What Causes the High Rate of Pregnancy-related Deaths in the U.S.?

This post originally appeared here on Psychology Today.

The United States can be a dangerous place to be pregnant and to deliver a baby. According to recently released data, the rate of pregnancy-related mortality continues to rise in the U.S. In 2021, the  maternal mortality rate in the U.S. was 32.9 per 100,000 births, far worse than the rates in all other developed countries (note that government agencies report this statistic as “maternal mortality” while we prefer the term “pregnancy-related mortality”).

That rate is even  worse among Black women in the U.S., who had a maternal mortality rate 2.6 times higher than White women in 2021 (note that, again, we prefer referring to “pregnant people” instead of “pregnant women,” but are using the terminology here that is common to most reports).

 What are the causes of pregnancy-related deaths in the U.S.? In an article in  Yale Medicine, obstetrician-gynecologist Kathy Katella tellingly wrote last May: “Perhaps surprisingly, both suicide and homicide are considered leading causes of death both during pregnancy and the postpartum period.” That mental health conditions are in fact the number one cause of pregnancy-related mortality in the U.S. comes as a surprise to many. According to a 2022 press release from the Centers for Disease Control and Prevention (CDC), 22% of pregnancy-related deaths occurred during pregnancy, 25% on the day of delivery or within seven days after delivery, and 53% between seven days to one year after pregnancy.

Suicide and Overdose are the Leading Causes

Of these pregnancy-related deaths, the CDC says, 23% were caused by mental health conditions, including suicide and overdose related to substance use disorder, more overall than any other cause of pregnancy-related death. There are, however, important race- and ethnicity-related differences. For White and Hispanic people, mental health conditions were the leading cause of pregnancy-related deaths, while for Black people the leading cause was cardiac and coronary conditions.

Some reports we viewed do not even mention mental health conditions as a leading cause of pregnancy-related death in the U.S. or point out the differences among Black, Hispanic, and White people in what causes these deaths. A  National Institute of Mental Health online post curiously includes suicide and drug overdose in a list of conditions associated with pregnancy-related mortality that it calls “unrelated to pregnancy.”

Yet, we know that depression during pregnancy and the postpartum period is a major cause of morbidity and can lead to suicidal ideation and suicide. It is extremely important then to point a spotlight on mental health conditions that are major causes of pregnancy-related death. This is especially the case because many of these deaths are preventable.

Screening for Depression and Substance Use is Essential

Screening for cardiac causes of pregnancy-related morbidity and mortality, like monitoring blood pressure, is obviously critical to prevent deaths. So is screening for mental health conditions. The  American College of Obstetrics and Gynecology practice guidelines call for pregnant persons to have prenatal and postnatal screening for depression and anxiety. So does the  Society for Maternal Fetal Medicine. Screening for substance use disorder should be added because of the risk for overdose deaths during and after pregnancy.

Pregnancy-related mortality could get worse because of abortion bans in, so far, 14 U.S. states. According to an article in  ProPublica, “A study by the University of Colorado estimates a 24 percent increase in maternal deaths if the United States bans abortion federally. They predicted the increase would be even higher for Black patients, at 39 percent.”

Some things could get a bit better as well. In August, the U.S. Food and Drug Administration announced approval of the first oral antidepressant medication for postpartum depression, zuranolone (brand name: Zurzuvae). The  medication is said to work much faster than currently available antidepressant drugs, as early as three days, and is given over the course of 14 days. The major adverse side effects appear to be sedation and headaches.

The approval of zuranolone for post postpartum depression reminds us that there are evidence-based, effective, and safe treatments available for mental health illnesses that occur during and after pregnancy. The American Psychiatric Association and the CDC Foundation have just issued a  toolkit for reproductive mental healthcare. We need to be more vigilant about screening pregnant people for depression and offering them accessible, effective interventions.That is the only way to cut down on the leading cause of pregnancy-related deaths.