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Invited Commentary
Obstetrics and Gynecology
February 2, 2021

Data and a Call for Action to Improve Maternal Health

Author Affiliations
  • 1Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Netw Open. 2021;4(2):e2037291. doi:10.1001/jamanetworkopen.2020.37291

In 1985, Rosenfield and Maine1 asked the question, “Where is the M in MCH [maternal and child health]?” in response to the tragedy of maternal death in low-income countries; at the time, 500 000 women were estimated to die each year in these countries from complications of pregnancy, abortion, and childbirth. This question has resurfaced but with an emphasis on the domestic crisis of maternal death and burden of severe maternal morbidity (SMM). The US maternal mortality rate is higher than those in most other high-resource countries, and intractable racial/ethnic disparities have existed since 1940.2 Apart from the high rate of cesarean deliveries, most women in the US experience childbirth with few risks or complications. However, the article by Chen and colleagues3 reminds us that the percentage of women with both public and private insurance who experience SMM is not negligible; overall, they found that more than 2% of women newly experienced SMM during pregnancy, labor, and delivery and the postpartum period combined, and some groups experienced more than 1.5 times the odds of these events, particularly women of color. SMM not only has an immediate impact for women and their families, but also long-term consequences for women.

Chen et al3 provide a new and updated look at SMM during labor and delivery. They captured newly emerging SMM during the postpartum period using data obtained from the 2010 to 2014 IBM MarketScan Commercial Claims and Encounters database and the IBM MarketScan Multi-State Medicaid database for women aged 15 to 44 years who gave birth between January 2010 and September 2014; delivery and postpartum hospitalization data were used to measure de novo morbidity postpartum, which was defined as SMM first diagnosed after the delivery hospitalization, for deliveries sampled in the study. The number of deliveries available from the databases is very large, allowing the researchers to capture less-frequent, but important, postpartum conditions and to compare the most common conditions for both delivery and the postpartum period. The emergence of de novo morbidity postpartum is a major contribution of the current article.3 The identification of newly emerging conditions associated with postpartum SMM necessarily occurs in the community and relies on support networks of women at a time when the benefit of accessing health care may be more limited for marginalized groups.

Earlier work on postpartum SMM has been based on state-level data or did not report de novo SMM. Girsen et al4 tracked postpartum readmission for women with SMM in California but did not report whether the women also experienced SMM during labor and delivery. Harvey and colleagues5 tracked postpartum hospitalizations for women with and without SMM during labor and delivery in Massachusetts but did not provide data about SMM during the hospitalizations. Callaghan and colleagues6 described rates of delivery and postpartum SMM using the National Inpatient Health survey, a sample of hospitalizations among community hospitals, but did not report de novo postpartum conditions.

Chen et al3 also describe major indicators of SMM during delivery and post partum, providing nuanced information about important conditions in the latter period. Preeclampsia is noted for both periods, but its prevention after discharge is a high priority, especially to prevent maternal death. Preeclampsia may be particularly difficult to identify among women in communities where education about its signs and symptoms may be limited or support networks are less knowledgeable about the complication, or among practitioners who are less experienced with preeclampsia in the postpartum period; this difficulty extends to other conditions in the postpartum period. The emergence of postpartum sepsis as a major condition is also a concern, as are other conditions such as air and thrombotic embolism and puerperal cerebrovascular disorders. As Chen et al3 note, by focusing on SMM emerging after discharge, knowledge of the burden of SMM may create new opportunities to improve maternity care. Identifying the postpartum conditions most frequently experienced by women also provides opportunities to develop more focused preventive measures and improve care.

The databases used in the analysis are not without limitations.3 Although the commercial insurance database may provide a wider swath of the US than the Medicaid database (which covers enrollees in 9 to 13 states each year during the study period), this database lacks important demographic data about the sample. Regional differences in SMM reported from these data are insufficient to capture this demographic information. Even the Medicaid data are limited in demographic characteristics. State-level analyses have provided more insight in this regard, especially when hospital discharge data are linked with birth certificates. The development of such linked data in other states, such as Massachusetts5 and California,4 is needed to capture more-detailed data about the characteristics of women and to confirm whether the findings extend to other states. The state-level databases also provide increased follow-up beyond the traditional 42-day postpartum period5 and, in some instances, may extend beyond a year post partum.

Strategies to improve maternal health by public, private, and professional organizations are needed to parallel data about SMM. The Preventing Maternal Deaths Act of 2018 authorized federal support for state maternal mortality review committees as a major step toward addressing high rates of maternal mortality and SMM. These committees undertake comprehensive assessments of maternal deaths to inform prevention activities at state and community levels. Collaboration across states about the committees’ results offers an important opportunity to develop strategies to address associated causes of mortality that are less apparent in national statistics, such as mental health, domestic violence, drug overdose, and suicide.7 In 2015, the American College of Obstetricians and Gynecologists published the first detailed guidelines for maternal levels of care with an important update in 2019. The recent action plan announced by the Department of Health and Human Services addresses goals for achieving healthy births for all US women of reproductive age by improving prevention and treatment, prioritizing quality improvement, optimizing postpartum health, and improving data and research to inform interventions. By addressing the fourth goal, Chen et al3 also call attention to the need to address the other 3 goals. Data about maternal morbidity are critical in recognizing the need for improved care, including systems of care to put the M into MCH. The Department of Health and Human Services agenda will only be successful, however, if when addressing improved care, we also listen to the voices of women and their experiences by recognizing their burden of SMM.

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Article Information

Published: February 2, 2021. doi:10.1001/jamanetworkopen.2020.37291

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Strobino DM. JAMA Network Open.

Corresponding Author: Donna M. Strobino, PhD, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205 (

Conflict of Interest Disclosures: None reported.

Rosenfield  A, Maine  D.  Maternal mortality—a neglected tragedy: where is the M in MCH?   Lancet. 1985;2(8446):83-85. doi:10.1016/S0140-6736(85)90188-6PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Differences in maternal mortality among black and white women—United States, 1990.   MMWR Morb Mortal Wkly Rep. 1995;44(1):6-7,13-14.PubMedGoogle Scholar
Chen  J, Cox  S, Kuklina  EV, Ferre  C, Barfield  W, Li  R.  Assessment of incidence and factors associated with severe maternal morbidity after delivery discharge among women in the US.   JAMA Netw Open. 2021;4(2):e2036148. doi:10.1001/jamanetworkopen.2020.36148Google Scholar
Girsen  AI, Sie  L, Carmichael  SL,  et al.  Rate and causes of severe maternal morbidity at readmission: California births in 2008-2012.   J Perinatol. 2020;40(1):25-29. doi:10.1038/s41372-019-0481-zPubMedGoogle ScholarCrossref
Harvey  EM, Ahmed  S, Manning  SE, Diop  H, Argani  C, Strobino  DM.  Severe maternal morbidity at delivery and risk of hospital encounters within 6 weeks and 1 year postpartum.   J Womens Health (Larchmt). 2018;27(2):140-147. doi:10.1089/jwh.2017.6437PubMedGoogle ScholarCrossref
Callaghan  WM, Creanga  AA, Kuklina  EV.  Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.   Obstet Gynecol. 2012;120(5):1029-1036. doi:10.1097/AOG.0b013e31826d60c5PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention Foundation. Report from nine maternal mortality review committees. Published 2018. Accessed January 5, 2021.
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