CA pregnancy deaths are down to pre-COVID levels, but Black moms still face high risk
Maternal deaths are finally back down to their prepandemic levels in California — and the numbers hold some lessons for future pandemics, investigators said.
The California Pregnancy-Associated Review Committee, which convenes experts under the leadership of the state’s departments of Public Health and Health Care Services to look into the causes of pregnancy- and birth-related deaths, finished reviewing 2023 maternal deaths last year.
The maternal death rate had soared in 2020 and 2021 especially. Pregnancy suppresses the immune system, and dozens of pregnant women or women who had recently given birth died from COVID in California. But by 2023, the death rate stabilized to its pre-COVID level of 12 deaths per 100,000 live births. As the California Maternal Care Quality Collaborative reported, however, the Black maternal death rate has also gone back to a prepandemic “normal” — but that is still four times as high as the overall rate. Black women also suffered disproportionately from COVID infections.
Dr. Kimberly Gregory, who chairs the California Pregnancy-Associated Mortality Review committees, attributed the drop in part to the COVID vaccine, which is recommended during pregnancy. Medical professionals also learned how to better treat COVID cases. Gregory said the structural adaptations contained lessons for the next pandemic, noting that in another pandemic fears about fetal health should not be prioritized over protecting maternal health.
“The biggest lesson is we can’t save the baby if we don’t save the mom,” said Gregory, who is also a professor of obstetrics and gynecology at Cedars-Sinai Medical Center. She explained that some healthcare professionals hesitated to offer pregnant people new treatments out of fear that they might cause harm to the fetus.
In the next pandemic, “We need to be aggressive about rolling out those improvements and those interventions and innovations into pregnant people instead of being concerned about, ‘Oh, she’s pregnant, we can’t do that,’ or, ‘Oh, she’s pregnant: That might impact the baby,’” Gregory said. “Something as simple as the vaccine, it was a real call to arms by the obstetricians and (the American College of Obstetricians and Gynecologists) and the Society of Maternal-Fetal Medicine that said, ‘Why are you denying this segment of the population this medication that works?’”
More than 100,000 Californians died of the virus between 2020 and the fall of 2022, with a huge spike in 2021. In that year, the state saw 21.6 maternal deaths per 100,000 live births, but only 12.6 when researchers excluded people who died of COVID. None of the pregnant or recently-pregnant Californians who died of COVID from were fully vaccinated.
From 2019 to 2021, COVID led to 58 maternal deaths; of the dead, seven — about 12% — were Black. The Census, which records people who report their race as solely Black, found that they represented only 6% to 7% of the state’s population.
What’s behind California maternal deaths?
Amid the overall drop to prepandemic numbers, Black maternal mortality dropped back to its alarmingly high prepandemic level: 47.9 deaths per 100,000 live births. The rate is four times higher than the overall death rate.
The rates include deaths due to medical causes “related to or aggravated by the pregnancy or its management,” wrote Dr. Christine Morton, who manages the California Pregnancy Associated Mortality Review; the number would not include suicides, homicides, overdoses or most other injuries. Data from the Centers for Disease Control and Prevention show that homicide is the leading cause of death for people who are pregnant and up to 42 days postpartum in the U.S.
As COVID ebbed due to an aggressive public health response and improved treatments, including vaccines, data show that cardiovascular disease became the leading cause of maternal deaths.
Black women, Gregory said, seemed to have a higher incidence of peripartum cardiomyopathy, a rare form of heart failure arising during or shortly after pregnancy. White women, meanwhile, had higher incidences of heart disease related to methamphetamine use.
Gregory said that she’s excited about many of the interventions and California Maternal Care Quality Collaborative “toolkits” being rolled out in hospitals across the state to address recommendations from experts reviewing maternal deaths. The hemorrhage toolkit and emergency room trainings on postpartum blood pressure, she said, had “been a huge success.”
“Standardizing the treatment of hemorrhage, standardizing the measurement of blood loss so that it’s not what you think, it’s what you know,” she said. With the toolkit that’s been deployed statewide, she said, “Every hospital has a hemorrhage protocol; they have a hemorrhage cart so that the medication you need is on the floor and immediately available.”
For high blood pressure, or hypertension, investigators realized that women sometimes went to the emergency room with blood pressure levels that didn’t seem particularly high — higher than 160/110 — but were concerning in someone who had recently given birth. Obstetricians and other maternal healthcare providers were well aware, but primary care and emergency room providers weren’t always flagging their blood pressure because they didn’t always ask whether the patients were postpartum.
The management of hypertension is now included in continuing medical education for both OB-GYNs and emergency room doctors.
“We’ve been able to significantly lower the number of deaths associated with preeclampsia,” Gregory said. “This has been demonstrated pretty significantly among Black women, as well.”
