Sherri Willis-Prater’s baby boy was 2 months old and she was about to return to her job in a Chicago school cafeteria. But as she climbed the short flight of stairs to her kitchen one night, she almost collapsed and gasped.
At the hospital, Mrs. Willis-Prater, who was 42 at the time, was hooked up to a ventilator that pumped air into her lungs. Her heart, doctors said, was operating at less than 20 percent of its capacity. She had developed a rare form of heart failure that develops after pregnancy.
The diagnosis was the last thing she expected to hear. After giving birth, Ms. Willis-Prater thought, “I made it to the finish line,” she recalled in an interview. “I don’t have to worry about anything anymore.”
Most people consider labor and birth to be the most dangerous part of pregnancy. But new scientific research challenges this assumption, finding that substantial risks persist for an entire year after birth itself. The deadliest time for mothers is actually after the baby is born.
And for every woman who dies, an estimated 50 to 100 women experience serious complications that can leave them with lifelong health problems. The number is growing as more American women gain weight and hypertension and diabetes become more common.
More and more women are putting off having children until later in life, making it more likely that they start a pregnancy with chronic medical conditions that can lead to complications.
The new figures come amid a worrying rise in deaths among pregnant women and new mothers in the United States, which has the highest maternal death rate in the industrialized world. Rates rose during the pandemic to 32.9 deaths per 100,000 live births in 2021, up from 20.1 per 100,000 in 2019. Rates for black and Native American women are two to three times higher than those for white women.
But those numbers reflect a traditional definition of maternal mortality, deaths that occur during pregnancy or up to six weeks after birth.
A greater magnitude of the problem came to light in September, when the Centers for Disease Control and Prevention took a more comprehensive look at maternal deaths, analyzing a full year after childbirth, including deaths from mental illness.
Based on data from 36 states on 1,018 pregnancy-related deaths between 2017 and 2019, the CDC concluded that about a third of those occurred during pregnancy or on the day of delivery, and about another third before the baby turned six weeks old. A full 30 percent occurred from then until the baby’s first birthday, a period that had not been a focus in maternal mortality research.
The data has led to calls for closer follow-up care and more support for new mothers during what’s been dubbed the “fourth trimester,” with a special focus on vulnerable women.
“Our approach from birth was that the baby is the candy and the mother is the wrapper, and once the baby is out of the wrapper, we toss it aside,” says Dr. Alison Stuebe, a professor of obstetrics and gynecology at the University of North Carolina School of Medicine. “We have to recognize that the packaging is a person — mothers get really sick and die.”
The leading causes of maternal death among white and Hispanic women are mental illness leading to suicide or fatal overdoses. In Asian women, bleeding is the main cause.
Among black women like Mrs. Willis-Prater, heart disease was the leading cause of death. High blood pressure, a predisposing factor, is more common in black women and they are more likely to have poor access to health care, a legacy of both poverty and racism.
The risk of later maternal death — from six weeks to a year after giving birth — is 3.5 times higher in black women than in white women.
Medical practice often changes slowly. But the numbers are accelerating revisions to Medicaid, the health plan that covers low-income Americans, which includes more than 40 percent of pregnant women in the United States.
Thirty-three states and Washington, D.C., have expanded Medicaid coverage for new mothers to a full year after giving birth, so women are covered while they recover from pregnancy, and eight other states plan to do so, according to the Kaiser Family Foundation.
Three states, including Texas, are expanding only limited coverage, and six — including Arkansas, which has one of the highest maternal mortality rates in the country — have no plans to expand Medicaid coverage, according to the foundation.
Other initiatives include a new law in New Jersey requiring emergency room physicians to ask women of childbearing age about their pregnancy history. Some illnesses that bring women to the hospital can be diagnosed more quickly if doctors know they are new mothers.
In North Carolina, caregivers earn a $150 bonus when a patient comes for a postpartum visit. Historically, nearly half of new moms have missed postpartum checkups.
Doctors are now advised to see new mothers within three weeks of giving birth, rather than waiting for the six-week checkup that was once standard.
“Now it’s ‘I’ll see you in two weeks, right? And yes, you will definitely come,” said Dr. Tamika Auguste, a co-author along with Dr. Stuebe, of New Guidelines on Postpartum Care from the American College of Obstetricians and Gynecologists.
New mothers with medical conditions such as hypertension should be seen even earlier, Dr. Auguste said.
More importantly, though, doctors and other healthcare providers listen when women express concerns, paying special attention to Black and Native American women who say something is wrong.
“There’s no more ‘Oh honey, you’re fine,'” said Dr. Auguste. ‘There’s nothing left to do with that. There’s ‘Let’s see if we can get you in today or tomorrow.’”
Multiple risks
Many doctors call pregnancy “nature’s cardiac stress test.” The condition puts a strain on a woman’s heart and circulatory system: Blood volume increases by up to 50 percent, the heart works harder, and the heart rate goes up.
Increases in blood pressure can affect other vital organs and put a woman at greater risk for cardiovascular disease during pregnancy or even decades later, said Dr. Rachel Bond, a cardiologist and systems director of the women’s heart health program at Dignity Health in Chandler, Ariz.
“We tell women, ‘You’ve passed your first stress test — you either pass or you fail,'” said Dr. Bond. “Failure doesn’t necessarily mean you have heart disease, but it means we as clinicians need to treat you more aggressively.”
Once the baby is born, the uterus shrinks and blood pressure can rise, which can cause a stroke.
New mothers are also more likely to develop life-threatening blood clots and infections. At the same time, hormonal changes can lead to mood swings. Some of these are transient, but more severe, longer-lasting postpartum depression can also develop.
While most women survive pregnancy-related complications after childbirth, prompt medical care is critical.
Deidre Winzy, a 28-year-old New Orleans physician assistant, already had high blood pressure when she became pregnant with her third child. Doctors gave her a blood pressure cuff to use at home, along with Babyscripts, a remote monitoring system that sent readings to her obstetrician.
Ms. Winzy was induced two and a half weeks early after being diagnosed with preeclampsia, a dangerous hypertensive condition. But three weeks after giving birth, she woke up in the middle of the night feeling disoriented and dizzy. She called a friend for help, her speech slurred.
Medics thought she was having a panic attack and didn’t want to take her to the hospital at first. In fact, she had a stroke. “I got there just in time,” recalls Mrs. Winzy herself. “If I hadn’t, I might have been paralyzed for the rest of my life.”
Ms. Winzy is now struggling with short term memory loss and weakness, but she is able to work. Still, as a single mother of three children, she worries.
“My biggest fear is not being there for my kids,” Ms Winzy said. “What if I have another stroke and it permanently paralyzes me or kills me? It’s terrifying.”
Among white women, mental illness accounts for 35 percent of pregnancy-related deaths, according to CDC data. This is 24 percent for Hispanic women. Pre-existing anxiety or depression can make women vulnerable to postpartum depression, as can a difficult pregnancy or having a sick baby.
The stress of parenthood can trigger a relapse for someone recovering from a substance use disorder, said Katayune Kaeni, a psychologist and chairman of the board of Postpartum Support International.
Karen Bullock, 39, who lives outside of Peoria, Illinois, had a difficult pregnancy and a traumatic preterm birth, and she struggled to breastfeed.
“Nothing went smoothly,” she said. “I wasn’t happy when the baby was born – I was scared. Every time I looked at him I thought, I don’t know what to do with you.” Ms. Bullock was eventually diagnosed with postpartum depression and started taking medication.
Complications can surprise even women who have had a trouble-free pregnancy. After a cesarean section, Aryana Jacobs, a 34-year-old health technology analyst in Washington, D.C., was told her blood pressure was fluctuating. At home, Mrs. Jacobs checked with a blood pressure cuff she kept because of a family history of hypertension. Within days, the reading had reached 170/110.
She went to the hospital and was treated for preeclampsia – which usually develops during pregnancy, not after.
“I wish every new mother was sent home with a box of chocolates and a blood pressure cuff to emphasize that as a mother you are still a patient,” Ms Jacobs said. “Your body is recovering from something huge.”