By Rachel Crumpler

Drug overdoses, infections and homicides were the top three causes of pregnancy-related deaths in North Carolina from 2018 to 2021.

That’s according to a report released last month by North Carolina’s Maternal Mortality Review Committee, a volunteer group of multidisciplinary experts that examines all deaths during pregnancy or within one year of the end of a pregnancy to understand the causes and make recommendations to prevent future deaths.

The committee reviewed 450 maternal deaths over the four-year period, which included the height of the coronavirus pandemic. They determined that just under half the deaths were pregnancy-related. 

On average, 49 pregnancy-related deaths occurred each year. 

“We are still having moms who die from pregnancy or complications connected to their pregnancy, and that is the sad part of it,” said Belinda Pettiford, chief of the Women, Infant and Community Wellness Section at the N.C. Department of Health and Human Services. “Most people, if they lose a loved one and it is connected to a maternal death, it is not shared broadly… It is a very private moment, so most people don’t realize it is happening.”

The report found persistent disparities in pregnancy-related deaths across demographic groups. Rural women were nearly three times more likely to have a pregnancy-related death than women living in urban counties. Black women were 1.7 times more likely to have a pregnancy-related death than non-Hispanic white women.

Overall, committee members determined that about nine in 10 pregnancy-related deaths were preventable, meaning there was “at least some chance of the death being averted by one or more reasonable changes.”

“That’s really heartbreaking,” said Tina Sherman, national director for maternal justice at MomsRising, who is a member of the Maternal Mortality Review Committee. “The hardest part for me is that these deaths — nearly 90 percent — are preventable, and those are policy choices.”

But, she added, “The fact that it’s policy-oriented means that we can also fix it.”

Mental health conditions accounted for about 1 in 3 deaths

North Carolina’s Maternal Mortality Review Committee, established in 2015 through state legislation, currently has 18 members who pore over the medical records, histories and circumstances of each death and work to pinpoint the causes.

Among the 195 pregnancy-related deaths from 2018 to 2021, mental health conditions — including substance use disorders — were the overall leading cause of death, accounting for 60 deaths, or nearly one-third of the total.

Suicides accounted for 13 of those 60 deaths. A larger portion of the mental health-related deaths — 47 — were attributed to accidental drug overdoses. Fentanyl was involved in 38 of those overdoses.

Mel Ramage, a nurse practitioner who has treated patients with substance use disorder for over a decade and who is a member of the Maternal Mortality Review Committee, said it’s staggering to see overdoses account for such a large portion of pregnancy-related deaths. 

“If I told you the leading cause of preventable death in North Carolina is mental health conditions, that does not add enough specificity to action,” Ramage said. 

While screening for anxiety and depression in pregnant and postpartum women is crucial, she said those screenings are “insufficient” to address all the risk factors leading to accidental overdoses.

Beyond North Carolina, overdose deaths account for a growing share of maternal deaths nationally. A 2024 CDC report examining pregnancy-related deaths from Maternal Mortality Review Committees in 38 states found that substance use was a contributing factor in about one in four pregnancy-related deaths nationwide in 2020. 

Ramage said one of the biggest barriers to perinatal substance use disorder treatment is the low number of providers in the state that offer it. Some doctors treat pregnant patients, while others treat substance use; few treat both.

The North Carolina Perinatal Substance Use Disorder Network, which Ramage leads, is working to address that gap by building providers’ comfort in treating pregnant and postpartum patients. Formed in 2024, the network brings together six perinatal substance use disorder programs aimed at expanding access to medications for opioid use disorder and sharing best practices through a “hub and spoke” approach.

The maternal mortality review report makes several recommendations to combat future overdose deaths, including for obstetric providers to proactively offer naloxone — an overdose reversal medication — to pregnant and postpartum patients with histories of opioid use disorder or overdose. Another recommendation is for outpatient obstetric settings to integrate behavioral health and substance use specialists on their teams to facilitate better access to addiction treatment.

Discrimination, social stressors contribute to deaths

North Carolina’s pregnancy-related deaths are not evenly distributed across the population. 

The committee’s review documented gaps across race, age, education, marital status and geography:

• Black women had a pregnancy-related mortality ratio of 59.6 deaths per 100,000 live births — 1.7 times higher than non-Hispanic white women.
• Rural women had a pregnancy-related mortality ratio of 90.2 deaths per 100,000 live births — nearly three times higher than women in urban counties. 
• Women who were unmarried, divorced, separated or widowed had a pregnancy-related mortality ratio of 68.8 deaths per 100,000 live births, compared with 20.5 among women who were married at the time of death. 
• North Carolina’s pregnancy-related mortality ratios increased with maternal age and were highest among women 35 and older.
• Pregnancy-related mortality is inversely related to maternal education: As education levels increased, mortality rates decreased. 
• Women covered by Medicaid had significantly higher pregnancy-related mortality ratios compared with women who were not covered by Medicaid.

Notably, discrimination was identified as a contributing factor in 128 pregnancy-related deaths — nearly two-thirds of the cases reviewed. Committee members found that people were discriminated against because of their racial and/or ethnic background, obesity, where they lived, criminal justice involvement and substance use — all factors that can contribute to stigma, according to the report.

“The report is clear on where discrimination is seen, and one of the best ways to start addressing some of those concerns is to ensure that the providers that are providing care look like the families that are receiving the care,” Sherman said.

In her advocacy work with MomsRising, Sherman has pushed for expanding access to doulas and midwives as one way to improve maternal health outcomes.

In addition to reviewing the medical circumstances, the committee has in recent years started assessing potential levels of social and emotional stress at the time of each person’s death. The stressors they identify and examine include: a history of domestic violence, a history of psychiatric hospitalizations, child protective services involvement, a history of substance use, unemployment, a history of treatment for substance use, unintended pregnancy, recent trauma, a history of childhood trauma and prior suicide attempts.

Among the 195 pregnancy-related deaths from 2018 to 2021, nearly two-thirds had some evidence of social or emotional stress at the time of their death, according to the report. Unemployment, a history of substance use and a history of domestic violence were the most frequently documented stressors.

“Whether it’s unstable housing and a history of homelessness or a history of incarceration, we can’t escape how socioeconomic conditions really affect maternal health,” Sherman said. 

“Healthy pregnancies don’t just happen. Families really need to be safe and have economic stability and supportive communities.” 

For example, Sherman voiced concern about the impact of federal cuts to Medicaid and impending work requirements that she fears could result in people losing coverage, potentially worsening maternal health outcomes. 

Turning tragedy into recommendations for change 

After extensively reviewing each pregnancy-related death in the state, the North Carolina Maternal Mortality Review Committee makes recommendations aimed at preventing future deaths. 

The committee developed 764 recommendations based on the deaths during the four-year period, with an average of five recommendations per case, according to the report. Many focus on system- and provider-level changes, such as ensuring standardized screening for mental health and substance use at every trimester and postpartum visit, and increased public health initiatives focused on intimate partner violence.

“To be able to turn that tragedy into a tangible recommendation, it’s so meaningful to be able to do that, and it really, for me, puts meaning behind all the numbers and the losses,” Sherman said.

Pettiford said the committee’s recommendations inform state policy and maternal health priorities. 

“One maternal death is one death too many, but [this committee] does help us think through what should we do to reduce the incidents moving forward,” Pettiford said.

For example, Sherman said the committee raised the need to expand postpartum Medicaid coverage. In 2022 — after the window examined in the report — the state legislature extended coverage from 60 days after delivery to up to 12 months, giving women a way to pay for medical care during a critical time when many health concerns can arise after birth.

Reducing deaths

Because the committee’s work is time-intensive and its members serve as volunteers, the data lags behind by several years. 

Pettiford said North Carolina’s Maternal Mortality Review Committee is working to catch up, and a 2022 change expanding the committee from nine to up to 20 members has been positive, bringing more viewpoints to the table and dividing up the workload.

“The more voices we have at the table, the more expertise we have at the table,” Pettiford said, noting there’s representation from high-risk obstetrics, midwifery, social work, mental health and substance use treatment providers. “It really helps drive the conversation and the discussion that the committee is having.”

She said the committee has almost finished reviewing maternal deaths from 2022 and plans to release those findings in early 2027.

Knowing that so many deaths are preventable is a source of discomfort and of optimism for Ramage and Sherman, who said they believe maternal outcomes can be improved in North Carolina.

“The [health care system] was not set up yesterday as well as it could be set up tomorrow,” Ramage said. 

It will take an all-hands-on-deck effort to bring about the needed change, she said, as the United States confronts the worst maternal mortality rate among developed nations. North Carolina’s rate has trended higher than the national average.

“Our report shows it’s not just the responsibility of our perinatal health providers [to reduce these deaths],” Sherman said. “There’s so many different stakeholders that are a part of the solution, and so grabbing onto that piece that you see and running with it.”

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