If it does not count, it is not counted.
“If it does not count, it is not counted.”This is an adage that succinctly describes a central issue for maternal mental health. The bane of reproductive psychiatrists’ work is the shocking lack of data in our field. As clinicians and educators, we work around the lack of evidence, we teach how to critically interpret the studies we do have, and we fight the battle against generalizations. We clarify with disclaimers and provide guarded assurances. Despite the effort, there are often situations where we have no way to provide a clear evidence-based recommendation. We need more high-quality data in the field.
The data we do have does not accurately capture outcomes for maternal health in the United States. For example, the maternal mortality ratio (MMR) is a generally quoted statistic to reflect maternal health. This rate is reported by the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics and National Vital Statistics System (NVSS). Although this data set is frequently cited, it is incomplete.
In this statistic, maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”1 The maternal death captured by the MMR does not include causes of death related to mental illness such as suicide or overdose. They are excluded in the ICD-10 death codes used to classify maternal deaths. They are not counted.
In the CDC dataset, maternal death by suicide falls under the accidental and incidental causes. This definition was set by the World Health Organization (WHO) and is followed internationally. Mortality due to mental illness is not counted. Despite this, the US MMR has increased from 17.4 deaths per 100,000 pregnancies in 2018 to 23.8 in 2020. For reference, France, Canada, the United Kingdom, Australia, Switzerland, Sweden, and Germany all have MMR <10.
The other national reporting system in the United States is the Pregnancy Mortality Surveillance System (PMSS). Although the PMSS has a broader definition and time period for classifying death, it continues to exclude significant causes of mental health-related mortality. In PMSS, a pregnancy-related death is defined as “the death of a woman while pregnant or within 1 year of the end of pregnancy regardless of the outcome, duration, or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management.” The specific categories of deaths reported by PMSS include “other cardiovascular conditions, infection or sepsis, cardiomyopathy, hemorrhage, thrombotic pulmonary or other embolism, cerebrovascular accidents, hypertensive disorders of pregnancy, amniotic fluid embolism, anesthesia complications, [and] other non-cardiovascular medical conditions.” The PMSS website does not mention suicide or overdose-related death or count either one as a category of mortality.2
Deaths due to mental illness—namely suicide and overdose—are not counted by these 2 main sources of maternal mortality data. Because they are not counted, we are missing crucial information, and we lack data on how to best address these causes of mortality. We need this data to be able to effectively drive national and state-level initiatives, policies, and funding.
One of the ways the maternal health community has tried to better understand the full context of maternal mortality is via data provided by maternal mortality review committees (MMRCs). MMRCs are multidisciplinary committees that convene at the state or local level to comprehensively review deaths of women during or within a year of pregnancy. MMRCs use both clinical and non-clinical information to get a richer understanding of the events leading to each death. MMRC data includes the category of “mental health conditions.” This category includes “deaths due to suicide, overdose/poisoning, and unintentional injuries as determined by the MMRC to be related to a mental health condition.”
There are various challenges in datasets that are collected by states, with the national perspective being a primary challenge. The only current dataset we have to extrapolate national trends from is from 2008 to 2017. A total of 14 states’ MMRCs voluntarily shared data with CDC. The trends demonstrated by this set show that approximately 1 in 3 deaths among women during or within a year of pregnancy were pregnancy-related, with 23.6% of deaths occurring in the 43- to 365-day window. Mental health conditions were noted to be responsible for 8.8% of pregnancy-related deaths.3
The data that we do have more readily available is in reference to maternal mental health morbidity. Various datasets exist to point out the high prevalence of mental illness in the perinatal time period, with the latest estimates indicating that at least 1 out of every 5 new mothers in the United States will experience some form of mental health concern.4-6 The United States has about 3.6 million children born every year. This suggests that there are about 750,000 mothers out there who need support, treatment, and assistance. Among those affected, 75% go untreated.7
We have also established the impact of untreated maternal mental health conditions on both the woman and the child. Per the data that we do have, we know that these patients are more likely to have comorbid substance use8 and poor nutrition. These patients are also at risk of having breastfeeding challenges and to have fewer positive encounters with their baby.9,10 The impacts on the children are also well established. We know that the children born to and/or raised by mothers with untreated maternal mental health conditions are at high risk for low birth weight, preterm birth, and excessive crying.10-12 They have also been demonstrated to have longer NICU stays.13 Additionally, the parent-child relationship can be impaired and give rise to adverse childhood experiences that have already demonstrated impact on the long-term health of children.14
Preventing maternal mental health morbidity and mortality is a complicated, yet vital task. Maternal health is correlated with various factors including socioeconomic status, disease burden, and population dynamics. It is a poignant representation of the state of the country. The problem is multifactorial; it needs to be addressed on various levels, and we need systemwide organized and strategic efforts. Our patients are counting on us to address this issue. At minimum, we need to have accurate accounting of the problem, policies to promote continuous health coverage, and national standards for timely screening and assessment of mental health conditions.
Various professional societies, alliances, and organizations are developing educational materials, policies, and processes. It is essential for these groups to have ongoing support and ability to coordinate their efforts.
We need to start counting, and the count needs to change.
Dr Kalia is an associate professor of psychiatry at the University of Arizona College of Medicine – Tucson. Dr Kalia wears many hats: She is a perinatal psychiatrist and an educator; she serves as the associate training director for the Department of Psychiatry Residency program; and she is the director of the Psychiatry Department’s Perinatal Psychiatry Track.
1. Hoyert DL. Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention. Last reviewed February 23, 2022. Accessed May 20, 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
2. Pregnancy mortality surveillance system. Centers for Disease Control and Prevention. Last reviewed April 13, 2022. Accessed May 20, 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#trends
3. Pregnancy-related deaths: data from 14 U.S. maternal mortality review committees, 2008-2017. Centers for Disease Control and Prevention. Last reviewed April 13, 2022. Accessed May 20, 2022. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html
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13. Cherry AS, Mignogna MR, Roddenberry Vaz A, et al. The contribution of maternal psychological functioning to infant length of stay in the Neonatal Intensive Care Unit. Int J Womens Health. 2016;8:233-242.
14. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245-258.