Elizabeth Filipovich, MPH

The Centers for Disease Control defines maternal mortality as “the death of a woman during pregnancy, at delivery, or soon after delivery.” Maternal deaths are further divided into two categories: pregnancy-related and pregnancy-associated deaths. Pregnancy-related deaths are defined as “the death of a woman while pregnant or within one year of the end of pregnancy, regardless of the outcome, duration, or site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” 

Pregnancy-associated but not related deaths are “the death of a woman while pregnant or within one year of pregnancy from a cause or cause unrelated to pregnancy. Often, when maternal mortality is researched and discussed, the body of work emphasizes pregnancy-related deaths. For example, the statistics used in the above paragraph reference pregnancy-related deaths exclusively. However, a better understanding of factors contributing to many accidental, pregnancy-associated but not related deaths is essential for effective methods to reduce the number of maternal deaths in the United States, regardless of cause or manner of death. 

Well-documented maternal death causes include hemorrhage, cardiomyopathy, or other cardiac causes, and worsening underlying conditions or other medical causes often deemed pregnancy-related. Equally important are other causes of death, including accidental poisonings or overdoses, maternal suicides, or homicides. These are pregnancy-associated, not related, or not directly caused or exacerbated by pregnancy. The many touchpoints of care in the perinatal period provide opportunities for intervention and opportunities for improved perinatal care, particularly for birthing people who have a history of substance use disorder (SUD), history of anxiety, depression, or other mood disorders, or families who may be at risk for violence, instability, or other significant hardship. 

Statewide and local Maternal Mortality Review Committees (MMRC) are convened to examine maternal death trends by comprehensively reviewing deaths that occur during or within one year of pregnancy. MMRCs are multidisciplinary and include representatives from a spectrum of perinatal care providers, including public health, obstetrics, maternal-fetal medicine, pediatrics, nursing, midwifery, community health organizations, mental and behavioral health, and patient/family advocacy groups. MMRCs meet to discuss cases and collaboratively create evidence-based recommendations to prevent future deaths. MMRCs provide critical evidence for legislatures, health systems, and public health leaders to endorse safety bundles and new laws to prevent future deaths. 

While MMRCs retrospectively review maternal deaths to understand preventable causes of these deaths further, providers and clinicians across all disciplines, as well as the public, can proactively impact the alarming rate of maternal deaths in this country. Neonatal care providers have a critical role. Despite becoming increasingly standard practice to have postpartum follow-up visits before four weeks postpartum, this is not universally implemented. Even if a postpartum follow-up is scheduled, not all birthing people attend a follow-up visit, as evidenced by several studies documenting that 11-46% do not attend a postpartum visit. However, well-child visits are very well attended by postpartum people. By capitalizing on the touchpoint of the well-child visits, providers capture an opportunity for assessment and potential referral or intervention. 

Neonatal providers can contribute to reducing maternal mortality in several ways. Pediatric and family providers are often left out of the conversation, but the reality is that many providers for infants have more touchpoints with birthing people in the postpartum period than their prenatal providers. Pediatric visits for neonates and infants provide the opportunity for intervention that begins with a thorough assessment of the birthing person and include awareness of resources available to provide to patients, as well as understanding that wellness is facilitated by a host of factors extend beyond the physical health of the patient. 

The scope of this newsletter article is not broad enough for the depth of discussion, but rather draws attention to how social determinants of health contribute to maternal deaths and how providers can continue to care for their patients by addressing them. Providers should attempt to understand the environment of each family. By exploring significant relationships, one can understand the birthing person’s support systems, the likelihood of experiencing violence, housing circumstances, income stability, etc. By connecting identified birthing persons to support services and resources and following up on successive pediatric visits, perinatal providers can reduce maternal mortality. For more information on perinatal mood disorders, perinatal substance use, and many other resources for providers and families, please visit NationalPerinatal.org.