Maternal mortality rates are increasing in the United States and include
deaths due to medical causes thought to be directly related to
pregnancy, such as hemorrhage, thromboembolism and hypertensive disease.
Intimate partner violence, substance use disorder and mental illness
may be as threatening to health and survival during pregnancy in United States
cities as medical issues.
The findings, which appear online in the American Journal of Public Health
suggest that public health programs and health systems could more
effectively prevent maternal deaths by addressing psychosocial
contributors to health when pregnant women present for care.
‘Intimate partner violence, substance use disorder and mental illness may be as threatening to maternal health in United States as medical issues.’
Although substance use, serious mental illness and IPV may also be
exacerbated by pregnancy and are known to worsen perinatal outcomes,
deaths specifically due to these causes are not included in current
definitions of U.S. maternal mortality.
Rather than focusing on maternal mortality cases alone, researchers
reviewed cases of all women who died during or within a year of
pregnancy in Philadelphia from 2010 to 2014. They extracted cause of
death, contributing factors and any recorded history of health care use
from the case summaries created by the medical examiner's office.
found that approximately half (42 of 85) of pregnancy-associated deaths
were from unintentional injuries, homicide or suicide. Drug overdose was
the leading cause of death and substance use was noted during or around
events leading to death in almost half of non-overdose deaths.
history of serious mental illness was found in more than a third of
non-suicide deaths. And a history of intimate partner violence was
documented in 15 of 77 non-homicide deaths. Regardless of cause of
death, nearly half of all decedents had an unscheduled hospital visit
documented within a month of their death, suggesting missed
opportunities to intervene in these deaths.
"Our analysis used a broader framework than traditional studies of
death during pregnancy and found that a narrow focus on the medical
causes of maternal mortality may be inadequate. Even women who died from
medical causes frequently had histories of substance use disorder,
serious mental illness or partner violence - hidden potential
contributors to maternal mortality," explained lead author Pooja Mehta,
assistant professor of obstetrics & gynecology at Boston
University School of Medicine.
Traditionally, public health and physician efforts to make pregnancy
safer have focused on medical causes, for example, the prevention of
excessive bleeding, blood clots, high blood pressure and heart disease.
"An approach that relies on a broader framework to define the
"preventable" pregnancy-associated death and leverage health system
contacts to address mental illness and social context is vital to
addressing the U.S. maternal health crisis," said Mehta, a practicing
obstetrician-gynecologist and health policy researcher at Boston Medical
The researchers believe there are missed opportunities to intervene
on behalf of those who are struggling during pregnancy, not just on
Labor and Delivery, but also in emergency rooms, triage settings and in
the community. "Out-of-the-box strategies such as shifting resources,
screening and support to these other settings may be important for
pregnant people at risk for poor outcomes who turn to the health system
for a helping hand," she added.