The Maternal-Mortality Crisis That Didn’t Happen

In 2019, the United States recorded twice as many maternal deaths as in 1999. You may have seen articles under headlines such as “More Mothers Are Dying” that frame this situation as a crisis. The notion that the U.S. has fallen behind other highly developed nations in addressing rising maternal deaths has filtered from academia into activist circles, newsrooms, social media, and everyday conversation. The general public might conclude: In America, pregnancy is getting deadlier by the year.

Recently, however, Saloni Dattani, a scholar with the research organization Our World in Data, reported definitively that measurement changes are largely to blame for the seemingly inexorable rise in maternal deaths. Things aren’t getting worse for women; we’re just getting better at tracking what’s going on.

That’s great news, of course—but the “crisis” argument might prove hard to shake, and that’s not great news. The persistent narrative that maternal deaths have been rising grows out of a counterproductive belief that doom and gloom is the only way to motivate change. Pregnancy is risky. The wealthiest country in the world could and should do more to prevent deaths and non-fatal harms, which are chronically ignored. Doing so will require being clear-eyed about what the evidence is telling us.

To address past concerns about underreporting maternal deaths, Dattani explains, states gradually updated their reporting standards to be more inclusive. The old definition of maternal mortality focused on deaths during childbirth or closely following birth; the new one expanded to include deaths during pregnancy or the first six weeks after the end of pregnancy. States also added a checkbox on death certificates indicating whether a woman had been pregnant at the time of death or within a year of her death. The reported maternal-mortality ratio on average doubled after the checkbox implementation. Because individual states changed their standards at different times over the course of a decade and a half, the national maternal-death count seemed to keep rising.

[Annie Lowrey: The case for spending way more on babies]

Medical professionals have always had to make subjective determinations about causes of death. The lack of objective standards became a familiar issue during the coronavirus pandemic: If a deceased patient had several comorbidities, without which they likely would have lived, was the cause of death the virus or their other underlying health conditions? It’s a tricky question.

In some cases, when a patient dies during or soon after pregnancy, the proximate cause of death is plainly related to childbirth. In others, causation is harder to establish; pregnancy may exacerbate an existing condition or have no clear connection at all. But the new checkbox lumps all of those cases together. And so, in trying to correct for underreporting maternal deaths, we may actually be overreporting them.

Although Dattani’s findings have prompted some pushback from other researchers, other peer-reviewed studies back her up. She cites research from as far back as 2017 about the effects of the checkbox. One skeptical ob-gyn turned blogger was throwing cold water on the crisis narrative in 2010. So why is it still so firmly rooted in the public discourse?

For many commentators, correcting the record on a delicate or emotionally fraught topic simply feels awkward. You risk sounding as if you’re trivializing pregnancy and the costs women shoulder to have children. In March, the American Journal of Obstetrics and Gynecology published a study arguing that the “recent changes in maternal mortality surveillance, such as maternal death identification based solely on pregnancy checkbox information on death certificates, have led to an overestimation of maternal mortality.”  

Christopher M. Zahn, the interim CEO of the American College of Obstetricians and Gynecologists, wrote a lengthy statement in response, arguing that “reducing the U.S. maternal mortality crisis to ‘overestimation’” is “irresponsible and minimizes the many lives lost and the families that have been deeply affected.” Why? Because it “would be an unfortunate setback to see all the hard work of health care professionals, policy makers, patient advocates, and other stakeholders be undermined.” Rather than pointing out any major methodological flaw in the paper, Zahn’s statement expresses the concern that it could undermine the laudable goal of improving maternal health.

Similar argument are rarely stated aloud but are highly influential behind the scenes: If you want to help people, you should show how they are in crisis. Anything that makes others more complacent about their problem is working against the victims.

This dynamic is evident well beyond the maternal mortality debate. A couple of years ago I reported on dire COVID-related economic predictions that didn’t pan out: Among them were the eviction tsunami, in which 30 million or more renters would be kicked out of their homes, and the “she-cession,” wherein women would drop out of the labor market en masse.

One problem, my article noted, is that experts and activists alike have policy preferences—such as a preference for greater housing assistance for people at risk of eviction—that influence what they observe: “Some advocates may have regarded the coronavirus pandemic as an opportunity to shoehorn in important social policies that they felt were long-justified, and, to a certain extent, they saw in the data what they wanted to see.” One sociologist told me that high estimates of potential evictions may have been useful “from a lobbying standpoint.” “It was helpful to the movement of activists who were pushing for relief measures to be put into place to cite some of these larger figures,” a housing analyst told me. At the time, my assertion that these predicted catastrophes had not come to pass prompted a significant backlash.

Still, many experts and journalists do push back on unwarranted crisis narratives. In a persuasive recent report headlined “The Child Care Cliff That Wasn’t,” Vox’s Rachel Cohen wisely argued that “advocates don’t need to rely on cataclysmic economic predictions to make the case for better and more humane family policy.”

For policy advocates, though, the problem with downplaying or ignoring evidence that things aren’t as bad as expected is threefold.

First, you lose credibility with elected officials if you’re always telling them that something is in crisis and then the facts show otherwise. If you’re not the one to update them when more encouraging evidence emerges, they’ll begin to write off advocacy organizations as hysterical and untrustworthy. Elected officials and their staff aren’t in the business of vetting your arguments; they’ll just tune you out.

Second, misinformation is destructive on its own terms. Democracy—and by extension the free press—is supposed to work by clarifying what is true to our best approximation. Muddying that goal because you fear that the truth will lead people astray is a mistake. It undermines trust in institutions and makes people think that scientific research and news reporting are motivated by activism more than truth.

[Emi Nietfeld: America’s IVF failure]

Finally, by drumming up a crisis where none exists, you may make people’s lives worse in concrete ways. I want kids. I have a lot of friends who want kids. We know that it’s risky, but the widespread discussion around the maternal-mortality rate has made me more fearful of pregnancy and childbirth than the numbers would indicate. The constant drumbeat that maternal mortality is “commonplace” and that pregnancy is “deadly” doesn’t empower me with information to make my own decisions. It just stresses me out.

I’m glad we now openly acknowledge the costs of pregnancy and childbirth. But reality is scary enough. We don’t need to rely on flawed data to make the case for change.