Dangerous complications from labor and delivery nearly doubled in Massachusetts between 2011 and 2020, according to a new report, part of an increasingly dire national picture of maternal health as the United States continues to lead high-income countries in maternal mortality.
The complications, known as severe maternal morbidity, include unexpected and life-threatening events such as heart attacks, dangerously high blood pressure known as eclampsia, and extreme situations requiring life-saving interventions including the use of ventilators. The complications disproportionately affect communities of color and people with disabilities, according to the report, released Wednesday by the state Department of Public Health.
“Sobering findings continue to hammer the message that severe maternal morbidity and mortality are simply too high and the inequities baked in are not getting better over time,” said Dr. Allison Bryant, associate chief health equity officer at Mass General Brigham, who was not involved in the report.
DPH researchers analyzed all 678,382 deliveries in the state between 2011 and 2020 and found that rates of severe maternal morbidity climbed from 52.3 per 10,000 deliveries in 2011 to 100.4 per 10,000 deliveries in 2020, an average increase of 8.9 percent each year.
Although the rates increased for all populations during the 10-year period, women of color continue to face higher rates of complications, with Black women consistently experiencing the highest rates. Compared to white non-Hispanic women, Black non-Hispanic women experienced 2.3 times higher rates of complications on average during that time period, and Hispanic and Asian/Pacific Islander women experienced rates 1.2 times higher.
Measuring and understanding severe maternal morbidity is a key part of combating the maternal care crisis and preventing pregnancy-related deaths, particularly as many conditions of severe morbidity can be fatal if not addressed, according to the Commonwealth Fund, a foundation supporting independent research on health care issues. For every maternal death, there are 70 to 80 instances of severe maternal complications, researchers found.
Although Massachusetts has lower maternal mortality rates than most other states, according to the Centers for Disease Control and Prevention, the state is seeing the same increase in negative outcomes and racial disparities as the rest of the country. Earlier this year, a report from the CDC found a sharp national increase in maternal deaths, which spiked by 40 percent between 2020 and 2021. Rates among Black women soared from 55.3 to 69.9 deaths per 100,000 live births and were 2.6 times higher than those among white women.
“The fact that these rates and the gaps have continued to worsen over time indicates that Black non-Hispanic birthing people have not benefited from improved medical knowledge and care,” said Dr. Hafsatou Diop, DPH’s director of the Division of Maternal and Child Health Research and Analysis, in a statement. “It has been long recognized that racism — not race — is the risk factor, as it leads to discriminatory beliefs and behaviors toward Black non-Hispanic birthing people.”
The Massachusetts data also showed evidence that the already-wide gap between white and Black women is growing. According to the report, the rate of complications among Black non-Hispanic women in 2020 was 2.5 times higher that than of white non-Hispanic women, a 25 percent increase from 2011, when there was a twofold difference between the populations.
Rates were also found to increase with age, with complications highest among people 40 and older. Black women age 40 and older experienced by far the highest rates of any group: 238.6 per 10,000 deliveries.
The report also spotlighted troublingly high complication rates among people with disabilities. For every 10,000 deliveries, researchers found 131.6 instances of severe maternal morbidity among people with intellectual disabilities, 108.4 among those with impaired vision, and 94.6 among people with a disability that affects their mobility. Factors that drive higher rates of morbidity among people with disabilities “include active and passive denial of medical care, inequitable access to social determinants of health such as housing and proper nutrition, and higher rates of other risk factors such as smoking, stress, and clinically unwarranted obstetric intervention,” researchers wrote.
To address those issues, DPH is implementing several interventions, including a pilot program for remote blood pressure monitoring currently underway at Baystate Medical Center, Brigham and Women’s Hospital, and Boston Medical Center aimed at reducing serious complications caused by hypertensive disorders like eclampsia and preeclampsia, which are the leading cause for hospital readmission after labor.
It also supported the recommendations of a 2022 report by the Special Commission on Racial Inequities in Maternal Health, charged with investigating and studying methods to reduce racial inequities in maternal health in Massachusetts. These include creating legislation expanding access to midwifery care, improved mental health and housing support, and diversifying the perinatal workforce.
“[The new report] provides more evidence that the state Legislature has to do something,” said Eugene Declercq, professor at the Boston University School of Public Health. “Very little has happened since the publication of the report. If they truly want to address disparities, they need to take action.”
There’s no single policy change to reverse the increase in maternal morbidity, said state Representative Lindsay Sabadosa, but there is legislation under consideration that could help. A bill she has proposed would require MassHealth to cover the costs of hiring doulas, professionals trained to support and advise families during and after pregnancy, giving expecting parents better access to professionals with important insights into which symptoms are normal during pregnancy and which might need medical attention. Sabadosa is also a sponsor on a bill that would require insurers to provide full coverage, with no cost to parents, for all pregnancy care, including prenatal, childbirth, and postpartum care.
That bill is included in sweeping legislation sponsored by state Senator Liz Miranda that would, among other goals, give expectant parents uncomfortable giving birth in a hospital more choices to deliver babies at home or in birthing centers.
According to Miranda, reducing maternal morbidity means tackling the obstacles pregnant parents of color or in poverty face in accessing care for chronic conditions like diabetes, heart disease, and obesity that can cause complications during and after delivery. These barriers include a lack of transportation to get to large health care providers and community health centers not equipped to give adequate maternal care.
“In poor communities with poor transportation and poor access they’re not going to get their primary health care,” she said. “The first time they’re meeting the person who is delivering their baby is when they’re delivering their baby.”
State Senator Rebecca Rausch is lead sponsor of a bill to create a licensing process for midwives who assist births outside of hospitals, which would expand insurance coverage for their services. She agreed choice is a key component of maternal health. “It allows pregnant people and birthing people to choose their provider, to choose their setting, to not be restricted on who is allowed to come and visit,” she said.