New report examines risk factors associated with maternal morbidity, mortality

^{Carrie Neerland}

The U.S. faces a grave — and worsening — public health challenge related to maternal mortality and morbidity.

Despite spending more on maternal care than any other country, the U.S. has the highest rate of maternal mortality (the death of an individual while pregnant or within the first six weeks after pregnancy ends) among high-income countries. Black women are three times as likely to be affected, and Indigenous women are twice as likely, compared to white women.

While an estimated 700 people die annually from pregnancy-related complications, instances of maternal morbidity — which the Centers for Disease Control and Prevention (CDC) defines as life-threatening complications of childbirth and pregnancy that undermines a pregnant person’s functional ability — is also a public health crisis, and it disproportionately affects people of color. 

Despite the scope and gravity of this public health crisis, previous efforts to explain the factors driving maternal mortality and morbidity have fallen short. A new report conducted through the University of Minnesota School of Public Health Minnesota Evidence-Based Practice Center including School of Nursing Assistant Professor Carrie Neerland, PhD, APRN, CNM, FACNM, aims to fill this gap by undertaking a comprehensive review of academic studies focused on risk factors associated with maternal morbidity and mortality during the prenatal and postpartum periods.

“Systematic reviews are considered the gold standard and are the best tool we have to examine and synthesize evidence,” says Neerland. “However, we identified many gaps in the available evidence.”

The research was conducted as part of the National Institutes of Health Pathways to Prevention (P2P) Program, which helps identify research gaps in key health topics. The researchers sought to understand population-level increases in maternal mortality and morbidity by examining studies that analyzed social and structural determinants of health. Social determinants of health represent the broader conditions in which people live their lives and include factors like access to health care, socioeconomic and educational status, physical environment and social support networks.

Written by a team of interprofessional researchers, including School of Public Health Associate Professor Mary Butler, PhD, MBA, who served as principal investigator for the project, the report informed a P2P workshop held to discuss the topic of maternal mortality and morbidity. 

Researchers exhaustively searched academic databases for observational studies examining exposures related to social and structural determinants of health and at least one health or health care-related outcome for pregnant and birthing people. The main insights and recommendations in the report include the following:

• While the studies broadly covered social-structural determinants of health for pregnant and birthing people, the determinants they identified represent only a subset of potential factors of interest and did not address interdependence of risk factors, including biological or medical risk factors.

• The studies reviewed in the report covered maternal risk factors broadly, including identity and discrimination issues, socioeconomic status, violence, trauma, psychological stress, structural institutional factors, rural and urban differences, environmental conditions, comorbidities, and health care use factors.

• The limited depth and quality of available research within each risk factor domain — including racism and other forms of discrimination — impeded the researchers’ ability to understand pathways connecting social-structural determinants of health and maternal health outcomes.

• The report found an unexpectedly large volume of research on violence and trauma relative to other potential social determinants of health for pregnant people.

• Among the maternal health outcome categories in the studies (which included hypertensive disorders, gestational diabetes, cardiometabolic disorders, depression, other mental health or substance use disorders), depression and other mental health outcomes represented a large proportion of the health outcomes captured.

In addition to the full report, the team of researchers published an article in Obstetrics & Gynecology, which condenses the report for clinicians including OB/GYNs and midwives. Neerland, who was lead author of the Obstetrics & Gynecology article, says it was important that the research was disseminated in various formats.

“The hope is that it can impact future research because we identified many gaps in the research related to the social and structural determinants of health related to maternal mortality and morbidity,” says Neerland.