By JD Heyman
The Centers for Disease Control and Prevention (CDC) have reported for years that U.S. women are more likely to die during pregnancy and postpartum than peers in other wealthy nations. While the findings have sparked debate, racial inequities in maternal mortality are consistently stark. And there’s consensus that nurses, with their central role as patients’ advocates, are key to crafting long-term solutions.
Maternal Deaths in the U.S by Year
2019: 754
2020: 861
2021: 1,205
~32.9 deaths per 100,000 live births
2022: 817
For nurse educators at the UC Irvine Sue & Bill Gross School of Nursing, the headline statistics reinforced the conviction that U.S. healthcare needs to be more dynamic, inclusive and responsive in a diverse society. “We all benefit from a holistic model that cares for the whole person and focuses on the disparities in healthcare,” says Leanne Burke, a midwife, associate clinical professor of nursing and director of teaching, excellence and innovation at the school. She points out that at UCI Medical Center, nurses and other caregivers now focus on providing a continuum of care that considers patient experience before, during and after pregnancy. With relevance to the current crisis, that patient-centered approach is critical to improving the American way of birth.
UC Irvine is located in Orange County, home to more than three million people from a vast array of cultures, ethnicities and economic circumstances; UCI Medical Center additionally treats patients from low-income areas of neighboring counties. Those populations reflect an emerging “minority majority” America that puts UC Irvine on healthcare’s frontlines. “We have our true north,” says Burke. “Healthy moms give birth to healthy babies, who grow up to be healthy adults, and every healthy adult builds a healthy community.”
As Orange County’s largest healthcare provider, UC Irvine is uniquely positioned to make an impact. In collaboration with the Sue & Bill Gross School of Nursing and UC Irvine’s medical schools, UCI Health is rolling out Black PEARL (Promoting Equity Anti-Racism and Love), which will integrate maternity
care with a network of doulas of color to reach at-risk populations. The $4.9 million federally funded initiative unites the university with First 5 Orange County, the state-supported organization overseeing the doula program.
The Black, Indigenous and People of Color community partners collaborating with faculty at the Sue & Bill Gross School of Nursing on maternal cardiovascular health promotion include:
ACIRAH Health
Arri Kenzo Foundation
BIRRTH Womxn OC
DoulaLove’sCreation
Dr. Curls for the Girls
HealYourLovePeriod
“Community maternal support services optimize health outcomes, and pregnancy and post-pregnancy care are improved for Black birthing patients and families when doulas and midwives are a part of the care team,” says Candice E. Taylor Lucas, associate clinical professor of pediatrics and co-director of the Program in Medical Education: Leadership Education to Advance Diversity—African, Black, and Caribbean (PRIME LEAD-ABC) at UCI Medical School. “Community birth workers provide continuity in care and holistic support, which extends beyond clinic and hospital walls into one’s home and community settings. The Black PEARL model acknowledges these facts and advocates for the importance of community engagement and integration in the care of pregnant people and their babies before, during, and after pregnancy.”
The effort is part of a wave of initiatives nationwide. Maternal mortality—defined by the World Health Organization as death while pregnant or within 42 days of the end of pregnancy from any cause related to its condition or management—is a problem with myriad causes. Historically, the U.S. healthcare system focused on acute pathologies in a hierarchy led by specialists. The result is a society that often views pregnancy as an abnormality rather than a normal experience. High rates of caesarean sections, about one in three American births, elevate risks. Research indicates that midwives, at the center of maternal care in much of Europe, are central to improving outcomes, but they remain less common in the U.S.
Cardiac and coronary conditions are the leading underlying cause of pregnancy- related deaths among non-Hispanic Black people.
CDC, 2022 report on 2017-29 data
Progress requires rethinking perinatal care. “Health is not just a physical thing. It’s also socioeconomic, psychological and cultural,” says Yuqing Guo, associate professor of nursing at the Sue & Bill Gross School of Nursing. Along with colleague Shelley Burke, assistant clinical professor at the school, Guo collaborates on a maternal cardiovascular health promotion program with Black, Indigenous, and People of Color community partners including ACIRAH Health, Arri Kenzo Foundation, BIRRTH Womxn OC, DoulaLove’sCreation, Dr. Curls for the Girls, and HealYourLovePeriod. “As a nurse scientist,” she says, “I’m focused on understanding what factors [influence mortality] and developing new methodologies.”
Deciphering the causes of maternal death in a diverse society of 335 million is daunting. In the 20th century, reducing infant mortality became a public health focus, while maternal health was often ignored. After a long decline, the maternal mortality rate, or MMR, climbed in recent decades. When the CDC reported a spike in maternal deaths in 2021—1,205, or 32.9 deaths per 100,000 live births, compared with 861 in 2020 and 754 in 2019—the 40 percent jump rocked the healthcare establishment. While that sharp rise is tied to the Covid pandemic (deaths have since declined to 2019 levels), the overall death rate is still far higher than in other affluent countries.
The pandemic exposed underlying comorbidities. Four in five U.S. pregnancy deaths are preventable, but diabetes, hypertension, poor diet, cardiovascular disease, mental health conditions, violence and poverty contribute to dangers. “Resources have now been directed to prenatal and postpartum care,” says Carmen Alvarez, a family nurse practitioner, midwife and associate professor of nursing at the University of Pennsylvania. “But the reason we have poor outcomes across the board is in part because birthing people are coming into pregnancy in less optimal health—a function of systematic societal stressors and disadvantage.”
Four in five U.S. pregnancy deaths are preventable.
CDC, 2022 report on 2017-19 data
The U.S. spends twice as much per capita on healthcare as other rich nations but most of those countries have near-universal coverage for basic healthcare, while America relies on a patchwork of private insurers and public services that vary by state. In 2006, California launched the California Maternal Quality Care Collaborative, a multi-stakeholder effort that helped cut maternal mortality by half. The state has the nation’s lowest MMR, at 9.7 deaths for every 100,000 births in 2021. That year, Mississippi, the poorest state, had 82.5 deaths per 100,000 births.
“It’s embarrassing for everybody,” says Renaisa Anthony, a San Jose, California OBGYN, and founder of MOMentum Park, which leverages technology, including social media, and grassroots networks to improve outcomes for women of color and their babies. As part of her work, Anthony launched SHERO (Shaping Healthy & Equitable Reproductive Outcomes), a perinatal program for Black families, for which Guo helps evaluate impact. Says Anthony: “Regardless of if you’re Black, if you’re White, or if you’re Asian in this country, it’s a dangerous place to bring new life into this world…add to that that Black women and women of Native American backgrounds have the worst outcomes and are more likely to die than any other group in the U.S. That’s dismal.”
After some researchers challenged CDC methodology (a 2024 study published in the American Journal of Obstetrics and Gynecology claimed findings were inflated by misclassified data), the agency responded by gathering more information from states. The MMR for Black and Native American women remains two to three times higher than that of Whites and Asians, a death rate comparable to Uzbekistan. “Deaths from pregnancy-related complications during and within one year of pregnancy remain too high, and unacceptable racial disparities persist,” the agency said in a statement. “It’s important that we improve surveillance to ensure timely and accurate data on pregnancy-related deaths and that we take action.”
The maternal mortality rate for Black and Native American women remains 2-3 times higher than that of Whites and Asians.
University of California, Global Health Institute
Critical partners in that effort are at-risk women themselves. Poor outcomes for Black mothers persist at every income level. “The deaths and complications for black mothers have much to do with discrimination and historical trauma,” says Guo. “Many famous and wealthy Black women have faced problems similar to the poor.” African American mothers are at highest risk for preterm births and preeclampsia, a potentially lethal blood disorder in pregnancy, but the causes are multifactorial. “Black women are dying from preeclampsia because they are not consistently supported by either healthcare or the community,” says Anthony. “What happens when a person presents with preeclampsia and they’re ignored and not listened to, or they’re afraid to even go to the hospital in the first place?”
MMR RATES ACROSS THE
U.S., 2021
Lowest:
California – 9.7 maternal deaths for every 100,000 live births
Highest:
Mississippi – 82.5 maternal deaths for every 100,000 live births
The underlying biological, social, and cultural triggers are deeply rooted; mistrust of institutions persists among all Americans and is generational in high-risk groups. With that in mind, the Indian Health Service, which serves Native American nations and Alaska Native groups, screens patients for a host of factors that includes hypertension and opioid use. The agency also stresses the importance of public health nursing and home visits in perinatal care.
For mothers identified as Hispanic on the CDC’s pregnancy checklist—a multiethnic category that accounts for 19 percent of the U.S. population and 34 percent of Orange County—the picture is evolving. Data show the mortality rate for self-identified Hispanics is rising faster than non-Hispanic Whites but is lower than in highest-risk groups. “We’re trying to get better accounting,” says Alvarez, who studies adverse childhood experiences (ACES) and intimate partner violence (IPV) among Latinas. “Within the last few decades or so, they have finally started disaggregating the data among Latinx groups.” A racial differential also seems to surface within that population, with Afro-Latinos having poorer health outcomes when compared to non-Black Latino groups.
Additionally, the children of immigrants have worse perinatal outcomes than their parents, perhaps because assimilation into our atomized society has a cost: old networks fray in ways that can be detrimental to health. That trend can also be seen among the native-born. A century ago, “granny midwives” looked after Black mothers in the South, but migration and the modernization of healthcare took birth out of communities.
The Sue & Bill Gross School of Nursing is a partner in the Black PEARL (Promoting Equity Anti-Racism and Love) model. Black PEARL is a four-year, $4.9 million maternal health project supported by the U.S. Department of Health and Human Services.
There were benefits for those with high-risk pregnancies, but the downsides are only beginning to be understood. “Pregnancy is normal; people should not be dying from the experience,” says Alvarez. “We’ve replaced the natural wonder of pregnancy with a clinical maze of jargon and bureaucracy, leaving expectant parents feeling alienated from their own bodies.”
Student nurses at the Sue & Bill Gross School of Nursing are taught not simply to identify symptoms but to engage with fellow human beings with experiences that predate pregnancy and endure after it—the “continuum of care” mentioned earlier. “No matter what we’re seeing in the clinical setting, we’re always trying to show the whole picture,” says Leanne Burke. “We’re all starting to see the historical brokenness of birth.”
The process of building a brighter future has already begun. At UC Irvine and across the country, providers have new resources to identify risk factors. More importantly, they are working with stakeholders to reform perinatal care. “Maternal mortality rates are an important indicator of the health and wellbeing of a society,” says Guo. “We’re now collaborating with community organizations and using technology to collect much-needed maternal health data, and this could help address a whole host of health issues across social groups that have been discriminated against.”
Anthony, Guo’s partner at SHERO, believes a “sisterhood of surveillance” can change the narrative. “We’ve so compartmentalized our healthcare system that people don’t have the sense of community investment in birth they should,” she says. “We can learn from other cultural experiences, not just complex problems that are sexy to talk about in medical schools. Everyone brings life into the world. We just got it wrong.”
Leanne Burke agrees. “I want to set my patient up for success,” she says. “There’s so much data to support the collaborative model—collaboration between the pregnant person, doula, nurse midwife, physician. I do think there is openness now toward that conversation.”
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JD Heyman writes extensively about healthcare, politics and ideas. He is founder and chief creative officer of CultureWay, a newsletter covering culture and current events for entertainment industry influencers.
