How the false narrative of skyrocketing maternal mortality gained traction

Last July, numerous headlines proclaimed that U.S. maternal deaths doubled between 1999 and 2019. It was alarming news, and essentially wrong.

The official maternal mortality rate did increase from 9.9 deaths per 100,000 live births in 1999 to 20.1 in 2019, according to the National Center for Health Statistics (NCHS), which is part of the CDC.

But there was a giant caveat.

The observed increase reflected a change in how deaths are counted, several studies showed. From 2003 to 2017, states gradually switched to a new standard death certificate that included a checkbox to indicate pregnancy status. The checkbox greatly increased the identification of maternal deaths, which had been previously undercounted.

The disturbing narrative of a worsening crisis proliferated despite the CDC's transparency about the effect of the checkbox and an absence of similar increases in other tracking tools such as the CDC's Pregnancy Mortality Surveillance System (PMSS).

Both NCHS and PMSS reporting DO point to other important trends that journalists can rightly highlight in their reporting. Namely, the U.S. maternal mortality rate far exceeds that of other large industrialized countries, and sharp racial disparities persist.

Misrepresenting the data

In a letter to the editor of JAMA, NCHS experts blasted the study that led to the misleading headlines, saying the failure to account for the impact of the pregnancy checkbox biased the findings. (Some members of the research team defended their work in a reply.)

Despite this major flaw, criticism of the study received little if any news coverage, in stark contrast to the study findings, which were promoted in a news release issued by the Institute for the Health Metrics and Evaluation in Seattle and Mass General Brigham in Boston.

In addition to coverage in several prominent news outlets, a post on AHCJ's website reported the study's findings without cautioning about the impact of the checkbox on reporting.

It wasn't the first misrepresentation of the jump in the maternal mortality rate. Many reports, blogs and news releases have suggested that being pregnant in the U.S. became more deadly. (These examples predate a spike in maternal deaths that occurred during the pandemic.)

So why promote the idea of a worsening crisis?

"There's a desire, I think, among advocates to raise the alarms that haven't been raised for a long time around maternal mortality," Eugene Declercq, a professor at the Boston University School of Public Health who researches maternal mortality and morbidity, said in an interview. "I think the narrative that it's increasing makes (those alarms) more powerful."

Declercq added that the narrative that maternal mortality is "miserably high - a lot higher than it should be" should be "sufficient to motivate the political system."

Challenging the 'worsening crisis' narrative

Recently a study in the American Journal of Obstetrics & Gynecology thrust the maternal mortality rate back into the news - this time by challenging the narrative of a worsening crisis.

The findings weren't entirely novel, but they did lead to several stories, including in The Washington Post, Science and ProPublica.

For their paper, an international research team disregarded the checkbox and counted only deaths where pregnancy was mentioned among the causes of death. They concluded that the U.S. maternal mortality rate held steady during the period that the checkbox was introduced, from 10.2 deaths per 100,000 live births in 1999-2002 to 10.4 in 2018-2021.

The researchers acknowledged that their method undercounted maternal deaths, but it also eliminated overcounting due to the checkbox misclassifying deaths that are unrelated to pregnancy.

The study drew pushback from the CDC, which defended the use of the checkbox, and the American College of Obstetricians and Gynecologists, whose interim CEO, Christopher M. Zahn, M.D., expressed concern that the findings might undermine efforts to reduce maternal deaths.

Perhaps more importantly, though, it underscored something that many advocates and researchers have long agreed on: the need for more reliable surveillance methods.

Takeaways for journalists

However well-intended, exaggerating a problem can foster distrust in science, scare people unnecessarily, and lead to bad policymaking. The dubious narrative of skyrocketing maternal mortality serves as a reminder to critically examine the findings of journal articles.

That means reading the limitations that are described in a paper's discussion section, searching in PubMed for previous research on the topic, and requesting input from data experts such as academic and government researchers.

In the case of the disputed JAMA paper, reading other news stories would have been instructive. At least two news organizations, Scientific American and ProPublica, covered the impact of the checkbox, in 2015 and 2017 respectively.

Journalists who cover maternal health would also do well to bone up on the strengths and weaknesses of the different systems to track pregnancy-related deaths. Tomorrow, we'll provide a primer.

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