The trend is alarming: More mothers are dying during and after childbirth each year in Greenville County, across South Carolina and nationally.

Data from the Centers for Disease Control and Prevention also highlights Black women are dying at rates three to five times higher than white women.

Behind each number is a human tragedy marked by devastating loss for families and communities, exacerbated by the reality that most of the deaths are preventable.

The contributing factors pushing up local and national maternal mortality rates are varied and complex. Reversing the trend has become the goal of a growing number of health care professionals, policy makers and community organizations.

Uncomfortable truths

The fact that Black mothers are suffering at significantly higher rates raises some uncomfortable truths that need to be acknowledged and addressed, according to Dr. Manisha Shanbhag, medical director for Prisma Health’s Adult Congenital Heart Disease clinic.

“I don’t think the public knows,” Shanbhag said. “There hasn’t been enough of a light shined on it.”

Racial disparities in maternal health outcomes are not unique to Greenville or South Carolina and are not exclusively tied to income or social standing. The death in June of 32-year-old Olympic athlete Tori Bowie from childbirth complications grabbed global headlines and brought attention to the problem.

It also highlighted a growing body of research that paints a stark picture of the difference in outcomes between Black mothers and white mothers. This disparity has been long standing and was one of the motivating factors in driving Shanbhag to become a physician.

“This has been a passion of mine since medical school where I learned the statistics at Duke,” she said. “I felt like I came back here and nothing had changed.”

That discrimination plays a role in maternal outcomes is clear, according to the 2023 legislative brief from the South Carolina Maternal Morbidity and Mortality Review Committee.

The brief reports discrimination was a contributing factor in 56% of pregnancy-related deaths in the state in 2018-2019 — the most recent years for which the committee had data.

How discrimination affects outcomes is less well understood, according to Dr. Sharon Keiser, chairman of the committee and a maternal and fetal medicine specialist with Prisma Health.

Shanbhag said anecdotal accounts she’s encountered in her work and research indicate in many cases when Black mothers report problems, their concerns are often ignored or minimized.

In a May Yale Medicine article discussing maternal mortality rates, implicit and explicit bias are listed as contributing factors. Implicit bias is particularly hard to contend with as a person is not aware of their bias.

Reducing or eliminating racial bias is among the more ephemeral contributing factors affecting maternal mortality and will take a concerted, collective effort nationwide to address.

But as Keiser and Shanbhag point out, discrimination is only part of the picture affecting maternal mortality rates.

Complex causes

One of the most discernible contributing factors for increased maternal mortality is a woman’s age. The CDC and medical researchers across the country report a correlation between age and the risk of dying in pregnancy.

“Women are choosing to get pregnant at older ages, and I don’t think that’s going to change anytime soon,” Keiser said.

Dr. Kelly San Miguel, an obstetrics and gynecology specialist with Bon Secours St. Francis, said women over the age of 35 are more likely to have chronic conditions that affect their pregnancy.

Leading causes of pregnancy-related deaths include postpartum hemorrhage, cardiovascular conditions, infection and cardiomyopathy. Mental health — specifically postpartum depression — has also continued to play an increasing role in maternal deaths.

“That highlights the lack of resources — that’s kind of always been a problem with psychiatry, but particularly when I was working in a rural community,” San Miguel said.

Identifying the factors and conditions that can imperil a mother’s health is key. Keiser said significant progress has been made educating healthcare providers about what to look for.

Often, the first sign of danger comes when a woman seeks care at an emergency room. Keiser said education programs such as Prisma’s SimCoach have helped train emergency department staff on what to look for and how to treat — through realistic simulations — obstetric emergencies such as postpartum hemorrhaging or drug overdose.

While training for medical providers has improved, another missing piece is educating patients — and the people and communities surrounding them — about the risks.

“We still need to make sure that we’re educating on things to look for,” said Shatoria Craig, a clinical nurse for Prisma’s Adult Congenital Heart Disease Program. “There’s so much more to education other than, ‘You can take a Tylenol when you’re pregnant.’”

Access to maternity care and other services can help prevent poor health outcomes and health disparities. This can be challenging for mothers who don’t have insurance or live in maternity care deserts across the state. Maternity care deserts are areas without access to birthing and maternity care facilities.

“As a state, we don’t have enough OBGYN providers,” San Miguel said.

A path forward

Progress is being made, but more people and organizations need to be brought together for a concerted effort to lower maternal mortality rates.

Improving maternal health outcomes is a priority for Urban League of the Upstate. Its recent acquisition of the historic McClaren Medical Shelter is expected to play a key role in this work.

Shanbhag, who serves on the Urban League’s board, said the shelter has a powerful legacy of serving Grenville’s Black community. Founded by Dr. Edward McClaren in 1949, the clinic served more than 1,000 patients during the Jim Crow era.

The Urban League’s plan for the shelter will see it updated and transformed into the McClaren Institute for Health and Quality of Life.

Shanbhag said the new center will be a powerful tool in addressing the health care and wellness disparities for Greenville’s Black residents.

While projects like the McClaren clinic are expected to have a major impact on historically underserved patients, other efforts should be pursued to get the word out to women about their risks during pregnancy, Keiser said.

Keiser said it is important to reach women where they are. Tools like social media and community institutions like churches can play an important role in patient education.

“Church groups are probably a huge untapped resource” for addressing the problem, Keiser said.

A pregnancy-related death occurs when a person dies while pregnant or within one year of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or a condition made worse by the pregnancy.

From the South Carolina Maternal Morbidity and Mortality Review Committee

Maternal mortality fast facts

  • About 84% of pregnancy-related deaths are thought to be preventable
  • Mortality rates for women over the age of 40 are 7 times higher than for women 25 or younger
  • 70% of pregnancy-related deaths happen in the postpartum period
  • 26% of pregnancy-related deaths in South Carolina occur between 42 days and one year after pregnancy.

Racial disparities

Maternal mortality rates per 100,000 live births in the United States, according to the latest CDC report.

For Black women:

  • 37.3 in 2018
  • 44 in 2019
  • 55 in 2020
  • 70 in 2021

For white women:

  • 15 in 2018
  • 18 in 2019
  • 19 in 2020
  • 27 in 2021

For Hispanic women:

  • 12 in 2018
  • 13 in 2019
  • 18 in 2020
  • 28 in 2021

Contributing factors

According to the South Carolina Maternal Morbidity and Mortality Review Committee, contributing factors of pregnancy related deaths in 2018 to 2019 include:

  • 56% — Discrimination
  • 29% — Substance-use disorder
  • 25% — Mental health
  • 22% — Obesity

Effect of age

Data shows the rate pregnancy-related deaths correlate with a woman’s age when she becomes pregnant. Women in the 40 to 44 age range are three to four times more likely to die from maternal causes.