Toward an Improved Vision for Maternal Health and Pregnancy Outcomes

By Dr. Janine A. Clayton
 

The high rates of maternal morbidity and mortality (MMM) in the U.S. constitute a public health crisis, yet up to 60% of these deaths are preventable.¹  MMM is tragic and is affected by many factors, including prenatal and postpartum care, age of the mother, socioeconomic status, racial disparities, and mental health. However, the challenges are not insurmountable. We can and must do more to create tailored, evidence-based solutions for women across the country. To this end, the NIH Implementing a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE) initiative supports research to reduce preventable maternal deaths and improve health for all women before, during, and after delivery.

IMPROVE focuses on the leading causes of maternal mortality (MM) in the U.S.—cardiovascular disease and infection—as well as other health conditions and social factors that play a role, such as mental health disorders, diabetes, obesity, and substance use disorders. The initiative also focuses on significant pregnancy-related health complications, called severe maternal morbidity (SMM). IMPROVE is co-led by the NIH Office of the Director (OD), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and the NIH Office of Research on Women’s Health (ORWH). It builds on existing NIH grants and research. To date, over $7 million has been awarded to support 36 projects—and this is just the beginning. 

IMPROVE’s goals include: 

• Incorporating community partnerships and participation in MM/SMM research to lessen health disparities and increase equity in maternal health
• Expanding research on the leading causes of MM/SMM in the U.S. so evidence-based care and prevention strategies can be developed
• Gaining a better understanding of MM/SMM causes, including underlying comorbidities

The current IMPROVE awards are a first step, with more trans-NIH IMPROVE opportunities and partnerships expected in 2021 and beyond. 

Mental Health Affects Maternal Health
Mental health is one of many contributing factors to MM and SMM being addressed by IMPROVE. This is an often neglected but important part of maternal health, especially because pregnancy is a time of increased mental health vulnerability for some women. In fact, the widespread prevalence of maternal depression is a worldwide crisis, particularly affecting low-income women and their children.^2,3,4 The rate of postpartum depression for women of color is twice as high as that of all other postpartum women.⁵

The NIH IMPROVE initiative supports research to reduce preventable maternal deaths and improve health for all women before, during, and after delivery.

It’s a positive step that mental health problems are increasingly being recognized as underlying causes of maternal deaths, including accidental deaths and drug overdoses.⁶ According to a report on the causes of MM in nine States, 6.5% of pregnancy-related deaths were suicides.⁷ Unfortunately, pregnant and postpartum women who die by homicide or suicide—which in many cases is linked to intimate partner violence (IPV)—are not counted as pregnancy-related deaths in the U.S.⁸ The BMJ recommends that maternal suicide be carefully tracked,⁹ and existing monitoring mechanisms—such as the Centers for Disease Control and Prevention (CDC) surveillance system, which currently tracks pregnancy-related deaths—could be adapted to provide these useful data. 

Pregnancy Affects and Is Affected by One’s Lifelong Health 
A healthy pregnancy begins long before a woman becomes pregnant. The term “pre-pregnancy health” refers to the overall health of nonpregnant women during their reproductive years (generally 18–44). Birth outcomes and women’s overall postpartum health improve when pre-pregnancy health is optimized.¹⁰ However, research indicates that women ages 18–44 are less healthy than women in that age range were 20 years ago.¹⁰ They have higher rates of depression, diabetes, hypertension, and obesity, and they are less likely to be physically active. The risk factors for these conditions and behaviors vary by age group, race/ethnicity, insurance status, and geographic area. The results are profound: Poor health before pregnancy, sometimes leading to adverse pregnancy outcomes, can result in increased risks for long-term health problems, such as cardiovascular and metabolic diseases that occur later in life.¹¹

Racial and Ethnic Disparities Contribute to Poor Outcomes
A March 2020 Government Accountability Office (GAO) report lists the leading causes of MM by stage of pregnancy, age, and the race and ethnicity of the women affected.¹² The GAO data support many  concerning research findings:

• Race and ethnicity remain significant predictors of the quality of health care women receive, even after socioeconomic factors are taken into account.¹³
• Because of a complex interaction of social determinants of health, Black women are more likely to have preexisting conditions when they become pregnant, such as hypertension and diabetes.¹⁴
• Pregnancy-related death rates are more than three times as high for Black women as they are for White women. The reasons for this disparity are multifaceted and not fully understood. Factors may include health behaviors, genetics, physical and social environments, and access to and delivery of quality health care.¹⁵ Education and higher socioeconomic status don’t lessen these elevated risks of MM among Black women.¹⁶

The Need to Address Racial and Ethnic Inequities Within the Health Care System
Black women are often not listened to when they report signs of possible complications of pregnancy and birth. Traumatic birthing experiences are so common that one-quarter of Black women report disrespect and abuse from medical professionals.¹⁷ A survey specifically addressed inequity and mistreatment during pregnancy and childbirth in the U.S. Results indicated that 1 in 6 women said they had been shouted at, scolded, or threatened by a health care provider or they had received no response to requests for help. The rates of mistreatment for women of color were consistently higher than for White women.¹⁸ Black women often do not seek follow-up treatment because of such experiences of mistreatment, which can add to distrust of the medical system. In addition, cultural stigma surrounding depression and mental health conditions may discourage Black women from seeking mental health services. They may have concerns that talking about their feelings of depression to a professional could result in the involvement of child protective services or their being judged as bad parents.¹⁹

Clinicians and researchers are facing the need to address the intersection of several concurrent and evolving situations in society—increased attention to racial disparities, high MMM/SMM rates, and the pandemic. Public health emergencies, such as pandemics, may exacerbate racial and ethnic inequities that are already present in society. More research is needed to help us understand the ways in which these monumental shifts are impacting society and determine evidence-based approaches to preventing and alleviating possible harms. 

Research Is Underway, and Much More Is Beginning
The IMPROVE initiative harnesses the remarkable skills and energy of the many Institutes, Centers, and Offices (ICOs) across NIH. ORWH is proud to help lead this effort. In addition, ORWH is co-funding an IMPROVE administrative supplement with the National Library of Medicine (NLM) that will link existing MM/SMM data sets, electronic health records, and clinical and biomarker data from existing national cohorts, biobanks, national surveys, and registries to improve the health of women of color. A variety of maternal health resources will then be developed and disseminated to pregnant and postpartum women. Examples include a Navigating Wellness Maternal Health module and toolkit with a focus on women of color in urban settings. The program will use a range of communication approaches, including podcasts, web resources, and public library toolkits to reach and influence the health behaviors of this audience. It is hoped that this will help address the current lack of trusted resources in underserved communities. 

This supplement builds on other ORWH efforts to address women’s health needs, particularly in underserved communities. Through its U3 Administrative Supplement Program, the Office is promoting interdisciplinary research focused on understudied, underrepresented, and underreported (U3) populations of women. The program encourages studies on the effects of sex and gender influences at the intersection of many social correlates, such as race, ethnicity, socioeconomic status, education, health literacy, and urban/rural residence. U3 research is especially critical in the area of social determinants of maternal health. Additionally, ORWH, in partnership with the National Institute of General Medical Sciences and other ICOs, issued “Administrative Supplements for Research on Women’s Health in the IDeA States.” It aims to expand women’s health research in States that have had low levels of NIH funding and are among those with the highest maternal and infant mortality rates.  

The IMPROVE initiative is prioritizing comprehensive, interdisciplinary research that engages communities with high rates of maternal deaths and complications. Through the efforts led by many ICOs across NIH, research is underway that will help us better understand the causes of MMM and SMM, the circumstances that contribute to them, and, most importantly, ways to prevent them.

References

¹ Centers for Disease Control and Prevention. (2019, May). Pregnancy-related deaths: Saving women’s lives before, during and after delivery. https://www.cdc.gov/vitalsigns/maternal-deaths/index.html#:~:text=Overview,a%20year%20afterward%20
² Goeglein, S. K., & Yatchmink, Y. E. (2020). Pediatrics. PMID: 32817439.
³ Atif, N., et al. (2015). Seminars in Perinatology. PMID: 26164538.
⁴ Netsi, E., et al. (2018). JAMA Psychiatry. PMID: 29387878.
⁵ Taylor, J., & Gamble, C. M. (2017, November 17). Suffering in silence: Mood disorders among pregnant and postpartum women of color. Center for American Progress. https://www.americanprogress.org/issues/women/reports/2017/11/17/443051/suffering-in-silence
⁶ Mangla et al., (2019). AJOG. PMID: 30849358.
⁷ Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. https://www.cdcfoundation.org/sites/default/files/files/ReportfromNineMMRCs.pdf
⁸ Alhusen, J. L., et al. (2015). Journal of Women’s Health. PMID: 25265285.
⁹ Iacobucci, G. (2016). The BMJ. PMID:  27927645.
¹⁰ Robbins, C., et al. (2018). Morbidity and Mortality Weekly Report Surveillance Summaries. PMID: 29346340.
¹¹ Neiger, R. (2017). Journal of Clinical Medicine. PMID: 28749442.
¹² Government Accountability Office. (2020, March 12). Maternal mortality: Trends in pregnancy-related deaths and Federal efforts to reduce them. https://www.gao.gov/products/GAO-20-248
¹³ Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. (2003). PMID: 25032386.
¹⁴ Metcalfe, A., et al. (2018). Acta Obstetricia et Gynecologica Scandinavica. PMID: 29030982.
¹⁵ Fingar, K. R., et al. (2018). Healthcare Cost and Utilization Project Statistical Briefs. PMID: 30371995.
¹⁶ New York City Department of Health and Mental Hygiene. (2016). Severe maternal morbidity in New York City, 2008–2012. https://www1.nyc.gov/assets/doh/downloads/pdf/data/maternal-morbidity-report-08-12.pdf
¹⁷ Farrington, L. (2020, September 18). How the CDC and others are failing Black women during childbirth. STAT.  https://www.statnews.com/2020/09/18/how-the-cdc-and-others-are-failing-black-women-during-childbirth/?utm_source=STAT+Newsletters&utm_campaign=fa3ec7fbc8-MR_COPY_01&utm_medium=email&utm_term=0_8cab1d7961-fa3ec7fbc8-151259769
¹⁸ Vedam, S., et al. (2019). Reproductive Health. PMID: 31182118.
¹⁹ Robles-Fradet, A., & Coursolle, A. (2020, February 28). Maternal mental health care is critical to reducing racial disparities. National Health Law Program. https://healthlaw.org/maternal-mental-health-care-is-critical-to-reducing-racial-disparities