death, but also the lowest use of early prenatal care.

Dr. May Sudhinaraset, professor and vice chair of FSPH’s Department of Community Health Sciences, focuses on understanding the social determinants of migrant and women’s health, both globally and in the U.S., particularly as these pertain to maternal and reproductive health inequities. Dr. Rebecca Delafield, assistant professor of community health sciences and the Jonathan and Karin Fielding Presidential Chair in Health Equity, examines the factors that inf luence healthcare quality and outcomes in the pregnancy and perinatal period, with a focus on the Native Hawaiian and Pacific Islander communities.

IN WHAT SENSE DOES A COUNTRY’S MATERNAL MORTALITY RATE REFLECT THE STATUS OF WOMEN AND THE QUALITY OF THE HEALTHCARE SYSTEM? 

MAY SUDHINARASET: The same kinds of power inequities and underlying structures that determine who is valued in a society are going to play out in a healthcare setting; so, when you look at who is disrespected, dismissed, or ignored in that setting, it’s typically individuals who experience vulnerabilities outside of healthcare settings as well. Maternal mortality is a reflection of broader inequities and societal attitudes related to who is deemed valuable and deserving of certain treatments and outcomes.

REBECCA DELAFIELD: It’s also important to recognize that how a society treats women outside of the healthcare setting plays a critical role in maternal mortality and the disparities we see. When you don’t invest in women and their health, when you don’t recognize the vulnerability of pregnancy and parenting and have supports for women and families to help them remain healthy and strong through this experience, it’s going to lead to bad outcomes. So, it’s not just healthcare —pregnancy-related deaths are often a result of failures by multiple systems across a person’s life course. Maternal mortality is highly preventable, but among high-income countries, the U.S. is not doing well.

IN WHAT WAYS IS THE U.S. BEHIND OTHER HIGH-INCOME COUNTRIES WITH REGARD TO POLICIES THAT MIGHT BE CONTRIBUTING TO HIGHER MATERNAL MORTALITY?

RD: One glaring difference is the lack of universal healthcare. The U.S. is also among the only high-income nations without paid family leave. Many of these deaths are postpartum, including from suicide, and much of the support in the postpartum period is built into other countries’ systems in a way that isn’t consistently available in the U.S., particularly in the safety-net system. 

MS: While there are some countries where reproductive rights policies have been expanded, in the United States we have seen an increase in restrictive reproductive rights policies, particularly after the Dobbs [U.S. Supreme Court] decision. That has made it a lot more difficult to provide person-centered women’s healthcare. It has resulted in clinic closures and people having to travel longer distances. Clinics that have historically provided the comprehensive range of sexual and reproductive healthcare, including miscarriage management or counseling, have had to scale back. As a result, people are facing delays in women’s healthcare broadly — not just abortion services — that impact maternal health outcomes as well.

WHAT ARE SOME OF THE OTHER ACTIONS THAT WOULD HELP TO PREVENT THESE DEATHS AND REDUCE THE DISPARITIES?

RD: We have to look at what happened not only at the time of the death, but also in the progression toward it. What occurred in the prenatal period, and what has this individual experienced prior to the pregnancy? If they experienced trauma, were they asked about that and connected with treatment? Dr. Sudhinaraset and I examine access to care, but integral to that is the relationship and communication with the provider. Is the care appropriate? Are the right questions asked? Are there language barriers or hostilities that prevent the healthcare setting from being a healing space? California is a leader in improving perinatal medical interventions, but there are also many things that happen before and after the pregnancy that contribute to maternal mortality.

MS: One of the leading contributors to maternal mortality is mental health conditions during the pregnancy and the postpartum period. California now has a mandate to screen for these conditions during the perinatal period, but in practice we’re well short of universal screening. And many healthcare providers find that even if women are diagnosed, there aren’t necessarily places for them to go for treatment when they need mental healthcare.

When we think about what drives the disparities, we have to look both inside and outside the healthcare system. There are inequities related to reproductive justice, which means the right to have a child or not to have one, and to be able to parent that child in a safe and supportive environment. There are inequities that bear on preconception health, including social determinants such as housing and nutrition. And for many communities, people don’t necessarily have adequate language access, culturally concordant, or respectful care.

WHAT DO YOU HOPE TO PASS ON TO STUDENTS WHO ARE INTERESTED IN PURSUING THIS AREA OF WORK?

MS: One of the things that is most meaningful for me is when I mentor the types of students who aren’t always part of the traditional academic space or the research process. Some of the skills I hope to impart is the focus on structural inequities related to maternal healthcare — how we understand issues like racism and poverty, how policy shapes outcomes, and how we can think about solutions that focus on structures like policies and institutions rather than the individual.

RD: I love that focus on the structural issues in the context of maternal and perinatal health, because so often the message to mothers and families implicitly or explicitly is, “You’re doing something wrong.” A lot of the responsibility is placed on women who, many times, when something goes wrong will already blame themselves, which is heartbreaking and disempowering.



 

WHAT, IF ANYTHING, MAKES YOU HOPEFUL ABOUT PROGRESS IN THIS AREA IN THE FUTURE?

RD: There’s much more awareness of the disparities, and for that I credit community voices. Black women have been a huge part of getting maternal health into the public conversation. For the work that Dr. Sudhinaraset and I do, communities have successfully advocated for disaggregating data to advance our awareness. Without that information, you’re five steps behind. 

I do feel the change is yet to come. We still see concerning maternal mortality statistics, and just knowing the disparities isn’t enough. Individual stories are absolutely necessary, because data isn’t sufficient to change the minds of people in power. The fact that these disparities have persisted over time means we haven’t done it right yet.

MS: What gives me hope is that I’m seeing more and more community mobilization and galvanization. The power of collective action on the ground is more important than ever, and increasingly academia is working with community-based organizations and policymakers as partners, seeking to understand the impact of these policies and to bring about the changes we need.