US preterm birth and maternal mortality rates are alarmingly high, outpacing those in all other high-income countries

Every two minutes, in about the time it takes to read a page of your favorite book or brew a cup of coffee, a woman dies during pregnancy or childbirth, according to a February 2023 report^[1] from the World Health Organization. The report reflects a shameful reality in which maternal deaths have either increased or plateaued worldwide between 2016 and 2020.

On top of that, of every 10 babies born, one is preterm – and every 40 seconds, one of those babies dies^[2]. Globally, preterm birth is the leading cause^[3] of death in children under the age of 5, with complications from preterm birth resulting in the death of 1 million children under age 5 each year.

The WHO has designated preterm birth an “urgent public health issue^[4]” in recognition of the threat it poses to global health.

Those numbers reflect a worldwide problem, but the U.S. in particular has an abysmal record on both preterm births and maternal mortality: Despite significant medical advancements in recent years, the U.S. suffers from the highest maternal mortality rate^[5] among high-income countries globally. And the 2022 March of Dimes Report Card, an evaluation of maternal and infant health, gave the United States an extremely poor “D+” grade^[6]. That data also revealed that the national preterm birth rate spiked to 10.5% in 2021, representing a record 15-year high.

We are maternal fetal medicine experts^[7] and scholars of women’s health^[8] who focus on treatments and programs to help women have better maternal health, especially those that reduce preterm birth.

Our Office of Women’s Health^[9] leads the SOS Maternity Network^[10], which stands for the Synergy of Scholars in Maternal and Infant Health Equity, a research alliance of maternal fetal medicine physicians across the state of Michigan.

Maternal and infant death are the worst possible outcomes of pregnancy^[11]. These numbers make clear just how crucial it is to change this trajectory and to ensure all Americans have practical access to quality reproductive health care.

Dire state of maternal health care

Tori Bowie, an elite Olympic athlete, tragically lost her life^[12] at just age 32 because of complications of pregnancy and childbirth.

Bowie’s story drives home the devastating state of maternal health in the U.S. Maternal mortality is a sad and unexpected ending to the often beautiful journey of pregnancy and childbirth. It means that a baby has to go without its mother’s love, care and comforting touch and at the same time the family has to mourn the sudden loss of their loved one. Unless substantial progress is made for lowering maternal deaths, the lives of over 1 million more women^[13] like Bowie could be at risk by the year 2030, if current trends continue.

Unfortunately, the maternal and infant health crises are worsening^[14] in the U.S., and this association is far from being an unfortunate coincidence. There is an important link between infant health and maternal health, as they both rely on the accessibility and quality of health care^[15]. These U.S. rates have been increasing since 2018, when improved reporting of maternal deaths was adopted.

In 2020, the U.S. maternal mortality rate was 23.8 deaths per 100,000 live births – nearly three times as high as the country with the next-highest rate of 8.7 deaths per 100,000 live births, France.

The number of women who died within a year after pregnancy more than doubled in the U.S.^[16] over the 20-year period of 1999 to 2019. And there are significant racial disparities in this statistic: The highest number of pregnancy-related deaths were recorded among Black women, increasing from 26.7 per 100,000 births to 55.4 per 100,000 during that same time period.

Worse yet, the Centers for Disease Control and Prevention has determined that about 84% of such maternal deaths^[17] are preventable^[18].

Tragic rates of infant mortality and preterm birth

Notably, in 2020 the U.S. also experienced the highest infant mortality rate^[19] of all high-income countries. The U.S infant mortality rate was 5.4 deaths per 1,000 live births, in contrast to the 1.6 deaths per 1,000 live births in Norway, the country with the lowest infant mortality rate.

You may have heard the term “preemie” before, perhaps when a loved one delivered a baby more than three weeks before the expected due date. A premature birth is one that occurs before the 37th week of pregnancy. Preterm-related causes are responsible for 35.8% of infant deaths in the U.S^[20].

Preterm babies are often not fully physiologically prepared for delivery, which can result in a range of medical complications. While preterm births lead to rising infant mortality rates, even those who survive can face health problems such as breathing difficulties, problems with feeding, significant developmental delay and more throughout their lives^[21]. Preterm birth also presents additional risks for the mother, as women who deliver preterm are at higher risk for cardiovascular complications later in life.

Thus, preterm birth takes a significant toll^[22] on families and their communities, with serious ramifications in medical, social, psychological and financial contexts.

Maternal care during pregnancy is key

Maternal care appointments and screenings are essential to prevent prenatal complications and a women’s increased risk for developing long-term complications such as cardiovascular disease^[23]. For that reason, patients should secure prenatal care as early as possible in the pregnancy and continue to regularly have prenatal care appointments.

Preterm birth can occur unexpectedly in an otherwise normal-seeming pregnancy. It looks no different from the early signs of a typical labor, except that it occurs before 37 weeks of pregnancy. The symptoms of premature labor can include contractions, unusual vaginal discharge, the feeling of pressure in the pelvic area, low dull backache or cramps in the uterus or abdomen. A person who experiences these symptoms during pregnancy should seek medical attention.

Some people are more predisposed to preterm birth based on individual risk factors like substance use, multiple pregnancy – such as twins – infections, race, a medical history of prior preterm delivery and heightened stress levels. Our research team and others have shown that COVID-19 is a known risk factor^[24] for preterm birth.

It’s important to speak with your primary care provider to assess how your current health may affect future pregnancy and whether lifestyle changes – such as adopting a healthy diet and active lifestyle and avoiding smoking and drinking alcohol – can improve your likelihood of a full-term delivery.

Preterm birth prevention

The more that pregnant women take ownership of their health and ask their doctors to perform a simple cervical length screening during their pregnancy, the earlier preterm birth can be detected and prevented and the more lives will be saved.

Evidence has shown that patients with a short cervix face a greater risk of the cervix’s opening too early^[25] in pregnancy, resulting in preterm birth and other adverse outcomes. The cervix is the lower section of the uterus, which connects to the vaginal canal. As pregnancy progresses, it stretches, softens and ultimately opens in the process of normal childbirth.

All patients – even those who are seemingly low risk – should ask their doctors to have their cervical length checked by transvaginal ultrasound during pregnancy between 19 and 24 weeks. A short cervical length indicates a high risk of a premature delivery. Luckily, there are treatments available, such as vaginal progesterone, which can prevent preterm birth in women found by ultrasound to have a short cervix. This treatment can reduce the risk of preterm birth by more than 40%^[26].

We are optimistic that with greater awareness of these issues and a shift in the focus to evidence-based practices coupled with increased access to vulnerable populations, the U.S. can begin to give women like Bowie and so many others the health care they and their infants deserve.

This article has been updated to highlight the most recent trends in maternal mortality that were reported on July 3, 2023, and to highlight the stark racial disparities.

References

1. ^{^} February 2023 report (www.who.int)
2. ^{^} one of those babies dies (www.who.int)
3. ^{^} leading cause (www.who.int)
4. ^{^} urgent public health issue (www.who.int)
5. ^{^} highest maternal mortality rate (tcf.org)
6. ^{^} an extremely poor “D+” grade (www.marchofdimes.org)
7. ^{^} fetal medicine experts (physiology.med.wayne.edu)
8. ^{^} scholars of women’s health (womenshealth.wayne.edu)
9. ^{^} Office of Women’s Health (womenshealth.wayne.edu)
10. ^{^} SOS Maternity Network (today.wayne.edu)
11. ^{^} worst possible outcomes of pregnancy (doi.org)
12. ^{^} tragically lost her life (www.npr.org)
13. ^{^} 1 million more women (www.who.int)
14. ^{^} maternal and infant health crises are worsening (www.marchofdimes.org)
15. ^{^} accessibility and quality of health care (www.ajmc.com)
16. ^{^} more than doubled in the U.S. (doi.org)
17. ^{^} 84% of such maternal deaths (www.cdc.gov)
18. ^{^} are preventable (theconversation.com)
19. ^{^} highest infant mortality rate (www.ajmc.com)
20. ^{^} 35.8% of infant deaths in the U.S (www.marchofdimes.org)
21. ^{^} throughout their lives (www.cdc.gov)
22. ^{^} takes a significant toll (doi.org)
23. ^{^} long-term complications such as cardiovascular disease (doi.org)
24. ^{^} COVID-19 is a known risk factor (doi.org)
25. ^{^} cervix’s opening too early (doi.org)
26. ^{^} reduce the risk of preterm birth by more than 40% (doi.org)