Our ability to successfully resolve problems, not just as individuals but as a society, depends on the accuracy of our understanding of the problem. Without comprehensive data and quality analysis, we lack the critical information needed to make accurate judgments about the source and symptoms of any given issue. The more complex the issue, the more important thorough data truly is to developing a lasting and effective solution. The cause of human death is one of the most complex types of data to analyze. Such a wide variety of variables affect each death that determining the complete cause beyond simply the few words listed on the death certificate requires a full investigation.
Attempting to analyze the causes of death on a large scale, then, is extraordinarily complicated—yet having accurate knowledge of the cause of human death on a large scale is, as one might imagine, of paramount importance for addressing the most urgent problems facing our communities. One such problem, maternal mortality, is among the most complex and difficult topics about which to obtain comprehensive data.
Delving into this, the Policy Center for Maternal Mental Health hosted a webinar titled “The Latest in Maternal Suicide Trends” featuring speaker Cindy Herrick, the research and editorial manager at the Policy Center, and Joy Burkhard, the Center’s executive director. The Policy Center’s work began in 2018 and centered around maternal suicide tracking with a meeting that included experts in the field of maternal mental health, reproductive psychiatrists, the Association of Maternal Child Health Program, and the Centers for Disease Control (CDC).
The CDC informed them that the pregnancy mortality surveillance system, or PMSS, was being used to track all maternal deaths, not just maternal suicides, around the United States through vital statistics data based on death certificate data. However, this model posed some problems that were thwarted by having state committees examine medical records and death certificate data to find out each person’s story. “The gold standard is to do this in-depth review of maternal deaths, including learning if a death might be a maternal suicide,” said Burkhard.
Despite the lack of a comprehensive process in place for those committees at the time, they encouraged the CDC to report maternal suicide data regardless of the lack of those measures of thoroughness. 2019 was the first year that the CDC reported on maternal suicide. Since then, the Policy Center has been tracking and reporting on data collection efforts in the United States through blog posts and webinars. Last year, they published an issue brief on maternal suicide which was recently refreshed to include the data that the CDC reported last year.
Maternal mortality rates have been rising year over year and are substantially higher in the United States than in other nations, both developed and underdeveloped. In March 2023, the CDC reported that the maternal mortality rate of the U.S. is 10 times higher than the maternal mortality rate of other developed nations.
Among pregnancy-related deaths with timing information, 53% occurred between seven days to one year after the end of pregnancy. Of those deaths, 84% were determined to be preventable.
The World Health Organization defines maternal mortality as death within 42 days after the end of pregnancy, but in the U.S., maternal mortality means death within one year postpartum. According to the CDC, pregnancy-associated death is death that occurs within one year of pregnancy regardless of cause.
Pregnancy-associated deaths can be either pregnancy-related, meaning the death is from a pregnancy complication or a chain of events initiated by the pregnancy, or the aggravation of any unrelated condition by the physiological effect of pregnancy, or pregnancy-associated but not related death, meaning the death is from a cause that is not related to pregnancy.
One simple way to differentiate between the two categories of pregnancy-associated death is to determine whether the pregnant person would have died if they were pregnant or not. If the answer is yes, then the death is pregnancy-associated but not related. A recent report from the CDC indicates that maternal mental health conditions, including overdose, are the leading cause of pregnancy-related maternal mortality.
MMRC is the standardized term for maternal mortality review committees. The CDC has funded MMRCs for many states and territories and provides guidance and technical assistance to them in reviewing pregnancy-associated deaths. The task of the MMRCs is to review pregnancy-associated deaths and provide accurate data about pregnancy-related or not-related deaths.
“They basically have requirements and standards for them to abstract data and enter committee decisions, and this data is improved and can better inform recommendations for preventing future deaths,” Herrick explained. Through such thorough best practices, the CDC and the MMRCs it funds ensure that the data they provide will form an accurate foundation for any measures intended to target maternal mortality rates in the U.S.
Missouri’s maternal mortality review program is called the Pregnancy-Associated Mortality Review (PAMR) program, and its website can be found here. According to its statistics, an average of 70 Missouri women die each year during pregnancy or within one year after pregnancy. The program’s board of health care experts investigate these deaths each year in accordance with MMRCs’ goals of obtaining the most accurate maternal mortality data possible.
Thanks to these comprehensive efforts and practices, more information is available about data collection, risk factors, correlations, prevention, and treatment. The Policy Center’s recently published report, accessible here, has the complete information. “The punchline from that report is that the leading underlying cause of pregnancy-related deaths was mental health conditions,” Herrick said. Here, mental health conditions are defined as including deaths from suicide and overdose poisoning related to substance use disorders. A full 23% of deaths in the report were caused by such underlying mental health conditions.
MMRCs have a rigorous process of determining maternal suicides, including such potential measures as interviews with family members. Maternal suicides are now defined and classified by looking at each maternal suicide case and going through a series of questions concerning whether the suicide would have happened if the person were not pregnant. Abstracting this information purely from medical records can be almost impossible in many cases, so the CDC has set forth recommendations and guidelines for doing informational interviews with family members so that the most accurate data can be compiled.
Maternal suicides can happen during pregnancy, but most of them occur in the postpartum period—and not in the immediate postpartum period. “We see it spike between 43 and 365 days postpartum, so it’s really important to keep up that support for moms and postpartum people in this space to prevent more maternal suicides,” Herrick said.
Understanding suicide is a large part of preventing maternal suicides. Black and Hispanic women are twice as likely to report suicidal ideation than white women, but in the immediate postpartum period, Asian women are nine times more likely to report suicidal ideation than their white counterparts. Both moms and dads experience intrusive or unwanted thoughts of suicide during the perinatal period.
Between 70-100% of new moms experience these unwanted, intrusive thoughts. However, white and native moms have the highest rates of maternal suicide deaths. While research has shown that these thoughts, although distressing, do not actually increase the risk of infant-harming behavior, there is not currently much research about whether these intrusive thoughts increase suicide. Screening new birthing parents for suicidal thoughts and ideations is important to ensure that everyone who needs it will receive appropriate care and support.
To learn more about the Policy Center for Maternal Mental Health, visit https://www.2020mom.org/.
