Eugene Declercq, a School of Public Health professor of community health sciences, and his students collect birth-related data, including the grim log of US maternal deaths. Photo via iStock/Motortion

Public Health

BU Professor Tracks the Many US Pregnancy-Related Deaths

Mortality is about “the way we treat women in healthcare,” Eugene Declercq says

“It’s just shameful for our country. There’s too many moms dying, and it doesn’t have to be that way.” 

The March of Dimes president, Elizabeth Cherot, lamented last year about the harrowing maternal death rate in the United States. How harrowing? According to a database compiled by a BU scholar, American mothers in 2021 and 2022 died at more than six times the rates in Germany, Spain, Japan, and Australia.

Eugene Declercq, a Boston University School of Public Health professor of community health sciences, created Birth by the Numbers in 2010, long before the current crisis in maternal mortality. “My nerdiness goes back decades,” he says. His work with pregnancy began with a documentary, Orgasmic Birth. Declercq was interviewed for that 2009 film, which depicted birth as a positive and even potentially pleasurable event. The film, he quips, was “the highlight of my career, which will be eternally embarrassing to my children.” 

Subsequently consulting on another movie, The Business of Being Born, he says, really spawned Birth by the Numbers as a way to continually update pregnancy-related information. The most recent US data, from 2023, offers hope, with mortality dropping below pre-COVID rates: 669 women died during pregnancy or after giving birth that year, versus 817 in 2022 and 1,205 in 2021. The bad news is the racial disparity: Black mothers died at 3.5 times the rate of their white counterparts.

While the declining mortality rate stems from positive developments such as the end of the pandemic and expanded postpartum coverage under Medicaid, the federal-state health program for the poor, Declercq says it also was a factor of math: declining US birth rates translate into fewer deaths related to pregnancy.

Declercq and the SPH student volunteers who assist him collect and post data from various sources, including the Organization for Economic Cooperation and Development and the federal Centers for Disease Control and Prevention (CDC). It’s not just a simple task of cutting and pasting; mortality data is gathered by different levels of government, here and abroad, and by different metrics that Declercq must account for in order to make apples-to-apples comparisons. 

No matter how you slice it, though, the US record makes a grim read.

The rate of deaths of American mothers spiked between 2018 and 2021, exacerbated by COVID-19, before dipping in 2022, the most recent year for which final numbers are available, to 22.3 maternal deaths for every 100,000 live births. (The “provisional” or estimated, rate for 2023 is 18.6 deaths per 100,000, Declercq says, although he adds that its source, the federal National Vital Statistics System, historically overestimates deaths.) The 2022 rate translates to 817 deceased mothers, according to the CDC. That’s higher than in other developed countries, and for African American mothers, the rate was worse: 49.5 per 100,000.

Birth by the Numbers is publicly accessible; Declercq does not tally visitors. One user is the Bay State Birth Coalition, a nonprofit advocating midwifery (Declercq is a board member). Cofounder Emily Anesta says Declercq’s data “illuminates the reality of birth practices, and importantly, the trends over time.

“I know of no other resource that distills birth trends and changes to maternal outcomes as comprehensively and clearly,” she adds. “Each of the free charts made available at Birth by the Numbers is worth 1,000 words. I regularly use [them] to quickly and powerfully help lawmakers understand trends in maternal care, preferences, and outcomes.” 

And not just Anesta is using them. “Birth by the Numbers’ charts describing trends in birth preferences and midwifery care have appeared in briefings, letters, and documents for state legislators, regulators, and government offices,” she says.

Birth by the Numbers is a cornucopia of data that extends beyond maternal mortality, including trends in induced labor, home births, and resort to midwives. Students choose whichever birth-related topics interest them—except maternal mortality, “because that’s mine,” Declercq says.

When he launched Birth by the Numbers, Declercq’s biggest public health concern was the rocketing number of C-sections performed in the United States. He began researching maternal mortality around 2015. An intriguing pie chart on his site captures his explanation for why America is often such a dangerous place to give birth. The chart shows that among maternal deaths from 2017 to 2019, a quarter occurred on the day of delivery or within six days of it. But more than one fifth happened before delivery, and half came one week to one year after birth. 

The numbers show that while hospitals, obstetricians, and midwives work to improve care at the time of birth, he says, maternal mortality is “a much bigger issue, and it’s a community-level issue—that women are dying before they ever get to birth. And women are dying after they give birth.”

All of this points to “a weaker women’s healthcare system” than in other countries, Declercq says. “In the United States, it’s not about birth, it’s about the way we treat women in healthcare in general, that they come into the pregnancy less healthy than in those other countries. They have less likelihood of having maternity leave than those other countries.” He helped survey women about when they begin their maternity leaves, and “the most common answer was, ‘My due date.’ They want to have as much time with the new baby as possible. But ideally, you want them to take it starting, say, in the last month” before delivery.

Postdelivery, he says, we as a nation too often stop caring: “We have a system that’s geared to healthy babies, not healthy mothers and healthy women,” with poverty and racial inequity making the situation more bleak for Black mothers, especially.

The Affordable Care Act subsidizes states to expand Medicaid, the federal-state health program for low-income Americans. Ten states have not done that, and “particularly in the states that refuse to expand Medicaid, these women are going to be entering pregnancy in a less healthy state,” Declercq says. Locally, Massachusetts Governor Maura Healey recently signed a bill increasing midwife and doula care that aims, among other things, to reduce labor complications among Black residents, who experience them at twice the rate of white residents.

While Birth by the Numbers is a data site rather than an advocacy site, Declercq hopes that it ultimately will drive more reasonable decisions about public health policy.

“The whole idea of data is to undermine easy preconceptions. What I want people to do is have to make decisions about what’s real, and not what they think is real.” While data can be a snapshot in time, applying in particular circumstances, “it leads to present information that people can use,” he says.

“I’m a public health person. I believe in the fact that if we cover people and support people and have systems that take care of them, or at least provide them opportunities to be taken care of, then we’re going to have healthier people. That doesn’t seem like rocket science.”