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.
By Roni Caryn Rabin
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 [United States’] 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.
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.”
This article was originally published in the New York Times on May 28, 2023
Be aware of urgent maternal warning signs during pregnancy and in the year after delivery. Seek medical care immediately if you experience any of these symptoms.
The assessment is the first advance in diagnosing the deadly condition since it was discovered more than a century ago, experts said.
By Roni Caryn Rabin
The [United States] Food and Drug Administration has approved a blood test that can identify pregnant women who are at imminent risk of developing a severe form of high blood pressure called pre-eclampsia, a leading cause of disability and death among childbearing women.
The condition disproportionately affects Black women in the United States and may have contributed to the recent death of Tori Bowie, a track star who won gold at the 2016 Olympics. Two Black teammates of Ms. Bowie — Allyson Felix and Tianna Bartoletta — also developed pre-eclampsia during their pregnancies.
The new test may offer an early warning, identifying which of the many pregnant women who have suggestive symptoms will go on to develop the life-threatening disease within the next two weeks.
“It’s groundbreaking. It’s revolutionary,” Dr. Doug Woelkers, a professor of maternal-fetal medicine at the University of California, San Diego, said of the test. “It’s the first step forward in pre-eclampsia diagnostics since 1900, when the condition was first defined.”
To what extent the test will improve outcomes and save lives is not clear, however, as there is no effective treatment for pre-eclampsia, which usually eases after birth.
“We don’t have a therapy that reverses or cures pre-eclampsia other than delivery of the baby, which is more like a last resort,” Dr. Woelkers said.
The new blood test, made by Thermo Fisher Scientific, has been available in Europe for several years. It is intended for pregnant women who are hospitalized for a blood pressure disorder in the 23rd to 35th weeks of gestation.
The test can tell, with up to 96 percent accuracy, who will not develop pre-eclampsia within the next two weeks and so can safely be discharged from the hospital. Two-thirds of the women who get a positive result, on the other hand, will progress to severe pre-eclampsia in that time, and their babies may need to be delivered early.
Distinguishing between the two groups of women is a challenge that has long vexed physicians.
“The warning signs of pre-eclampsia are not very specific,” said Dr. Sarosh Rana, a professor of obstetrics and gynecology at the University of Chicago who has studied the test. “A lot of women will have edema and headaches.” (Edema means swelling.)
“But we don’t really know who among those patients is at higher risk for the really adverse outcomes,” she said.
Pre-eclampsia affects about one in 25 pregnancies, and the incidence has been on the rise in recent years in the United States. The problem usually starts about halfway through a pregnancy, though it can also occur after childbirth. It can lead to a condition called eclampsia, which can lead to seizures and death.
Black women in the United States have pre-eclampsia rates much higher than those of white women, and they are three times as likely as white women to suffer kidney damage or death from pre-eclampsia. Black women are also more likely to lose their babies.
The blood test measures the ratio of two proteins that are produced by the placenta. A study published in NEJM Evidence in November tracked 1,014 pregnant women hospitalized with a hypertensive disorder of pregnancy at 18 medical centers in the United States from 2019 through 2021. Just under one-third were Black, and 16 percent were Hispanic.
The researchers found that the two proteins were greatly unbalanced in the blood of women who developed severe pre-eclampsia. Those with the widest ratios had a 65 percent chance of progressing to severe pre-eclampsia and of delivering their baby within two weeks, either spontaneously or through induction.
“If your levels are among the highest, you deliver in a few days,” said Dr. Ravi Thadhani, an author of the study.
Women who have symptoms suggesting pre-eclampsia but who test negative can be reassured and sent home, but they may need to have the test repeated every two weeks, Dr. Rana said.
Pre-eclampsia develops precipitously, and without the blood test, the warning signs can be vague.
“A woman can go from feeling fine and being completely healthy and having normal kidney and liver function, and within 24 to 48 hours those organs can fail and she develops brain swelling and seizures,” Dr. Thadhani said. “That is the scary part of the disease.”
This article was originally published in the New York Times on July 3, 2023