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Recent research shows that most pregnancy-related deaths occur in the year after a baby is born. The discovery is changing how doctors care for new mothers.
Sherri Willis-Prater’s baby boy was 2 months old, and she was about to return to her job at a school cafeteria in Chicago. But as she walked up the short flight of stairs to her kitchen one evening, she nearly collapsed, gasping for breath.
At the hospital, Ms. Willis-Prater, who was 42 at the time, was connected to a ventilator that pumped air into her lungs. Her heart, doctors said, was operating at less than 20 percent of its capacity. She had developed a rare form of heart failure that emerges after pregnancy.
The diagnosis was the last thing she expected to hear. After giving birth, Ms. Willis-Prater thought “I made it across the finish line,” she recalled in an interview. “I don’t have to worry about anything anymore.”
Most people think of labor and birth as the most dangerous part of pregnancy. But new scientific research is challenging this assumption, finding that substantial risks persist for a full year after birth itself. The deadliest time for mothers is actually after the baby is born.
And for each woman who dies, an estimated 50 to 100 women experience severe complications that may leave them with lifelong health problems. The numbers are growing as more American women become heavier, and hypertension and diabetes become more common.
More women are also postponing childbearing until later in life, so they are more likely to start pregnancy with chronic medical conditions that can lead to complications.
The new figures come amid a troubling rise in deaths of pregnant women and new mothers in the United States, which has the highest maternal mortality rate in the industrialized world. The figures soared during the pandemic, to 32.9 deaths for every 100,000 live births in 2021, up from 20.1 per 100,000 in 2019. Rates for Black and Native American women are two to three times higher than those for white women.
But those figures reflect a traditional definition of maternal mortality, deaths that occur during gestation or up to six weeks after birth.
A fuller extent of the problem came to light in September, when the Centers for Disease Control and Prevention took a more expansive look at mothers’ deaths, analyzing them for a full year after childbirth and including deaths resulting from mental health conditions.
Based on data provided by 36 states on 1,018 pregnancy-related deaths from 2017 to 2019, the C.D.C. concluded that about a third of them occurred during pregnancy or on the day of delivery, and roughly another third before the baby turned six weeks old. A full 30 percent occurred from that point until the baby’s first birthday, a period that had not been a focus of maternal mortality research.
The data have led to calls for closer follow-up care and more support for new mothers during what has been called the “fourth trimester,” with special attention given to vulnerable women.
“Our approach to birth has been that the baby is the candy and the mom’s the wrapper, and once the baby is out of the wrapper we cast it aside,” said Dr. Alison Stuebe, a professor of obstetrics and gynecology at the University of North Carolina School of Medicine. “We need to recognize that the wrapper is a person — moms are getting really sick and dying.”
The leading causes of maternal mortality among white and Hispanic women are mental health conditions that lead to suicide or fatal overdoses. Among Asian women, the leading cause is hemorrhage.
Among Black women like Ms. Willis-Prater, heart conditions were the leading cause of death. High blood pressure, a predisposing factor, is more common among Black women, and they more often have poor access to health care, a legacy of both poverty and racism.
The risk of later maternal death — from six weeks to a year after delivery — is 3.5 times higher among Black women, compared with that among white women.
Medical practice is often slow to change. But the numbers are accelerating revisions to Medicaid, the health plan that covers low-income Americans, including more than 40 percent of pregnant women in the United States.
Thirty-three states and Washington, D.C., have extended Medicaid coverage for new mothers to a full year after childbirth, so women are insured while recovering from pregnancy, and eight other states plan to do so, according to the Kaiser Family Foundation.
Three states, including Texas, are extending only limited coverage, and six — including Arkansas, which has had one of the nation’s highest maternal mortality rates — have no plans to extend Medicaid coverage, according to the foundation.
Other initiatives include a new law in New Jersey that requires emergency room doctors to ask women of childbearing age about their pregnancy history. Some illnesses that bring women to the hospital may be more quickly diagnosed if physicians know that they are new mothers.
In North Carolina, health providers earn a $150 bonus if a patient comes in for a postpartum visit. Historically, nearly half of new mothers have missed postpartum checkups.
Doctors are now advised to see new mothers within three weeks of childbirth, rather than wait for the six-week checkup that was once standard.
“Now it’s ‘I’ll see you in two weeks, right? And yes, you are definitely coming,’” said Dr. Tamika Auguste, a co-author, along with Dr. Stuebe, of new guidance about postpartum care from the American College of Obstetricians and Gynecologists.
New mothers with medical conditions like hypertension should be seen even sooner, Dr. Auguste said.
Even more important, however, is that physicians and other providers listen when women express concerns, and pay special attention when Black and Native American women say something is wrong.
“There’s no more ‘Oh sweetie, you’re fine,’” Dr. Auguste said. “There’s no more of that to be had. There’s ‘Let’s see if we can get you in to see us today or tomorrow.’”
Multiple Risks
Many doctors refer to pregnancy as “nature’s cardiac stress test.” The condition strains a woman’s heart and circulatory system: Blood volume increases up to 50 percent, the heart works harder, and the heart rate goes up.
Elevations in blood pressure can affect other vital organs and leave a woman at greater risk for cardiovascular disease during the pregnancy or even decades later, said Dr. Rachel Bond, a cardiologist and system director of the women’s heart health program at Dignity Health in Chandler, Ariz.
“We tell women, ‘You went through your first stress test — either you pass or fail,’” Dr. Bond said. “Failure doesn’t necessarily mean you’ll have heart disease, but it means that we as clinicians need to treat you more aggressively.”
Once the baby is born, the uterus shrinks, and blood pressure may rise, which can prompt a stroke.
New mothers also are more likely to experience life-threatening blood clots and infections. At the same time, hormonal changes may lead to mood fluctuations. Some of these are transient, but more severe, longer-lasting postpartum depression may also develop.
Though most women survive pregnancy-related complications after childbirth, prompt medical care is critical.
Deidre Winzy, a 28-year-old medical assistant in New Orleans, already had high blood pressure when she became pregnant with her third child. Doctors gave her a blood pressure cuff to use at home, along with Babyscripts, a remote monitoring system that sent readings to her midwife.
Ms. Winzy was induced two and a half weeks early after being diagnosed with pre-eclampsia, a dangerous hypertensive condition. But three weeks after the delivery, she woke up in the middle of the night feeling disoriented and dizzy. She called a friend for help, her speech slurring.
Medics thought she was having a panic attack and at first did not want to take her to the hospital. In fact, she was having a stroke. “I made it there just in time,” Ms. Winzy recalled. “If I hadn’t, I might have been paralyzed for the rest of my life.”
Ms. Winzy now struggles with short-term memory loss and weakness, but she is able to work. Still, as a single mother of three, she worries.
“My biggest fear is me not being here for my kids,” Ms. Winzy said. “What if I have another stroke and it paralyzes me permanently or kills me? It’s terrifying.”
Among white women, mental health conditions are responsible for 35 percent of pregnancy-related deaths, according to C.D.C. data. Among Hispanic women, the figure is 24 percent. Pre-existing anxiety or depression may leave women vulnerable to postpartum depression, as can a difficult pregnancy or having a sick baby.
The stress of parenting may set off a relapse for someone in recovery from a substance use disorder, said Katayune Kaeni, a psychologist and board chairwoman of Postpartum Support International.
Karen Bullock, 39, who lives outside Peoria, Ill., had a difficult pregnancy and a traumatic preterm delivery, and she struggled to breastfeed.
“Nothing came naturally,” she said. “I wasn’t happy when the baby was born — I was scared. Every time I looked at him, I would think, I don’t know what to do with you.” Ms. Bullock was eventually diagnosed with postpartum depression and began taking medication.
Complications can surprise even women who had trouble-free pregnancies. After a cesarean section, Aryana Jacobs, a 34-year-old health technology analyst in Washington, D.C., was told that her blood pressure was fluctuating. At home, Ms. Jacobs checked it with a blood pressure cuff she kept because of a family history of hypertension. Within days, the reading had reached 170/110.
She went to the hospital and was treated for pre-eclampsia — which usually develops during pregnancy, not afterward.
“I wish every new mother was sent home with a box of chocolates and a blood pressure cuff to emphasize that you, as a mother, are still a patient,” Ms. Jacobs said. “Your body is recovering from something massive.”