Maternal deaths across the US more than doubled over the course of two decades, and Black mothers died at the nation’s highest rates, researchers said on Monday.

The findings were published Monday in a new study in the Journal of the American Medical Association. Researchers looked at maternal deaths between 1999 and 2019 — excluding the pandemic spike — for every state and five racial and ethnic groups.

Structural racism in the US

The US has the highest incidence of maternal mortality among developed countries, which is defined as a death occurring during pregnancy or up to a year following. Common causes include excessive bleeding, infection, heart disease, suicide, and drug overdose.

“It’s a call to action to all of us to understand the root causes — to understand that some of it is about health care and access to health care, but a lot of it is about structural racism and the policies and procedures and things that we have in place that may keep people from being healthy,” said Dr. Allison Bryant, one of the study’s authors and a senior medical director for health equity at Mass General Brigham.

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According to the report, high rates of maternal death are not just seen in the South but also in the Midwest and areas like Wyoming and Montana, where rates were high for a variety of racial and ethnic groups in 2019.

“I hate to say it, but I was not surprised by the findings. We’ve certainly seen enough anecdotal evidence in a single state or a group of states to suggest that maternal mortality is rising,” said Dr. Karen Joynt Maddox, a health services and policy researcher at Washington University School of Medicine in St Louis who wasn’t involved in the study. “It’s certainly alarming, and just more evidence we have got to figure out what’s going on and try to find ways to do something about this.”

Additionally, Maddox highlighted how, compared with other wealthy nations, the US underinvests in things like social services, primary care, and mental health.

Rates among Black women have long been the worst in the nation, and the crisis impacts people of all socioeconomic backgrounds. For instance, US Olympic champion sprinter Tori Bowie, 32, lost her life from complications of childbirth in May.

According to Bryant, the pandemic probably made all of the regional and demographic patterns worse, and "that's definitely an area for future study." Preliminary government data show that maternal mortality decreased in 2022 after reaching a six-decade high in 2021, a rise that experts mostly blamed on COVID-19. The official rate for 2022 is expected to be close to the pre-pandemic level, which was still the highest in decades, as per officials.

“Most of the deaths we reviewed and other places have reviewed … were preventable,” Greenfield said.

Read next: Black people in US die at higher rate than White counterparts: Study