Preventing Maternal Mortality Requires Attention to Mental Health – and the Factors That Lead to Disparities

When Meghan Markle detailed her struggles with mental health during a televised interview earlier this year, many were surprised to learn that a woman of her position had experienced suicidal thoughts during her pregnancy and postpartum. However, the most recent review of maternal deaths from Colorado’s Maternal Mortality Committee shows that the duchess’s experiences are sadly much more prevalent and relatable for other women than many people realized.

The United States has the highest maternal mortality rate among wealthy countries, so interventions centered on maternal health have been a focus for decades. However, suicide — not a medical crisis in the hospital — is the leading cause of death for new mothers, according to the committee’s report.

Many maternal health interventions have historically focused on deaths in the hospital at the time of childbirth. While the causes of these deaths should be addressed, nearly six in 10 maternal deaths in Colorado are attributed to either mental health or substance abuse. This alarming fact deserves more attention, as it suggests that many of these maternal deaths are preventable.

Colorado lawmakers passed three bills this year related to pregnancy and childbirth outcomes, with a special focus on maternal risks for women who are pregnant or a year postpartum — Senate Bill (SB) 101, SB 193, and SB 194.

These three bills not only present an opportunity to make significant improvements in the troubling trend of preventable maternal deaths, but also allow for policymakers to begin to address disparities between white mothers and mothers of color.

Maternal Mortality and Mental Health

The Maternal Mortality Committee reviewed 94 maternal deaths in Colorado between 2014 and 2016 and found that the leading cause of death of women during pregnancy or in the year following childbirth in Colorado was suicide. The second-highest cause of death was unintentional drug overdose.

Some 17% of the pregnancy-associated deaths examined in the report were due to suicide, and about 14% were due to drug overdose. Nearly 77% of the 94 deaths reviewed were determined to be preventable. The committee considered a death to be preventable if it determined that death may have been avoided by one or more interventions at the patient, community, provider, facility, or systems levels.

These figures illuminate a disturbing fact: Too many women are not receiving vital mental health care or associated supports during this critical period even though they are likely to have extensive engagement with the health care system.

This is unfortunately not a new issue in Colorado. Research examining maternal deaths in Colorado between 2004 and 2012 indicated that suicide and unintentional overdose were the leading causes of death during pregnancy and the first year after giving birth.

Maternal Death and Health Disparities

Nationwide, women of color, those with lower socioeconomic status and, accordingly, those with lower access to health services account for a disparate number of maternal deaths.

The Maternal Mortality Committee also calls for attention to disparities in maternal mortality among different groups of Colorado women. Native American women who gave birth between 2014 and 2016 were 4.8 times more likely to die during pregnancy or in the year after birth than non-Native American women in Colorado. The report does not find a significantly different percentage of maternal deaths among white, Hispanic, Black, and Asian Coloradans, but notes that this is partly due to the relatively small scale of the report, which means that just one or two deaths can notably change rates and disparities. The committee calls for continued vigilance to disparities. National statistics indicate that Black mothers are at a higher risk of maternal death — three to four times more likely than non-Hispanic white and Hispanic women.

These numbers must be understood within the context of longstanding structural and systemic inequities. Societal biases and ineffective systems have created considerable barriers to equitable care for women from certain groups. Meaningful attempts to address these disparities must start with an understanding of their true roots. And interventions seeking to address other disparities, such as those between women with different education levels, must also take into account disparities among racial groups. For example, national data still show significant disparities for some groups such as Black women when indicators like education level are held constant.

What Can Be Done?

Recent new laws are a step in the right direction. But preventing maternal deaths in Colorado will require continued, targeted attention to and investment in solutions that improve equity and access to care.

Refining Interventions Through Improved Data and Tracking Capabilities

Better and more data collection will provide better details about specific areas of opportunity, such as the groups that need additional care and when interventions are most critical. For instance, the committee’s report’s ability to examine racial disparities was limited by its small sample size. SB 193 is a step in the right direction: It requires the Colorado Civil Rights Commission to collect reports about mistreatment during pregnancy and birth and directs the Colorado Department of Public Health and Environment to collect additional data on maternal mortality and pregnancy outcomes.

Improving Maternal Health Through Related Sources of Disparity

Addressing disparities among racial and ethnic groups, socioeconomic levels, and insurance status also requires a focus on the roots of the inequities — namely, the social determinants of the unequal health outcomes. A greater focus on housing, education, economic factors, and the experience of systemic bias is needed to meaningfully support all Colorado mothers. Addressing a woman’s housing or food instability, for example, could support her mental health and make a difference in her experience of pregnancy and new motherhood.

Efforts to address the social roots of inequities among vulnerable groups require direct engagement with the communities most affected. It is critical to request guidance from grassroots organizations led by people from these communities and to establish mutual trust.

Expanding Access to Pre- and Postnatal Care, Including Through Medicaid

Expanding Medicaid and its services has proven to be a key way to address health disparities. The majority of women who gave birth in 2019 while insured by Colorado Medicaid were women of color, so improvements for this particular population will inherently contribute to improvements in equity overall.

SB 194 extends Medicaid coverage for women for 12 months postpartum, which will allow eligible new mothers to access medical care as well as mental health therapy and substance abuse treatment for a full year following the birth of their baby. Given the increased risk of mental health issues for mothers in the first year of their baby’s life, the opportunity for uninterrupted mental health supports could prove to be lifechanging for many women.

The Department of Health Care Policy and Financing’s recent report on 2019 maternity outcomes demonstrates an important commitment to identifying further opportunities to improve equity by acknowledging structural and systemic factors on Medicaid members’ health outcomes and actively striving to address the policies and practices that have contributed to those factors.

2021’s final perinatal health-focused bill, SB 101, extends regulations that allow midwives to practice in the state and allows them to practice at birthing centers — offering more options for mothers-to-be.

The perinatal period can be one of the most difficult aspects of the human experience. But with the right interventions, Colorado policymakers can make it a little easier and safer for mothers.

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