Why U.S. Maternal Mortality is WORSE Than You Think (Pt. 2)
Homicide is the leading cause of maternal mortality, we just don't count it
This article is part 2 of 2 in a series on maternal mortality and inequality in America.
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In last week’s article, I discussed why America may be dramatically overcounting maternal mortality. The short answer is first, the CDC botched the rollout of the pregnancy checkboxes, leaving states to count these deaths differently; and second, physicians are likely counting more deaths as pregnancy related than they ought to (i.e. a pregnant woman who dies in a car accident shouldn’t be counted in maternal mortality statistics).
Today’s article instead is about how America at the same time is dramatically undercounting maternal mortality. This is because we fail to include the #1 cause of deaths for pregnant women and new mothers: homicide.
Homicide is the leading cause of maternal mortality
Nationally, there were 10,715 deaths of people who were pregnant or within 1 year postpartum from 2018 to 2022, including 837 homicides, 579 suicides, 2083 drug overdoses, and 851 that involved firearms. If homicides were included in maternal mortality statistics, it would raise the rate by 5.23 deaths per 100,00 live births. Women who are pregnant or postpartum had a 35% higher risk of homicide, compared to their peers. When women under 25 get pregnant, their odds of death by homicide double.
Using Anant’s method, this would increase the maternal mortality rate from 10 deaths per 100,000 births to 15 deaths per 100,000 births — a significant jump.
Homicides are not counted in the official statistics of maternal mortality. While this is typical for most countries across the world, the incredibly high gun ownership rate, domestic violence rates, and crime rates in the US make this a much more stark problem. 68% of homicides of pregnant women or new mothers involved firearms. Homicide deaths among pregnant women are more prevalent than deaths from hypertensive disorders, hemorrhage, or sepsis.
Louisiana recently published a report on the causes of death for pregnant mothers and it revealed that homicide is the second leading cause of death after overdoses. Once again, the Louisiana data reveals that homicides for young pregnant Black women are five times more likely than for their White peers.
Nationally, pregnant Black women were eight times more likely to be killed by their intimate partner than non pregnant Black women.
The real story is that women aren’t dying in hospitals — they are dying in their homes, killed by husbands and boyfriends when they arrive with a newborn. Our hospitals aren’t necessarily the problem (and only 30% of hospitals ask about problems at home), it’s so much bigger than that. The stresses of early parenthood and pregnancy bring out the worst in people, and this can lead to murderous rage in America.
Could this death have been prevented?
13 states ask in their maternal mortality questionnaire “could this death have been prevented?” As the New York Times explains, “National-level data on the pregnancy-homicide phenomenon is difficult to find, as it’s often buried in individual state reports on maternal mortality or in databases inaccessible to the public.”
If you haven’t read this New York Times story of the tragic death of Markitha Sinegal I highly highly recommend it. The story unravels in heartbreaking detail about the fight Markitha had with her boyfriend in New Orleans as they struggled to raise their 9-month old twins together. Markitha’s father knew there were issues, and in fact she had called the police on her husband a few times about violence in the home. The night before the homicide happened, Markitha asked her dad to drop off some cash for gas money.
“She answers the door, but she isn't her usual happy self. He can't shake the feeling that something is wrong. He hugs her goodbye, and her hold on him feels like a vise grip. ‘I love you, he tells her.’
“As he gets back in his car, he looks up. Markitha is standing there, watching him from the door. Something is wrong, he thinks. Maybe he should go back up there. Maybe he should ask her what's going on. "I'm going to talk to her tomorrow," he tells himself.
The next day, Markitha’s husband shoots her in the back during an altercation while her mother-in-law slept in the next room. It was the day before Mother’s Day.
National statistics mask state challenges
Some states are massive outliers on maternal mortality and account for the vast majority of deaths relating to pregnancy. Mississippi has a maternal mortality rate that is double the US average, and during the pandemic, and during the height of the pandemic in 2021, the mortality rate tripled to 82 per 100,000 births, according to the Mississippi State Medical Association. But even if we look at the period before the pandemic (2016-2020) the maternal mortality rate for women aged 35-39 was still this high, at 81 per 100,000. At the time, Mississippi women this age had a higher mortality rate than for women in Libya who were in the midst of a civil war.
Black maternal mortality is consistently three times higher than that of both White women and Hispanic women. Using the CDC data, the White maternal mortality rate for 2024 was 15 per 100,000 while the Black maternal mortality rate was 50. The Hispanic rate was below all of them at 13.6. While there is no real consensus on why this is lower, some theories suggest the typically lower age of Hispanic mothers, healthier eating habits, and strong communities.
K.S. Joseph and Ananth’s new research did find disparities between Black and White women. Depending on the period, Black women were 3-4x more likely to die during childbirth than their White counterparts, even when controlling for income and education.
A Black woman with a college degree is 1.6x more likely to die as a result of pregnancy or childbirth as a white woman with less than a high school diploma.
The most harmful argument against maternal mortality statistics
The most harmful argument against maternal mortality statistics is a question of scale. These types of arguments have skyrocketed online after both Trump elections.
We’ve seen that the official numbers for maternal mortality do not capture the full picture. It is OK to question data and try to evaluate how we can improve it and understand what may be missing.
What is not OK to do is to say that some of these numbers do not matter. This is an argument I’ve seen about maternal mortality statistics…
The argument goes something like this: In 2022, there were 817 pregnancy related deaths in America. While it is difficult to find homicide date, between 2018-2022 there were likely 200 maternal homicide deaths per year. However, overall in America in 2022, there were more than 25,000 homicides. This makes homicides against pregnant women less than 1% of all homicides. Isn’t this just a drop in the bucket?
The argument continues: Heart disease kills more than 700,000; cancer kills more than 600,000;. Suicide kills more than 48,000; and overdoses kills more than 47,000. Shouldn’t we be focusing on the biggest killers in America instead of such a small population?
And finally: This is a problem for outliers. Only some states or some populations are really bad. The vast majority of Americans don’t experience these problems, it’s just a few areas that drive down the averages.
Politicians make these arguments out loud too. Michigan state house candidate Robert “R.J.” Regan in 2022 said that attacks against women are just a fact of life and in some cases there are more things the women should be doing to try to avoid these dangerous situations.
Sen. Bill Cassidy (R-La.) in 2022 said that despite Louisiana having one of the worst maternal mortality rates in the country, “if you correct our population for the race, we’re not as much of an outlier as it’d otherwise appear.” In other words: we’re not so bad if you don’t count our Black women.
Not one single mother should die in America. More pregnant women are the victims of homicide every year in America than total victims of all homicide in Iceland in a decade.
Women should not die from pregnancy complications, not from lack of care, not from the violent hand of their partners. 1 death is too high. These numbers aren’t statistics —- these are people. And in particular, these are people who leave behind babies who will grow up not knowing who their mother was.
The Path Forward
Since 2020, all 50 states have been reporting standardized data to the CDC on maternal mortality statistics. While we can be sure that everyone is comparing apples to apples, the scope is still misguided.
Expand Tacking to 1 Year Postpartum: The federal government should require all states to track maternal deaths up to one year postpartum, not just the 6-week period currently used in CDC statistics. This would go beyond the 37 states that currently do this and use those metrics for their own state-wide programs for maternal health. The CDC already funds a program called Maternal Mortality Review Committees (MMRCs). These MMRCs should be the ones to support states in this roll out to standardize reporting and create a national database. This will ensure we stop undercounting maternal mortality deaths by a full one-third.
Include Homicides in Maternal Mortality Statistics: The CDC needs to link its data with data from the National Violent Death Reporting System (NVDRS). While the CDC only publishes death certificates, the NVDRS links to police, autopsy and other reports that can clarify whether the homicide was an incident of intimate partner violence. Researchers have been able to link this data themselves, but this needs to be done in a systematic and federally registered way. As we saw in last week’s article, when different states or agencies are left to their own devices to track mortality data, it can become a nightmare.
Mandate Intimate Partner Violence (IPV) Screening: Measuring the problem is one thing, but we actually need to stop the problem. The American College of Obstetrics and Gynecologists recommends universal screening for intimate partner violence during pregnancy, research indicates that fewer than 30% of women are actually screened. This drops dramatically for Black women, who are at the highest risk. While it can be hard to ask a husband or boyfriend to step out of a room, doctors need to do this and it needs to become a national requirement, not just a recommendation.
With the overturn of Roe v. Wade, more women may become pregnant in America than in recent decades. Abortion pills may be harder to get and contraception may become less accessible. It is incredibly important to improve maternal mortality in America now.
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One reason the US maternal overdose death rate is so high is because multiple states criminalize drug use during pregnancy. Almost no other nation does this because it both places pregnant people under a different legal category and is bad public health policy. There are so many cases of women asking for help for their addiction and then being arrested. This has led to many pregnant people avoiding help or even avoiding hospitals altogether because they are afraid of being arrested if they test positive for drugs.
I wrote my dissertation about the topic focusing on Alabama, which has become the worst state for this, but it happens throughout the country. It's getting worse because the Dobbs decision has made courts more likely to treat fetuses as legal children and thus to treat drug use the same as poisoning a child.
Pregnancy Justice is the main advocacy group that collects research on this and provides legal aid to people affected by these laws. I highly suggest checking them out for anyone who is interested in this topic.
Great article based on statistics combined with logical reasoning.