February 22, 2021

Three pregnant women sitting in chairsA special issue of the Journal of Women’s Health (JWH) examines the maternal morbidity and mortality (MMM) crisis in the United States. Articles in the issue also suggest solutions and propose a research agenda for understanding, treating, and preventing maternal health complications. 

U.S. women—particularly those from underrepresented racial and ethnic populations and those who reside in rural areas—are more likely to die from complications related to pregnancy or childbirth than women in peer nations. Each year, about 700 U.S. women die as a result of pregnancy or delivery complications, and approximately 50% of maternal deaths are preventable. For every pregnancy-related death in the United States, 70 women experience a “near miss.” Cases of severe maternal morbidity (SMM)—unexpected outcomes of pregnancy, labor, or delivery resulting in serious short- or long-term consequences to a woman’s health—have almost doubled over the past decade. SMM affected more than 50,000 U.S. women in 2014.

ORWH Associate Director for Science Planning, Policy, and Analysis Samia Noursi, Ph.D., initiated this project, conceptualized it, identified and invited authors, and served as the Guest Editor for the JWH special issue. Dr. Noursi said, “The articles in this special issue address an alarming and disturbing public health crisis in the United States. NIH, other agencies within the U.S. Department of Health and Human Services (HHS), and members of the scientific community lay out the scope of this problem and ways to address it.”

Dr. Noursi and colleagues—Janine Austin Clayton, M.D., FARVO, Associate Director for Research on Women’s Health at NIH and Director of ORWH; Diana W. Bianchi, M.D., Director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD); and Dorothy Fink, M.D., Deputy Assistant Secretary for Women’s Health in the HHS Office of the Assistant Secretary for Health (OASH) and Director of the HHS Office on Women’s Health (OWH)—wrote the introduction to the special issue. They state that the articles describe “epidemiological patterns and trends, biological and physiological risk factors, external risk factors, social determinants of health, and proven and potential interventions that are poised to be delivered to a broader audience.”1

Below are more details on some of the subjects covered by the articles, several co-authored by ORWH staff.

Maternal Health Disparities in U.S. Subpopulations. Several JWH articles discuss how many U.S. subpopulations—including underserved racial and ethnic groups, transgender individuals,2 and women of advanced maternal age3—have higher rates of MMM as a result of socioeconomic disadvantages, comorbidities, implicit bias, and other factors. Joia Crear-Perry, M.D., and colleagues discuss how influences on the health care system—including individual, clinical, behavioral, social, historical, systemic, structural, and political determinants—and their intersection with race, class, and gender contribute to the problem of MMM.4 An article by Jennifer L. Heck, Ph.D., and colleagues reviews the available literature on MMM in American Indian and Alaska Native women; identifies hemorrhage, cardiomyopathies, and hypertensive disorders of pregnancy as leading causes of maternal mortality in this population; and points to the numerous knowledge gaps on MMM in this group.5 Juanita J. Chinn, Ph.D., of NICHD and colleagues describe persistent MMM health disparities among Black women relative to other U.S. women and discuss associated comorbidities and relevant structural inequities within and outside of the health care system.6 Finally, ORWH graduate intern Bani Saluja, M.P.H., and former ORWH research scientist Zenobia Bryant, Ph.D., discuss implicit bias and its contribution to racial disparities in MMM in the United States.7

Comorbidities and MMM. Women with medical conditions predating conception or with those that emerge during pregnancy experience higher rates of MMM than women with no comorbidities. Several articles in the special issue of JWH discuss how the risk of MMM increases as the result of co-occurring conditions such as dysglycemia,8 physical and cognitive disability,9 cardiovascular disease,10 perinatal depression,11 sleep-disordered breathing,12 and infection.13 Several articles also discuss evidence-based clinical practices for monitoring and treating such patients before, during, and after pregnancy.

Other MMM Considerations. The JWH articles also explore other factors contributing to and issues associated with MMM, including homicide, suicide, drug overdose, and intimate partner violence;14 environmental factors;15 and dietary supplements during pregnancy.16 ORWH Special Advisor David A. Thomas, Ph.D., and colleagues discuss pain and pain management during pregnancy.17 An article by ORWH Senior Program Officer Régine Douthard, M.D., M.P.H., and colleagues considers the problem of MMM in a global context.18

Addressing the Problem of MMM. Two articles focus on current and proposed efforts to mitigate the problem of MMM in the United States. Catherine Squire Eppes, M.D., and colleagues describe the implementation of new clinical tools and protocols (or “care bundles”) designed to improve obstetric safety.19 An article by Beda Jean-François, Ph.D., and colleagues discusses how existing health information technologies could be leveraged to address health disparities in MMM stemming from racial, ethnic, socioeconomic, and geographic factors.20

A New Research Agenda. Michael Lu, M.D., and Dr. Noursi discuss all articles and conclude the JWH special issue by proposing a new MMM research agenda for the biomedical community.21 Synthesizing the contents of the JWH articles, Drs. Lu and Noursi identify four key questions indicating where scientific knowledge is lacking:

  • Why are some populations at higher risk for MMM? 
  • How can we prevent pregnancy complications and their long-term effects?
  • How can we improve the safety and quality of maternity care?
  • What are the social, structural, and environmental determinants of maternal health? 

These questions suggest an agenda for the next stages of research and provide a guide to biomedical investigators, policymakers, and funding organizations addressing MMM.

Note that in addition to spearheading this issue of JWH, ORWH has created and collated resources, initiated or cosponsored programs and funding opportunities, and promoted research efforts related to MMM. (See ORWH MMM Initiatives.)

ORWH Director Janine A. Clayton, M.D., FARVO, said, “ORWH is grateful to have the opportunity to bring the issue of maternal morbidity and mortality to the forefront. MMM is a broad-ranging subject with no simple solution. Only by taking a multifaceted approach and studying the intersections between MMM, comorbidities, and social determinants of health will we be able to improve the health of women. This issue of JWH is important because it addresses the compound impact of these factors and also provides a road map for where research needs to move in the future. I would like to thank Dr. Noursi for taking the lead on this project, and I would also like to thank all of those who have contributed their time and research to this significant issue. Science has solved many of the world’s greatest challenges and cured many diseases. I know that by forging ahead with this vital research, science will also solve this problem.”

The articles from the special issue of JWH may be openly accessed by the public and are available here.


1  Noursi et al. 2020. J. Womens Health PMID: 33226879.
2  Patel and Sweeney. 2020. J. Womens Health PMID: 33275854.
3  Correa-de-Araujo and Yoon. 2020. J. Womens Health PMID: 33185505.
4  Crear-Perry et al. 2020. J. Womens Health PMID: 33181043.
5  Heck et al. 2020. J. Womens Health PMID: 33211616.
6  Chinn et al. 2020. J. Womens Health PMID: 33237831.
7  Saluja and Bryant. 2020. J. Womens Health PMID: 33237843.
8  Silva et al. 2020. J. Womens Health PMID: 33147099.
9  Signore et al. 2020. J. Womens Health PMID: 33216671.
10  Varagic et al. 2020. J. Womens Health PMID: 33259740.
11  Dagher et al. 2020. J. Womens Health PMID: 33156730.
12  Laposky and Pemberton. 2020. J. Womens Health PMID: 33181042.
13  PrabhuDas et al. 2020. J. Womens Health PMID: 33232632.
14  Campbell et al. 2021. J. Womens Health PMID: 33295844.
15  Boyles et al. 2020. J. Womens Health PMID: 33211615.
16  Brown et al. 2020. J. Womens Health PMID: 33164624.
17  Thomas et al. 2020. J. Womens Health PMID: 33216677.
18  Douthard et al. 2020. J. Womens Health PMID: 33211590.
19  Eppes et al. 2020. J. Womens Health PMID: 33227226.
20  Jean-Francois et al. 2020. J. Womens Health PMID: 33211604.
21  Lu and Noursi. 2020. J. Womens Health PMID: 33216690.