Mental health conditions, including substance use disorder and suicide, cause more than half the deaths
By Namira Haris and Sophia Lucente
NewsWorks Lab
Seven months pregnant with her fourth child, Iyanna Bridges was told by her midwives she needed a series of blood transfusions.
They worried about how much blood she might lose during delivery, but when she asked about alternatives, the practice dropped her.
The obstetrician she was then referred to said blood loss was not the concern. Instead, he scheduled a cesarean at their first meeting, before introducing himself. He said it was because of her weight — the same as when she had delivered her first three children vaginally.
“So, at 34 weeks, I decided I’m not doing this with anybody,” Bridges told NewsWorks Lab. “I didn’t want to go to the hospital and die giving birth because, if you weren’t listening to me while I’m pregnant and I’m able to fully articulate myself, then I don’t even want to understand what the experience would be like in the midst of me being in labor and contractions.”
In May 2018, Bridges, who is Black, gave birth to her fourth child at home in Duquesne, unassisted and without complications. Later that year, she trained as a doula and founded The Birthing Hut, which provides maternal support services primarily for Black women across the Pittsburgh region.
As a Black woman in Duquesne, Bridges represents a group of women who face additional risks when it comes to pregnancy and delivery.
While previously released data shows Black women in Allegheny County are two to three times more likely to experience a severe childbirth complication, a NewsWorks Lab analysis reveals deeper meaning to these risks: Most deaths happen long after delivery, and most relate to mental health.
Of the 47 pregnancy-associated deaths recorded in Allegheny County between 2020 and 2023, 36 occurred more than six weeks after pregnancy ended, according to data provided to NewsWorks Lab by the Pennsylvania Department of Health.
The state defines a pregnancy-associated death as any death during pregnancy or within a year of its end, regardless of cause. Of the 47 deaths, the state’s maternal mortality review committee determined that 18 were pregnancy-related, meaning pregnancy caused or worsened the condition that led to death.
“We are beyond knowing there is a problem,” said Jada Shirriel, chief executive officer of Healthy Start Pittsburgh, a federally funded program that seeks to reduce poor birth outcomes. “The real question is whether we are willing to change policies, practices, funding and systems in ways that actually improve outcomes.”
Allegheny County’s five-year maternal mortality rate rose to 6.0 deaths per 10,000 births in 2018–2022 from 3.9 in 2013–2017. The gap between Black and white mothers widened over the same period.
“Tragically, we do see fatalities that are entirely preventable,” said Jean Fitzgibbons, a nurse practitioner with Allegheny Health Network’s Perinatal Hope program, which treats pregnant and postpartum women for addiction.
Deaths come later
Six weeks has long marked the traditional postpartum checkup. It is also the cutoff in the World Health Organization’s conventional definition of maternal mortality, which counts deaths within 42 days of a pregnancy ending. Pennsylvania tracks pregnancy-associated deaths through a full year.
“The six-week postpartum is where the WHO currently stops counting, and so what we found is when we do that, we miss about half of the deaths” after delivery, said Dr. Joia Crear-Perry, founder of the National Birth Equity Collaborative, an organization advocating for equitable maternal health care.
“The six weeks is not based on any kind of medical or clinical information,” she added. “There’s nothing magically that happens at six weeks.”
Clinical guidance already reaches further. National guidance from the American College of Obstetricians and Gynecologists calls for contact within the first three weeks after delivery and a comprehensive visit no later than 12 weeks, said Dr. Hyagriv Simhan, a maternal-fetal medicine specialist at UPMC and the University of Pittsburgh.
Mental health conditions, including substance use disorder and suicide, accounted for 27 of the 47 pregnancy-associated deaths in Allegheny County between 2020 and 2023, more than any other cause category, according to state data.
Mental health symptoms can emerge months after childbirth, long after routine postpartum visits.
“These kinds of feelings can last not even just in the first couple months after you deliver, but can even manifest six months or nine months after the delivery,” said Dr. Tracy Chen, an obstetrician-gynecologist with Allegheny Health Network. “Not just because of the hormonal changes, but because truly of the lifestyle changes that occur after.”
At Perinatal Hope, Allegheny Health Network’s addiction treatment program for pregnant and postpartum women, patients can continue receiving care long after giving birth. The program dropped its six-week cutoff years ago after watching patients fall away at it.
“We had patients who just were really intimidated and overwhelmed by finding new providers,” Fitzgibbons said. “You’re having to go to a pediatrician appointment every other day, it feels like, for weight checks for your newborn, and then you’re having to enroll in WIC and do all of these other appointments. And now you’ve got to find a new prescriber for your medication for opioid use disorder.”
For women receiving treatment for opioid use disorder, losing access to medication or having to find another provider can add to the risks during an already vulnerable period, she added.
“The rates of recurrence of use at this time and the number of deaths that occur from accidental overdose in the immediate postpartum period are staggering,” Fitzgibbons said. “The most common cause of an immediate postpartum death is an accidental overdose.”
One measure that could help prevent fatal overdoses, she said, is providing naloxone, a medication that reverses opioid overdoses, to patients when they leave obstetric care.
“If everyone was discharged with naloxone, and we had more naloxone in the communities, it would follow that we would hopefully have at least some fewer accidental overdose deaths,” she said.
Perinatal Hope carries about 100 patients at a time, some for years. But Fitzgibbons said some mothers hesitate to seek treatment because they fear losing custody of their children.
“Patients just often don’t feel comfortable disclosing this information. And there are concerns about CYF involvement and potential custody of their children,” she said, referring to the county’s Office of Children, Youth and Families. “The idea of if I go get help, I’m going to have to put my child in foster care is unthinkable for, I think, many moms.”
Fitzgibbons said childcare, transportation and a shortage of treatment facilities that accept mothers with children also make getting help difficult.
Bridges sees similar struggles outside the clinic.
“We are seeing a whole lot of moms nationally as well as locally going through a lot when it comes to postpartum psychosis, postpartum depression, and postpartum anxiety, and a lot of times it’s getting written off as ‘baby blues,’” Bridges said. “A woman’s body can take up to a year to recover from birth. To push that year down to about a couple of weeks — maybe four weeks, dependent on their work, to go back to work — is just crazy.”
Abby Perez, who leads Pittsburgh Bereavement Doulas, a group that supports families grieving pregnancy and infant loss, has lost two clients: One died during labor, along with her baby; another died about six weeks after giving birth. Both surviving partners are now raising children alone.
“We do not yet have a formal service plan specific to the death of a parent, whether or not the baby also dies,” Perez said. “Families need a clear path to care.”
Medicaid expansion
Pennsylvania extended Medicaid coverage to a full year after pregnancy ends in April 2022, closing a gap that previously ended coverage at 60 days.
“Some states still have not done the Medicaid expansion for up to a year after pregnancy, which doesn’t make any sense, as we see from the data that at least 50% of the deaths occur six weeks to a year after the baby is born,” Crear-Perry said.
Coverage alone does not guarantee timely care. At Allegheny Health Network’s perinatal mental health center, wait times run three to four weeks for medication management and longer for therapy.
Allegheny County Council voted 11-4 on Oct. 20 to require employers with 15 or more workers to provide 12 weeks of paid parental leave, and County Executive Sara Innamorato signed it into law two days later. The mandate, which covers birth, adoption and stillbirth, takes effect in a year. Allegheny is the first county in the nation to adopt such a policy in a state without one.
“As a birth worker, I’ve had experiences with families that had the luxury of paid leave, and I’ve also worked with families that, unfortunately, did not experience paid leave,” Bridges said at an event held by PA United, a statewide advocacy group. “The difference is day and night.”
A second story examining childbirth complications in Allegheny County, and the communities where they are concentrated, will follow.
If you or someone you know is struggling, the 988 Suicide and Crisis Lifeline is available 24 hours a day by call or text, in English and Spanish. The Postpartum Support International HelpLine is 1-800-944-4773; press 1 for Spanish, 2 for English.
Namira Haris is a data journalist for NewsWorks Lab who can be reached at nharis@newsworkslab.com. Sophia Lucente is a NewsWorks Lab contributor.
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