Why is maternal mortality rising?
The answer to why maternal deaths are on the rise is complex and likely to be
multifactorial. We postulate that at least four interrelated explanations are likely.
First, improved vital statistics data reporting may account for up to 33% of the
increase. A national study found that implementation of more specific diagnostic
codes may account for 13% of the rise while the addition of a specific query
about pregnancy on the death certificate implemented in 2003 may have
captured an additional 20% of reported cases that were previously missed.19, 20
Second, increasing age or increasing prevalence of maternal chronic conditions,
such as hypertension, diabetes or obesity, could be contributing to the rise in
maternal morbidity and mortality. Older women are also likely to have previously
given birth possibly by cesarean delivery, which may increase the risk for
complications in subsequent births. The major causes of pregnancy-related
deaths in the U.S. in the 1990s were pulmonary embolism, hemorrhage,
complications of other medical conditions and hypertensive disorders of
pregnancy.21 Between the periods 1979-1986 and 1991-1999, the percentage of
pregnancy-related deaths caused by cardiomyopathy and other medical
conditions more than doubled.
Third, social factors such as low levels of social support, lower socioeconomic
status, chronic exposure to environmental hazards or social stressors such as
racism, fragmentation of or difficulty accessing health care may be playing an
important role in the increase of maternal mortality.22-27
Fourth, factors related to health care systems and access to quality care, both
inpatient and outpatient, are likely to be involved and could include possible
overuse or underuse of obstetrical interventions. For example, rising rates of
cesarean delivery are increasingly considered a source of increased morbidity
and possibly of mortality. Nationally, the total cesarean delivery rates increased
by over 50%, from a rate in 1996 of 21% to 32% in 2007, the highest level ever
reported in the U.S.12
The answer to why maternal deaths are on the rise is complex and likely to be
multifactorial. We postulate that at least four interrelated explanations are likely.
First, improved vital statistics data reporting may account for up to 33% of the
increase. A national study found that implementation of more specific diagnostic
codes may account for 13% of the rise while the addition of a specific query
about pregnancy on the death certificate implemented in 2003 may have
captured an additional 20% of reported cases that were previously missed.19, 20
Second, increasing age or increasing prevalence of maternal chronic conditions,
such as hypertension, diabetes or obesity, could be contributing to the rise in
maternal morbidity and mortality. Older women are also likely to have previously
given birth possibly by cesarean delivery, which may increase the risk for
complications in subsequent births. The major causes of pregnancy-related
deaths in the U.S. in the 1990s were pulmonary embolism, hemorrhage,
complications of other medical conditions and hypertensive disorders of
pregnancy.21 Between the periods 1979-1986 and 1991-1999, the percentage of
pregnancy-related deaths caused by cardiomyopathy and other medical
conditions more than doubled.
Third, social factors such as low levels of social support, lower socioeconomic
status, chronic exposure to environmental hazards or social stressors such as
racism, fragmentation of or difficulty accessing health care may be playing an
important role in the increase of maternal mortality.22-27
Fourth, factors related to health care systems and access to quality care, both
inpatient and outpatient, are likely to be involved and could include possible
overuse or underuse of obstetrical interventions. For example, rising rates of
cesarean delivery are increasingly considered a source of increased morbidity
and possibly of mortality. Nationally, the total cesarean delivery rates increased
by over 50%, from a rate in 1996 of 21% to 32% in 2007, the highest level ever
reported in the U.S.12
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