When tennis superstar Serena Williams spoke up about scary blood clots and other complications she experienced after the birth of her first daughter in 2017, she highlighted a growing health problem.

Maternal mortality rates in the United States long have been the worst among developed countries around the world. Since the COVID-19 pandemic began, death rates among pregnant women and new mothers have climbed higher than ever.

Another top athlete, former Olympian Tori Bowie, suffered a tragedy in June when she died at 8 months pregnant of eclampsia and respiratory complications.

According to researchers at the U.S. Centers for Disease Control and Prevention, the maternal mortality rate for 2021 (the most recent year for which data are available) jumped to 32.9 deaths per 100,000 live births compared with a rate of 23.8 in 2020 and 20.1 in 2019.

Death rates for Black women in 2021 were much higher than those of women overall — an astounding 69.9 deaths per 100,000 live births in 2021. Hispanic and Native American women also face greater risks giving birth or as they recover from childbirth.

Providing help: Heart conditions during pregnancy

To support women who are at greater risk for maternal mortality, Colorado has a first-of-its-kind program for people who are at risk of cardiovascular problems during pregnancy.

“Cardiovascular disease is the No. 1 cause of maternal mortality in the in the United States,” said Dr. Josephine Chou, a cardio-obstetric specialist at UCHealth University of Colorado Hospital, who cares for those who are pregnant and also are coping with cardiovascular complications and heart disease.

For patients who already know they have a cardiovascular health issue like heart failure, arrhythmia, aortic disease, heart attacks or a previous heart transplant, Chou can help patients decide whether it’s safe to get pregnant and deliver a baby. She also helps care for patients who become pregnant and later learn that they are at risk for potentially dangerous cardiovascular complications.

To understand more about maternal mortality and how women with cardiovascular health risks can safely get pregnant and deliver healthy babies, we consulted with Chou. She answered key questions related to maternal mortality and cardiovascular health during pregnancy.

What is cardio-obstetrics?

“Cardio-obstetrics is the care of patients who have heart disease and who are pregnant,” said Chou, who is also an assistant professor of medicine and cardiology at the University of Colorado School of Medicine on the Anschutz Medical Campus.

What is unique about the program you run with fellow doctors?

The program is the only one of its kind in Colorado. Chou and fellow providers team up to serve patients who are pregnant or want to become pregnant who also are at high risk for cardiovascular health challenges.

“I partner with maternal-fetal medicine specialists, and we offer a multidisciplinary approach to care,” Chou said. “I focus on the mom and reducing risks of cardiovascular complications.”

Can women with heart conditions safely get pregnant and deliver healthy babies?

Yes. Many women who have pre-existing cardiovascular problems can safely get pregnant, deliver healthy babies and recover after childbirth. But they need specialized care and extra monitoring both during pregnancy and after they give birth to reduce the risk of complications. That’s why help from an expert like Chou is vital to staying safe and healthy during pregnancy.

What is preeclampsia?

“Preeclampsia is a type of hypertensive disorder of pregnancy. Patients experience elevations in blood pressure that develop at 20 weeks gestation or later,” Chou said.

Preeclampsia can range from what’s known as gestational hypertension, which is an elevated blood pressure that can be relatively minor, to a more severe form of the disease.

“That’s where we have high blood pressure that can result in organ damage,” Chou said. “Then we have the most severe form is eclampsia, which is high blood pressure with seizures.”

Why is pregnancy dangerous for some women?

Pregnancy can be especially dangerous for people who have had previous cardiovascular health challenges or those who are at risk for problems.

“Some patients already have an increased risk for cardiovascular diseases such as heart attack, stroke and heart failure. For these patients, that risk doesn’t go away during pregnancy and after delivery,” Chou said. “They need cardiovascular monitoring not only during pregnancy, but also throughout their lives.”

Some people already know they have risk factors for cardiovascular diseases. Others don’t know that they could be in danger during pregnancy. How do patients know if they need help from a cardio-obstetric specialist like you?

Sometimes a primary care provider or obstetrician will recommend that a patient should see Chou. In other cases, patients have dealt with heart problems earlier in their lives. Some may have been told that they could never safely get pregnant or deliver a baby. That’s not always true, Chou said. That’s why people who want to get pregnant and have had cardiovascular health issues should talk with an expert.

What are the common heart conditions that may require extra vigilance on the part of a patient and her doctor?

The various cardiovascular conditions that require extra monitoring during pregnancy and after the birth of a baby include: hypertensive disorders (elevated blood pressure), heart rhythm problems, also known as arrhythmia, heart failure, a history of blood clots and any kind of aortic diseases. Patients who have experienced a cardiac complication in a prior pregnancy also should receive cardio-obstetric care and monitoring since their risk of experiencing complications in subsequent pregnancies is higher.

What symptoms do people have if they’re dealing with cardiovascular health challenges in pregnancy or in the days and weeks after giving birth to a baby?

“If patients are having cardiovascular symptoms during pregnancy, we want to evaluate them right away,” Chou said. “These symptoms include chest pain, shortness of breath, lightheadedness and palpitations — which are feelings of abnormal heart rhythms,” Chou said.

These symptoms sometimes mean that a person has a cardiac abnormality.

“Other times, it may just be a manifestation of normal pregnancy, but it’s still important to get checked so we can make sure there’s nothing going on,” Chou said.

When Serena Williams described her heath challenges after the birth of her first daughter, she recognized that was dealing with a dangerous blood clot and insisted on getting the medical help she needed. Williams shared her frightening ordeal in a cover story in Vogue.

She described having previously experienced a pulmonary embolism, a sudden blockage of an artery in one of her lungs.

The day after giving birth to her first daughter, Williams said she was having trouble breathing. She said a nurse initially dismissed her concerns and wanted to give her pain medications. Williams suspected that she was having clots again and insisted on getting a CT scan, which proved that her hunch had been correct. She did, indeed, have multiple clots in her lungs and received treatment for the clots.

Williams and her husband announced the birth of their second daughter on Aug. 22. Williams has not shared any details yet about any health challenges related to her new baby.

I hear that Black women more frequently have to deal with heart complications while they are pregnant or following the birth of their babies. Why are ethnic and racial disparities related to maternal mortality so bad in the U.S.?

Ethnic and racial disparities related to maternal mortality are complex and, in all likelihood, stem from multiple causes, Chou said. These causes include:

• Lower rates of health insurance among some people from diverse backgrounds.
• Multi-generational exposure to discrimination and racism.
• Higher poverty rates among some people who are Black, Brown or Native American.
• Bias and dismissive attitudes among some health care workers toward all women and, in particular, to racial and ethnic minorities.

Sadly, a stunning four in five cases of pregnancy-related death were entirely preventable, according to a recent CDC study.

Relatively simple interventions like better patient education and improvements in health systems could make a big difference and save lives, Chou said.

Here were the key findings from the CDC study:

• More than 80% of pregnancy-related deaths were preventable, according to data from 2017-2019.
• Among pregnancy-related deaths with information on timing, 22% of deaths occurred during pregnancy, 25% occurred on the day of delivery or within 7 days after, and 53% occurred between 7 days to 1 year after pregnancy.
• The leading underlying causes of pregnancy-related death include:
  • Mental health conditions (including deaths related to suicide and substance use disorders) (23%)
  • Excessive bleeding (hemorrhage) (14%)
  • Cardiac and coronary conditions (relating to the heart) (13%)
  • Infection (9%)
  • Thrombotic embolism (a type of blood clot) (9%)
  • Cardiomyopathy (a disease of the heart muscle) (9%)
  • Hypertensive disorders of pregnancy (relating to high blood pressure) (7%)

The leading underlying cause of death varied by race and ethnicity. Cardiac and coronary conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black women. Mental health conditions were the leading underlying cause for Hispanic and white women, while hemorrhages were the leading cause of death among Asians.

Since just over half of pregnancy-related deaths happened up to a year after delivery, the CDC researchers said it’s critical for health care providers to follow up with women who have recently given birth.

“Health care systems, communities, families and other support systems need to be aware of the serious pregnancy-related complications that can happen during and after pregnancy,” CDC researchers wrote. “Listen to the concerns of people who are pregnant and have been pregnant during the last year, and help them get the care they need.”

Researchers recommended:

• Better access to health insurance and health care.
• Improving prenatal care and follow-up care after the birth of a baby.
• Reducing barriers to transportation.
• Better referrals and coordination to those who are pregnant or have recently given birth can access timely help.

Is it common for young women to have heart conditions and cardiovascular problems?

While most young people don’t have cardiovascular health conditions, Chou said it’s getting more common for younger people to have serious health issues that can make pregnancy riskier.

“More and more women are coming into pregnancy with worse heart health,” Chou said. “There are more women with chronic hypertension, diabetes, obesity and tobacco use. All of these cardiovascular risk factors are occurring at a younger age.

“So patients are coming into pregnancy with more cardiovascular risk factors, which, in turn, increases their risk of complications in pregnancy.”

If someone already has cardiovascular challenges, how risky is it to get pregnant?

Chou said it’s really valuable for anyone with health challenges to meet with experts, but she emphasized that patients should always make their own decisions.

“We don’t tell people that they can or can’t get pregnant. We give them the information to help them make decisions for themselves. Then we support them through and after that decision,” she said.

Is pregnancy safe for some people with heart conditions that might have caused experts in the past to tell women they absolutely could not safely get pregnant and have a baby?

Yes. Some women who have head heart transplants might have been discouraged in the past from ever getting pregnant. With very careful monitoring and support, some heart transplant patients can safely get pregnant and deliver a healthy baby.

Chou said there are other health conditions that might have been seen as deal-breakers for pregnancy in the past. But it may be possible for some patients to safely get pregnant and deliver a healthy baby.

These cardiovascular health challenges include:

• Heart failure (specifically a condition known as peripartum cardiomyopathy).
• Marfans disease (a condition that causes an enlarged aorta). It’s possible for patients to have surgery to repair the aorta and reduce the risk of subsequent pregnancy.

How did the COVID-19 pandemic affect those who were pregnant?

Maternal mortality rates in the U.S. jumped to startlingly high levels during the pandemic.

Some women did not get vaccinated, and some pregnant women who got COVID-19 faced major health challenges.

In addition to pregnant women being at greater risk for serious illness if they got COVID-19, Chou said prevent care declined during the pandemic. Thus, some women who were pregnant did not receive adequate pre-natal care, which could have put them at higher risk for pregnancy-related health problems.

How hopeful are you that health experts in the U.S. can drive down maternal mortality rates?

Chou is optimistic that health care providers can improve outcomes.

“We know that many of the causes of maternal mortality are preventable through clinical care and education, so that does give us a ray of hope,” Chou said. “We can improve our systems of care so we have better communication between specialists. We need rapid escalation of care when cardiovascular complications come up for a person who is pregnant. We also need to increase awareness amongst patients and providers so they know what to look for and when to seek help.”