On paper, one of the first deaths reviewed by Mississippi’s maternal mortality board looked like an accidental overdose. Reviewers could have stopped there, called it a tragic loss and added it to the list of the state’s 600 annual overdose fatalities, but not related to pregnancy.
But they didn’t stop there.
“We really wanted to take this as an opportunity to look at all preventable deaths around pregnancy — not just those technically caused by pregnancy,” said Dr. Charlene Collier, an OB-GYN in Mississippi and director of the state’s Maternal Mortality Review Committee, a board of physicians and public health experts tasked with studying why and how pregnant and postpartum Mississippians die.
When Collier dug deeper into the patient’s life and pregnancy, she unraveled a story that exposed a series of systemic failures. Records showed the patient had a history of depression and sexual assault as a teen. She delayed prenatal care. She also tried to quit her addiction to prescription pills, but didn’t have nearby treatment support. During pregnancy, she was arrested and locked up for drug possession and missed prenatal visits. Three weeks after her release from jail she was found dead of an apparent overdose in a friend’s apartment.
The more Collier found, the more clear it became: The woman’s substance use disorder had been preventable at multiple stages, but the systemic support wasn’t there — and it only got worse during pregnancy. And her death, at 22, was preventable too.
Overdoses and suicide are leading causes of maternal mortality. And over the last two decades, mental health disorders like severe depression and anxiety, as well as suicide, have all increased among pregnant and postpartum people, according to new research from the American Medical Association.
Yet most states don’t specifically track suicides or overdoses as pregnancy-related, despite their increasing prevalence. Mississippi is one of only a handful of states nationwide that counts suicides as part of its state-created Maternal Mortality Review Committee.
“If you dont look and don’t ask questions, you just write it off. A medical record isn’t a narrative, it’s just a checked box.” Collier said. “We’re trying to be inclusive and center the most marginalized people by prioritizing interviews to get a look at the whole person.”
Like the rest of the country, race disparities in perinatal deaths — ones that occur just before or after giving birth — are stark: Black Mississippians are nearly three times more likely to die during or after pregnancy than their white counterparts, regardless of socio-economic status. Many experts have for years pushed practitioners to face unconscious bias and systemic racism in U.S. healthcare, but it’s been an uphill battle, Collier said: “How do you measure the impact of racism? You have to listen those affected.”
Looking beyond the medical record informed not only Collier’s own examination of the data, but also how she presented it. She was sure to include in the first few paragraphs of her report for policymakers: “Suicides and overdoses accounted for approximately 11% of all maternal deaths.”
And the report’s subsequent recommendation: “Mississippi should increase access to mental health and substance-use services statewide for pregnant and postpartum women.” There are only two facilities in that state specializing in perinatal patients seeking addiction treatment, totaling just 44 beds.
The extent of the problem
In many ways, COVID-19 exposed deeper social inequities that have lurked for decades. Depression, for instance, skyrocketed for perinatal people.
In 2020, fatal overdoses reached record highs in the U.S., killing more than 92,000 people — a 30 percent increase from the previous record. The South drove much of the increase, particularly Mississippi, Louisiana, Tennessee, and Texas.
After stabilizing for a few years, national maternal mortality hit a record high in 2020. American women of reproductive age have the highest rate of mental health needs, all of which contribute to preventable pregnancy-related deaths, according to a new report from the Commonwealth Fund. Too, because there’s a lack of comprehensive data on perinatal trans and non-binary people, studies are likely understating the prevalence and risk of mental illness, and further undercounting pregnancy related deaths.
Already the highest of any developed nation — double that of France, the country closest behind, and 10 times the rate of New Zealand — perinatal deaths have risen about 40 percent since 2018.
While many people think of maternal mortality as a death during or just after birth, most pregnancy-related deaths occur well after birth — a sign that many of these deaths are preventable systemic failures, not caused by sudden complications. Across the nation, more than half of perinatal deaths happen postpartum with 1 in 4 occurring between six weeks and one year after delivery, a time when many have lost health insurance.
Much like cardiovascular disease, the leading cause of maternal mortality in Mississippi, suicides and overdoses are also preventable, Collier says.
Experts say the concurrent rise in maternal mortality and mental health complications not only create a perfect storm, they overlap. Though it’s hard to track, at least in part due to lacking support and diagnostics, upwards of 1 in 5 postpartum people experience depression.
A 2019 paper recognized depression, intimate partner violence, and substance use disorder as three of the most common risk factors for perinatal suicide. Other studies show nearly 1 in 4 reported recent suicidal thoughts.
“Is it a surprise to anyone that maternal mortality got worse in COVID? Of course it got worse. Obviously [the pandemic is] going to have a detrimental effect on mental health too, when we don’t feel safe to birth in a healthy way,” said Sinsi Hernández-Cancio, vice president for health justice at the National Partnership for Women and Family. “It boils down to: We don't have the data. Those of us in the communities know it’s a problem, but we aren’t tracking it.”
What’s being done?
Some Southern states are close to implementing rare bi-partisan policy changes. In Georgia, a behemoth bill addressing the lack of mental health insurance coverage and provider shortage is headed to Gov. Brian Kemp’s desk. Georgia and North Carolina extended Medicaid health insurance to postpartum people for a year postpartum. But in Mississippi, for the second year in a row, the statehouse failed to leverage bipartisan support to extend postpartum Medicaid from 60 days to a year after birth.
Though few states investigate overdoses and suicides as pregnancy-related, those like Mississippi that do are finding stark patterns. In California, overdoses are the second leading cause of postpartum death and suicide was seventh. Tennessee’s maternal death review tracked a 400 percent increase in suicides, from 2 to 10, in four years.
But most maternal mortality review committees either include suicide with mental health disorders, count neither, or consider these deaths unrelated to pregnancy. In a review of all southern states’ maternal mortality reports, only two investigated suicides. Five committees acknowledged it was a gray area, two lumped them in with all mental health disorders, and two — South Carolina and Louisiana — didn’t mention suicide at all.
And that inconsistency in the data collection is part of the problem, said Crystal Schiller, psychotherapist at the University of North Carolina Center for Women’s Mood Disorders.
“As an individual provider, it's easy to get focused on the patient who's coming through our door, but those are the patients with resources.” Schiller said. “There's so many gaps everywhere — it’s inaccessible to most women because it's expensive. And that leaves a huge swath of the population without access to the care that they most want, that has been shown to work.”
Despite the need, there is very little inpatient support for pregnant or postpartum people with depression: Only three inpatient psychiatric facilities for perinatal people exist in the U.S., including Schiller’s facility where she directs the inpatient unit.
Data collection will likely only be standardized if state legislatures or the U.S. Centers for Disease Control and Prevention advocate for it. Though the CDC excluded substance use disorder and suicide in its initial maternal death reviews, it later made efforts to address them, calling the association between mental illness and mortality "complicated.”
Back in Mississippi, Collier knows this. That’s why she pushes for their inclusion and more robust scrutiny of the circumstance behind each maternal death, which hopefully leads to more compassionate medical care. “A medical record is not a reflection of someone's experience. It's a reflection of what got documented by healthcare.”
Editor's note: This story includes several references to maternal mortality, a term that is standard and common in data collection and reporting. When not referring specifically to data, we use language to include all birthing people.
If you or someone you know is struggling with mental health or suicidal thoughts, round-the-clock help is available through the National Suicide Prevention Lifeline at 1-800-273-8255, the Veterans Crisis Line and Military Crisis Line at 1-800-273-8255, and the Crisis Text Line by texting “hello” to 741741.