700 women die in the United States each year
during pregnancy or the first year following pregnancy

60% of these deaths are preventable

The United States spends MORE on healthcare per capita than any other country
and is the ONLY industrialized nation seeing a rise in maternal mortality rates
Why are women in the United States dying
during and following pregnancy?
Even offices and institutes within the Centers for Disease Control & Prevention (CDC)
-- the government agency tasked with collecting information about maternal deaths -- struggle with defining and reporting maternal mortality rates. Some CDC offices use the World Health Organization standard (42 days postpartum), while others include deaths that occur anytime in the full year after pregnancy. Some CDC studies include self-harm; others do not. Finally, the CDC was not able to publish valid maternal mortality rates for 13 years (2007-2020) because states were changing how they gathered data about maternal deaths (see PREGNANCY CHECKBOX below).

In studies that look at deaths during pregnancy and throughout first year postpartum, more than half of pregnancy-related deaths occur after delivery, with a significant number occurring in the late postpartum timeframe (42-365 days following pregnancy):
Credit by Alison Steube, MD
Data from Pregnancy-Related Maternal Mortality in the United States, 2011-2013
Despite the differences in studies,
two key issues have emerged regarding
maternal mortality and maternal mental health:
Women of color are disproportionately affected  

Black women die at THREE TIMES
the rate of white women. American Native and Alaskan Indian women die at TWICE the rate of white women.
Suicide is a
leading cause of death  

In studies that include self-harm
and extend the full year postpartum,
suicide and overdose combined are

Much has been reported about the racial disparities in maternal mortality, including a series of articles, Lost Mothers: Maternal Mortality in the United States, that gained national attention. A consistent finding in these studies, reports, and articles is that black women are disproportionately affected by pregnancy-related illnesses. 
A complex combination of factors – including social determinants of health, chronic stress and trauma, and bias in the healthcare system – means that black women of all ages and socioeconomic levels are more susceptible to many causes of maternal mortality including cardiomyopathy, embolism, preeclampsia and eclampsia.
Black women are also MORE likely to experience mental health challenges during the perinatal timeframe but LESS likely to get help. Tragically, pregnancy-associated homicide victims are most frequently young, black, and under-educated.
Only a handful of studies include information for both the full year postpartum and for self-harm. In these studies, suicide and overdose are the leading causes of death. Here are a few key takeaways:
  • The majority of pregnancy-related suicides (66%) occur in the late postpartum timeframe, with the peak incidence at 6-9 months postpartum.
  • New mothers who die by suicide are mostly white and older.
  • New mothers who die by suicide often use the most violent forms of suicide (death by hanging, gunshot, or jumping).

Less than 50% of women who die by self-harm attended a postpartum obstetric visit. However, more than 50% of women who die by self-harm sought help at a hospital or emergency department within 1 month of their death . Clearly, screening only at the 6-week postpartum obstetric visit is not enough.

The World Health Organization provides additional coding to identify maternal death by suicide as a direct result of pregnancy . Suicides occurring 42-365 days following pregnancy are coded as late maternal death from direct obstetric cause. Suicides later than one year after pregnancy with an established diagnosis of postpartum depression or psychosis are coded as death from sequelae of direct obstetric cause.

First and foremost, the issue of mental health must be included in every discussion about maternal mortality, from national policy to office practice.

Secondly, medical care for pregnant and postpartum women must include discussions about mental health and needs to be as open and honest as conversations about any other aspect of health. Women see a healthcare provider on average 25 times during routine pregnancy and first year of baby's life, offering ample opportunity for healthcare providers to discuss and screen for mental health issues.
ALL pregnant and postpartum women should be screened EARLY and OFTEN including:
  • each trimester during pregnancy
  • at / around delivery (including in the hospital or birthing center prior to discharge and at all obstetric follow-up visits)
  • during all well-baby visits

Women who are at risk should be educated about possible interventions (including self-care, social support, talk therapy, and medication) and connected with resources for recovery.
EVERYONE who interacts with childbearing women -- doctors, nurses, midwives, childbirth educators, lactation consultants, doulas, home visitors, community health workers, emergency department staff -- needs to ask new mothers how they are doing and screen for mental health issues.

The purpose of the pregnancy checkbox is to help identify deaths that are pregnancy-related. These deaths are then analyzed by maternal mortality review committees to identify trends in how, when, and why women are dying.

While the pregnancy checkbox is supposed to provide information that is easier to compare and more accurate, the CDC reports that the checkbox has been both a “source of errors resulting in overestimation of maternal deaths as well as a source of improvement in appropriately identifying maternal deaths.” 

For example, a significant number of deaths related to pregnancy were ascribed to women over age 45 (including 147 pregnancies reported to women over age 85!). As a result, the coding is being refined to improve data quality, including restricting the pregnancy-related checkbox to women under age 45. Learn more HERE.

Most of the work in identifying, reviewing, and addressing maternal mortality occurs at the state and local level with several offices and organizations playing important roles:

  • Vital records offices review death certificates to identify women who die during pregnancy or the first year after being pregnant using information such as the pregnancy checkbox and codes for underlying cause of death. These offices also identify maternal deaths by linking death certificates to birth certificates or those of fetal death. This information is then made available to maternal mortality review committees.

  • Maternal Mortality Review Committees (MMRCs) are multi-disciplinary teams that convene at the state or local level to review deaths of women during or within a year of pregnancy. MMRCs review both clinical and non-clinical information (vital records, medical records, social service records) to more fully understand the factors that led to each death and to develop recommendations for action to prevent similar deaths in the future.

  • Perinatal Quality Collaboratives (PQCs) are state or multi-state networks aimed at improving the quality of care for mothers and babies. PQC's take information and recommendations from MMRCs and other sources to identify health care processes that need to be improved and use the best available methods to make changes as quickly as possible.
Building U.S. Capacity to Review and Prevent Maternal Deaths (2018). Report From Nine Maternal Mortality Review Committees.  LINK .

Davis N, Smoots A, Goodman D. Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017. Atlanta GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.  LINK .

Goldman-Mellor S, Margerison C. Maternal Drug-Related Death and Suicide Are Leading Causes of Postpartum Death in California.  American Journal of Obstetrics & Gynecology, Nov 2019; 489.e1-e9.  LINK .

Hoyert D, Uddin, S, Minino A. Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths. National Center for Health Statistics.  National Vital Statistics Reports , Jan 30, 2020; 69(1).  LINK .

Hoyert D, Minino A. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018. National Center for Health Statistics . National Vital Statistics Reports , Jan 30, 2020; 69(2).  LINK .

MacDorman M, Declercq E, Thoma M, Trends in Maternal Mortality by Socio-Demographic Characteristics and Cause of Death in 27 States and the District of Columbia.  Obstetrics & Gynecology , May 2017; 129(5):811-818.  LINK .

Mangla K, Hoffman C, Trumpff C, O’Grady S, Monk C. Maternal Self-Harm Deaths: An Unrecognized and Preventable Outcome.  American Journal of Obstetrics & Gynecology, Oct 2019; 221(4); 295-303.  LINK .

Mehta P, Bachluber M, Hoffman R, Srinivas S. Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia .   American Journal of Public Health , December 2016; 2208(3), 2208-2210.  LINK .

Metz T, Rovner P, Hoffman C, Allshouse A, Beckwith K, Binswanger I.  Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. American Journal of Obstetrics & Gynecology , December 2016; 128(6), 1233-1240.  LINK .

Petersen E, Davis N, Goodman D, Cox S, Mayes N, Johnston E, Syverson C, Seed K, Shapiro-Mendoza C, Callaghan W, Barfield W. Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017. Centers for Disease Control and Prevention.  Morbidity and Mortality Weekly Report, May 10, 2019; 68(18); 423-429.  LINK .

Petersen E, Davis N, Goodman D, Cox S, Mayes N, Johnston E, Syverson C, Seed K, Shapiro-Mendoza C, Callaghan W, Barfield W. Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007-2016. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, September 6, 2019; 68(35); 762-765.  LINK .

Rossen L, Womack L, Hoyert D., Anderson R, Uddin S. The Impact of the Pregnancy Checkbox and Misclassification On Maternal Mortality Trends in the United States, 1999-2017. National Center for Health Statistics. Vital Health Statistics , Jan 2020; 3(44).  LINK .

Wallace M, Hoyert D, Williams C, Mendola P. Pregnancy-associated Homicide and Suicide in 37 US States With Enhanced Pregnancy Surveillance . American Journal of Obstetrics & Gynecology , September 2016; 215(3), 364e1-364e10. LINK .

The WHO Application of ICD-10 to Deaths During Pregnancy, Childbirth and the Puerperium: ICD-MM. The World Health Organization, 2012.  LINK .
Working with Policy Makers to Address Maternal Mental Health Challenges
MMHLA -- founded in 2018 -- is a nonpartisan 501(c)3 non-profit organization
dedicated to promoting the mental health of childbearing women in the United States
by advocating for universal education, screening, referral, and treatment
of postpartum depression and related maternal mental health (MMH) challenges.

Our vision is that all childbearing women in the United States will be educated about and screened for maternal mental health challenges and have access to resources for recovery.