Fighting the Maternal Mortality Crisis
How Rollins researchers are working to decrease the maternal mortality rate in Georgia
If maternal mortality is an indicator of a nation’s health, then the United States is in bad shape. Of the wealthiest countries in the world, the nation has the highest maternal mortality rate—and it keeps getting worse. In 2021, maternal mortality (defined as a death during pregnancy or within one year of the end of pregnancy) rose by 40 percent in the U.S., with Black women dying at more than twice the rate of white women, according to a recent Centers for Disease Control and Prevention (CDC) report. While the pandemic certainly played a role in the uptick, the fact is, the U.S. maternal mortality rate has been climbing for decades.
The state of Georgia isn’t immune to the crisis. In fact, Georgia’s maternal mortality rate is among the worst in the country with 33.9 deaths per 100,000 live births, according to data compiled by the National Center for Health Statistics between 2018 and 2021. (For context, the national average is 32.9 deaths per 100,000 live births, per the 2021 CDC report.) Similar to the rest of the country, the numbers are worse for Black women: According to the Georgia Department of Public Health’s Maternal Mortality report, for the period 2018–2020, there were 48.6 pregnancy-related deaths per 100,000 live births among non-Hispanic Black women versus 22.7 pregnancy-related deaths per 100,000 live births among non-Hispanic white women.
Why is it so dangerous to give birth in Georgia? “The high mortality rate has a lot to do with structural and social conditions in our state, which include significant challenges accessing quality reproductive health care, systemic racial inequalities, and policy changes affecting pregnant and postpartum people,” says Whitney Rice, DrPH, MPH, Rollins Assistant Professor in the Department of Behavioral, Social, and Health Education Sciences and director of the Center for Reproductive Health Research in the Southeast (RISE).
Stock image from Adobe Stock
Stock image from Adobe Stock
Rollins researchers are working hard to improve the maternal mortality rate in Georgia, and, hopefully, the rest of the country. “We’re coming at it from all angles, from accessibility issues to the policies involved,” says Carmen Marsit, PhD, Rollins Distinguished Professor of Research and executive associate dean for faculty affairs and research strategy. Here’s a look at what Rollins researchers are working on now—and in the future.
Whitney Rice, DrPH, MPH, Rollins Assistant Professor in the Department of Behavioral, Social, and Health Education Sciences and director of the Center for Reproductive Health Research in the Southeast (RISE)
Whitney Rice, DrPH, MPH, Rollins Assistant Professor in the Department of Behavioral, Social, and Health Education Sciences and director of the Center for Reproductive Health Research in the Southeast (RISE)
Carmen Marsit, PhD, Rollins Distinguished Professor of Research and executive associate dean for faculty affairs and research strategy
Carmen Marsit, PhD, Rollins Distinguished Professor of Research and executive associate dean for faculty affairs and research strategy
Stock image from Adobe Stock
Stock image from Adobe Stock
The state of Georgia isn’t immune to the crisis. In fact, Georgia’s maternal mortality rate is among the worst in the country with 33.9 deaths per 100,000 live births, according to data compiled by the National Center for Health Statistics between 2018 and 2021. (For context, the national average is 32.9 deaths per 100,000 live births, per the 2021 CDC report.) Similar to the rest of the country, the numbers are worse for Black women: According to the Georgia Department of Public Health’s Maternal Mortality report, for the period 2018–2020, there were 48.6 pregnancy-related deaths per 100,000 live births among non-Hispanic Black women versus 22.7 pregnancy-related deaths per 100,000 live births among non-Hispanic white women.
Whitney Rice
Whitney Rice
Why is it so dangerous to give birth in Georgia? “The high mortality rate has a lot to do with structural and social conditions in our state, which include significant challenges accessing quality reproductive health care, systemic racial inequalities, and policy changes affecting pregnant and postpartum people,” says Whitney Rice, DrPH, MPH, Rollins Assistant Professor in the Department of Behavioral, Social, and Health Education Sciences and director of the Center for Reproductive Health Research in the Southeast (RISE).
Carmen Marsit
Carmen Marsit
Rollins researchers are working hard to improve the maternal mortality rate in Georgia, and, hopefully, the rest of the country. “We’re coming at it from all angles, from accessibility issues to the policies involved,” says Carmen Marsit, PhD, Rollins Distinguished Professor of Research and executive associate dean for faculty affairs and research strategy. Here’s a look at what Rollins researchers are working on now—and in the future.
Improving access to quality maternal care
When it comes to preventing maternal deaths, access to quality health care during pregnancy is crucial, but it can be difficult in a state like Georgia, where maternity care deserts are prevalent.
“In Georgia, the rate of OB-GYNs per residents in metropolitan areas is more than double that for non-metro areas,” says Rice. “Having to drive long distances to access care can carry health risks during and outside of pregnancy, and while this presents a challenge for everyone, it’s especially problematic for Black people, who are more likely to forgo care due to a lack of resources.”
Rural counties with a higher number of Black residents are also more likely to not have or lose access to obstetric care, notes Rice. All these factors increase the risk of maternal mortality.
One way to improve maternal care in rural areas (and beyond) is greater use of doulas, trained professionals who provide physical, emotional, and informational support to birthing people. Rice and her RISE colleagues have been working on a project that focuses on doula care during pregnancy.
One of their studies, published in Sexual and Reproductive Health Matters, showed how doulas were an essential part of health care teams during the pandemic and calls for doulas to be integrated into maternity care teams more broadly.
Stock image from Adobe Stock
Stock image from Adobe Stock
“Doulas play a critical role in elevating the patient care experience and can help bridge the gap in care that pregnant people in rural areas may experience,” says Rice. While doulas aren’t a replacement for medical care from a midwife or doctor, they can improve both physical and psychological outcomes for birthing and postpartum people, research shows.
Another barrier to accessing quality maternal care is recent policy changes like Georgia House Bill 481, which bans abortions after around six weeks of pregnancy. Being unable to access a safe abortion can have devastating consequences: A recent report from the Commonwealth Fund showed states that have restricted abortion have fewer maternity care providers, more maternity care deserts, and higher rates of maternal mortality and infant death, particularly among women of color.
Rice and her colleagues recently estimated what the potential consequences of Georgia’s early abortion ban could be. “Our findings show that nearly 90 percent of abortions that were provided in the past would no longer be allowed under the current ban,” says Rice. “While this certainly affects all people who seek care, the groups disproportionately affected are Black people, young people, and those with less education.”
Using data to inform policy change
In most U.S. states, maternal deaths are reviewed by Maternal Mortality Review Committees (MMRCs), multidisciplinary groups that look at clinical and nonclinical information to more fully understand the circumstances of a death and develop recommendations to prevent similar deaths in the future. MMRCs are important because they share their recommendations with stakeholders—such as hospitals, state and local policy-makers, and health care providers—who can implement system or policy changes.
For the past five years, Michael Kramer, PhD, associate professor of epidemiology and director of the Emory Maternal and Child Health Center of Excellence, has been developing a tool called the Community Vital Signs Toolkit to help MMRCs better understand the lives of the women who died. “It’s a data dashboard that creates a visualization of attributes of their lived experience that are important to maternal mortality, like how many OB-GYNs there are per capita, the prevalence of drug overdose mortality, the rate of housing instability, the number of violent crimes, etc.,” explains Kramer. “The goal is to get these factors into the conversation so the committee’s recommendations can reflect them.”
The tool was rolled out nationally in summer 2022 and is currently available in 35 states.
Users can enter any U.S. street address, and the tool generates a visualization (in PDF form) of the risk factors in that person’s area.
“It helps the committees see, for example, that maybe a woman didn’t make it to her follow-up doctor’s appointment because she lives in an area with poor transportation,” Kramer explains.“Maybe she needed a home nurse visitation."
Sarah Blake, PhD, MA, associate professor of health policy and management, has been supporting the roll-out of the Community Vital Signs Toolkit. She’s helped train users in different states to use the tool and is now evaluating how they’re building it into their MMRCs. For the past three years, Blake has served on Georgia’s MMRC as a health services researcher and Medicaid specialist. She meets with the committee every few months to review cases.
“It’s critical to my work because it helps me feel like I’m making a contribution and it informs my research,” says Blake, who helped petition the state legislature to extend Medicaid for low-income pregnant women from six to 12 months. “It’s one of the most successful things we’ve done.”
Blake also works with the CDC to educate its state-based Maternal Mortality Review Information Application (MMRIA) teams. MMRIA is a standardized data system that MMRCs use to understand maternal deaths—and hopefully prevent them in the future. “I show states how to interpret and use their data,” explains Blake. “That way, they can make meaningful policy changes.”
In her work with the CDC, Blake has also done analyses of maternal mortality data examining barriers to health care. “We’ve looked at pregnancy-associated overdose deaths, cardiac deaths, and mental health-related deaths,” she says. “The aim is to help the CDC understand from a qualitative lens what shapes women’s lives before they experience a maternal death. It’s important to understand what was going on in their lives to prevent other women from dying.”
Gathering and analyzing data is at the core of what many Rollins researchers do—but their results are only as good as their data. That’s why Emily Peterson, PhD, assistant professor of biostatistics, focuses her work on accurately capturing maternal deaths.
“There’s a high rate of misdiagnosed maternal deaths,” she says. “Diagnosing them is not as straightforward as diagnosing a heart attack, for example.” To be considered a maternal death, it must be related to complications of pregnancy (versus a pregnant woman dying in a car crash, for instance).
Previously, Peterson collaborated with the World Health Organization to analyze maternal deaths on a global scale and found that on average, across all countries, 50 percent of maternal deaths were misclassified or undercounted. Last year, in collaboration with the CDC, she started looking at the levels of misclassification in the U.S.
“It’s important because if you’re trying to create policy, you need to base it on an accurate picture of what's happening in that area,” Peterson explains. “And the way you get an accurate picture is by assessing how good your data are. If your data are perfect, you’re done—but our data aren’t perfect.”
Michael Kramer, PhD, associate professor of epidemiology and director of the Emory Maternal and Child Health Center of Excellence
Michael Kramer, PhD, associate professor of epidemiology and director of the Emory Maternal and Child Health Center of Excellence
Sarah Blake, PhD, MA, associate professor of health policy and management
Sarah Blake, PhD, MA, associate professor of health policy and management
Emily Peterson, PhD, assistant professor of biostatistics
Emily Peterson, PhD, assistant professor of biostatistics
In most U.S. states, maternal deaths are reviewed by Maternal Mortality Review Committees (MMRCs), multidisciplinary groups that look at clinical and nonclinical information to more fully understand the circumstances of a death and develop recommendations to prevent similar deaths in the future. MMRCs are important because they share their recommendations with stakeholders—such as hospitals, state and local policy-makers, and health care providers—who can implement system or policy changes.
In most U.S. states, maternal deaths are reviewed by Maternal Mortality Review Committees (MMRCs), multidisciplinary groups that look at clinical and nonclinical information to more fully understand the circumstances of a death and develop recommendations to prevent similar deaths in the future. MMRCs are important because they share their recommendations with stakeholders—such as hospitals, state and local policy-makers, and health care providers—who can implement system or policy changes.
Michael Kramer
Michael Kramer
For the past five years, Michael Kramer, PhD, associate professor of epidemiology and director of the Emory Maternal and Child Health Center of Excellence, has been developing a tool called the Community Vital Signs Toolkit to help MMRCs better understand the lives of the women who died. “It’s a data dashboard that creates a visualization of attributes of their lived experience that are important to maternal mortality, like how many OB-GYNs there are per capita, the prevalence of drug overdose mortality, the rate of housing instability, the number of violent crimes, etc.,” explains Kramer. “The goal is to get these factors into the conversation so the committee’s recommendations can reflect them.”
The tool was rolled out nationally in summer 2022 and is currently available in 35 states.
Users can enter any U.S. street address, and the tool generates a visualization (in PDF form) of the risk factors in that person’s area.
“It helps the committees see, for example, that maybe a woman didn’t make it to her follow-up doctor’s appointment because she lives in an area with poor transportation,” Kramer explains.“ Maybe she needed a home nurse visitation.
Sarah Blake, PhD, MA, associate professor of health policy and management
Sarah Blake, PhD, MA, associate professor of health policy and management
Sarah Blake, PhD, MA, associate professor of health policy and management, has been supporting the roll-out of the Community Vital Signs Toolkit. She’s helped train users in different states to use the tool and is now evaluating how they’re building it into their MMRCs. For the past three years, Blake has served on Georgia’s MMRC as a health services researcher and Medicaid specialist. She meets with the committee every few months to review cases.
“It’s critical to my work because it helps me feel like I’m making a contribution and it informs my research,” says Blake, who helped petition the state legislature to extend Medicaid for low-income pregnant women from six to 12 months. “It’s one of the most successful things we’ve done.”
Blake also works with the CDC to educate its state-based Maternal Mortality Review Information Application (MMRIA) teams. MMRIA is a standardized data system that MMRCs use to understand maternal deaths—and hopefully prevent them in the future. “I show states how to interpret and use their data,” explains Blake. “That way, they can make meaningful policy changes.”
In her work with the CDC, Blake has also done analyses of maternal mortality data examining barriers to health care. “We’ve looked at pregnancy-associated overdose deaths, cardiac deaths, and mental health-related deaths,” she says. “The aim is to help the CDC understand from a qualitative lens what shapes women’s lives before they experience a maternal death. It’s important to understand what was going on in their lives to prevent other women from dying.”
Emily Peterson, PhD, assistant professor of biostatistics
Emily Peterson, PhD, assistant professor of biostatistics
Gathering and analyzing data is at the core of what many Rollins researchers do—but their results are only as good as their data. That’s why Emily Peterson, PhD, assistant professor of biostatistics, focuses her work on accurately capturing maternal deaths.
“There’s a high rate of misdiagnosed maternal deaths,” she says. “Diagnosing them is not as straightforward as diagnosing a heart attack, for example.” To be considered a maternal death, it must be related to complications of pregnancy (versus a pregnant woman dying in a car crash, for instance).
Previously, Peterson collaborated with the World Health Organization to analyze maternal deaths on a global scale and found that on average, across all countries, 50 percent of maternal deaths were misclassified or undercounted. Last year, in collaboration with the CDC, she started looking at the levels of misclassification in the U.S.
“It’s important because if you’re trying to create policy, you need to base it on an accurate picture of what's happening in that area,” Peterson explains. “And the way you get an accurate picture is by assessing how good your data are. If your data are perfect, you’re done—but our data aren’t perfect.”
Creating a better future
Rollins researchers are committed to doing everything they can to reduce the maternal mortality rate in Georgia and the rest of the country. “I see this as the health challenge of our generation,” says Marsit. “Maternal health ties to child health, and that’s our future. If we aren’t thinking about how to have healthy moms and babies, then we’re putting our future at risk.”
Kathleen Adams
Kathleen Adams
Fortunately, a lot of research is coming down the pipeline. Rollins researchers have partnered with Emory School of Medicine on a National Institutes of Health-funded study examining the rates and explanatory factors behind Georgia’s severe maternal morbidity rates. Kathleen Adams, PhD, professor of health policy and management, is leading the effort to separate out the reasons for the differences between non-Hispanic Black women and non-Hispanic white women. “If we can reduce morbidity, then we can potentially reduce the mortality rate,” she says.
Hannah Cooper
Hannah Cooper
Hannah Cooper, ScD, professor of behavioral, social, and health education sciences and Rollins Distinguished Professor of Substance Use Disorders, has proposed research on substance use and harm reduction during pregnancy. If funded, her project will address an important issue since drug overdose is a leading cause of maternal deaths in the U.S. This fall, Blake will work with the Georgia Department of Public Health to look at the impact of COVID-19 on maternal mortality.
Based on work through RISE, Rice and her colleagues are writing up new findings from their evaluation of U.S. state-level contraceptive access policies—specifically how they may alleviate or worsen preventive health inequities. “We also have important work under way to make reproductive health education—particularly about abortion— more broadly accessible, and we’re doing research to evaluate those efforts,” notes Rice.
Undoubtedly, working to reduce the maternal mortality rate can feel like an uphill battle. But for Rollins researchers, passion fuels the work. “We’re all angry about what’s happening to moms in Georgia, and we’re especially outraged at the racial and ethnic disparities,” says Blake. “We want to change that, but we have to do it based on evidence. We need more than our hearts and our passion—as researchers, we need to provide proof, ask the right questions, and get the right data.”
Stock image from Adobe Stock
Stock image from Adobe Stock
For Rice, what keeps her going is knowing that reproductive health research can inform important stakeholders and hold them accountable to ensure that women achieve reproductive well-being, whatever that means to them. “I want to see that for my daughter, my family, my friends, my colleagues—everyone,” she says.
Her work in reproductive health also has an ancestral imperative. “My grandmother was a family planning nurse, and she was bold, brave, and committed to the work,” says Rice. “I’ve always felt my work in this field was in connection to her and what she strove for.”
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