The oldest medical event in human history is birth. It makes sense, then, that so many deities and religious practices surround a healthy birth. In ancient Rome for example, it’s estimated that as many as 2% of all births ended in maternal mortality. We’ve come a long way, with average US estimates of maternal mortality rates (MMR) being more like 0.018%. However, the US MMR is actually at its highest in decades.
The preliminary causes of these deaths are well documented, mostly rooted in cardiovascular conditions such as preeclampsia (or acutely high blood pressure during pregnancy). Other conditions such as gestational diabetes also present dangerous situations. Past these, post-partum infection is the next leading cause.
So why have these deaths increased? Deaths for other medical procedures and events have dramatically lowered. Shouldn’t we see lower MMR as well? In fact, in 2020, the MMR rose to 23.8 deaths per 100,000 births.
I wanted to explore the role chronic stress plays into this intense rise.
The Effects of Stress on the Pregnant Body
A common medical biomarker for chronic stress is C-reactive protein (CRP), an inflammatory protein. It is more likely in women who report they are stressed or report they have experienced discrimination. High CRP is also common in people experiencing obesity, insomnia, depression, smoking, and diabetes, and it’s more common in the female sex. High CRP might increase the risk of inflammatory disorders and cardiovascular disease, and should not be ignored in its connection with chronic stress.
In one 2019 study, blood levels of the stress hormone cortisol correlated with the perceived stress of pregnant test subjects. In the same study, high cortisol also correlated with preeclampsia, premature birth, and poor outcomes. Cortisol is associated with poor infant outcome too — with higher incidence of miscarriage, developmental delay, and metabolic diseases in a newborn. Chronic stress can even be found in hair samples, with cortisol samples in lengths of hair correlating with stressors as common as shift work over salaried work.
In any person, chronic stress is associated with an increased incidence of hypertension, heart disease, stroke, and insomnia. With cardiovascular incidents being the number 1 reason for maternal mortality, it’s not a stretch to connect the two.
One of the other top causes of death in maternal mortality is post-partum infection. Chronic stress is associated with lower immune function because of stress corticosteroids limiting the number of immune cells, or leukocytes in the body. Lower numbers of immune cells means that disease is harder to fight off and easier to catch.
Also in relation to infections, vaginal health is also associated with stress. Stress changes leukocytes, which in turn changes the bacterial flora of the vagina. Furthermore, chronically high cortisol lowers estrogen levels. Estrogen is an important regulator of vaginal health, as it spurs deposits of glycogen starches that are important to healthy bacterial development.
Chronic use of birth control can also change bacterial flora. Stress changes are associated with increased rates of bacterial vaginosis (or inflammatory bacterial infection of the vagina), but never with increased incidence of postpartum infection. More studies are to be done to rule out potential links.
Financial Stress — Paid Family Leave Policies
The leading causes of stress in the US are financial, across all genders and races. Money, work, and economic trends are the top 3 topics people are most stressed about — all related to finance.
The US notoriously has no paid maternal leave policy, leaving women to depend on state or private policies to make up the difference.
The stress of lost income is a foreboding and threatening reality post-partum. Even worse, there are some hard limits to unpaid family leave in the US, so there is a threat of job loss if one goes extends past unpaid timelines too.
Compare the MMR of the US and countries of similar GDP and wealth. US MMR is over twice that of similar countries, such as the UK or Canada, who all have a minimum of 12 weeks of maternity pay.
Individual state policies aren’t much better. Only 5 states in the US have any paid family leave, plus DC. Even then, all US state paid leave policies are 12 weeks or less, which lags behind most global policies of similar GDP countries.
Why is the potential threat of unpaid leave or losing a job potentially a factor in maternal death? Wouldn’t the fiscal stresses occur after birth? What’s interesting is that over half of all maternal deaths occur in the weeks post-partum, not just at birth or during pregnancy. So the realities of fiscal stress are present post-birth.
Influence of Racial Discrimination on Stress
Fiscal stress is closely tied with racial discriminatory stress. One cannot ignore the overwhelming racial pay gap and its contribution to chronic stress. Black households make over $20,000 less than the overall median income in the US.
What adds to the fiscal and racial dynamic, African American women are highly likely to be breadwinners for their household, and are also much more likely to be single breadwinners for their children.
42% of all births in the US are financed by Medicaid, with 65% of all births from black mothers financed by Medicaid. A little talked about topic in MMR is the limits of Medicaid’s post-partum coverage for the mother, as it ends 60 days after birth. Regardless, about 12% of maternal birth-related deaths occur 43 days or more following delivery. Many women only do a 6 week post-partum check up to follow their recovery, and as a result, follow up appointments might not be covered by Medicaid. Limiting access to care might be a contributing factor to MMR.
All of these factors may contribute to high maternal mortality rates for black Americans, and also add to the stresses.
Cumulative stress is something to discuss in relation to high black MMR. Most black Americans report that racial discrimination, whether subconscious, structural, or direct, affects their life. And there’s consistent evidence that thinking about racism and experiencing racism activates the sympathetic nervous system, and activates chronic stress. About 20% of black people in America say they experienced racism while accessing healthcare in the past year.
The COVID-19 pandemic highlights the disparity of stress, race, and MMR. Not only did maternal mortality increase in 2020 (whether from stress, lack of access to healthcare, or from COVID-19 itself), but this graph highlights that black mortality rates are more than double the national average.
Where to Go From Here?
It’s difficult to find the perfect solution to these rising mortality rates. One of the classic methods is to follow the policies and methods of countries with improved mortality rates. Increase in paid family leave (and a national policy), expansion of post-partum Medicaid, and more than just a 6 week post-partum check up are all great starts. However, it’s clear that there are issues more unique to the US that requires more complicated intervention. Americans are more stressed than most comparable countries, and the chronic stress affects the maternal body in ways we don’t entirely understand.
Improving maternal financial security, addressing racial discrimination (in workplaces and healthcare environments), and overall improving the health of Americans are more complex and difficult factors to address. Ways to improve outcomes in a smaller way, strong community bonds decrease feelings of chronic stress. Helping take care of pregnant people in your life might mean supporting them well before and well after birth, and considering the cumulative invisible stresses in our communities, and how it affects our bodies.
