With modern medicine, it’s almost unthinkable that women still die in childbirth in the US. But the fact is our rate of maternal deaths is higher than that of other industrialized nations and, what’s worse, it’s rising. The latest numbers show that 24 women die for every live 100,000 births—a 26% increase since 2000. Considering there are four million babies born every year, that’s 1,000 women. The problem is the greatest in rural communities where many local hospitals have shuttered, leaving women without access to the care they need. But pregnancy-related deaths can and do happen anywhere.

What puts a woman at risk?

  • Preexisting medical conditions such as high blood pressure, chronic kidney disease, HIV, lupus and thyroid disease raise the risk for serious pregnancy complications, including a life-threatening form of high blood pressure called preeclampsia, hemorrhaging and fetal embolisms (pregnancy-related particles that get into the bloodstream and can block arteries to your heart).
  • Diabetes, both types 1 and 2, as well as gestational diabetes (the type that first develops during pregnancy) can cause the baby to grow larger than normal, making delivery more difficult.
  • Being overweight. Obesity in itself increases risk of having diabetes and high blood pressure. When BMI is high, the risk of C-section and hemorrhage increases as well.
  • Being 35 or older. As we age, we’re more likely to develop conditions such as high blood pressure and diabetes. Women who get pregnant after the age of 35 seem to develop gestational diabetes at a higher rate than younger women…and women who become pregnant after age 40 are at higher risk for preeclampsia. All of these things combined can increase the risk for the most common causes of severe maternal morbidity including hemorrhage, blood clots and hypertensive urgency (extreme high blood pressure).
  • Carrying twins—or more, which increases the chances of an early delivery. Twins can essentially outgrow the uterus and cause a woman to go into labor early. Also, after delivery, the uterus does not stop its bleeding as effectively as it does after having a single baby.

What should you do? Beyond following a healthy lifestyle, the key to having a safe pregnancy and delivery with any of these conditions is having a skilled obstetrics team in place to closely monitor you and baby. Here’s how…

Choose an ob/gyn who specializes in high-risk pregnancies. The doctor you’ve been seeing for gynecology care may not be the best obstetrician if you have any preexisting conditions. Ask for a referral to a doctor who is certified as a perinatologist, a maternal-fetal medicine specialist. A perinatologist has two to three years of additional training in medical complications that can arise during pregnancy. You can also use the search option on the Society for Maternal Fetal Medicine site to find a specialist near you.

Maternal-fetal medicine specialists work with all obstetric providers, including physician assistants, nurse practitioners and traditional ob/gyns to provide care for you and your baby. Note: Do not consider a home birth or birthing center for a high-risk pregnancy.

You’re mostly likely to find a perinatologist at urban medical centers, which might require you to travel to get this care. Depending on your situation and the specialist’s geographic availability, a perinatologist may work alongside your existing ob/gyn, see you intermittently and then be at the delivery…as long as he/she has delivery privileges at a hospital in your area. If not, you’ll need to decide if, logistically, you’ll be able to travel to his  hospital (and find out if your insurance will cover it) when baby comes.

What can you do if you don’t have access to a perinatologist? Have a candid conversation with your existing ob/gyn to discuss his experience with the most serious and most common threats to a pregnant woman’s health. Ask how he will monitor you and the baby and make sure neither is in distress. If his experience with high-risk pregnancies is limited, ask if there’s a colleague you can be referred to. Also, find out if the hospital you’re scheduled to deliver at has a neonatal intensive care unit (NICU) for your baby should it be needed. Though you may be the one who needs intensive care, hospitals that have NICUs are likely to have high levels of care for mom as well.

What care can you expect? If you’re high risk, you may need to be seen as much as twice a week throughout your pregnancy. You likely will need more blood tests and ultrasounds than normal and possibly other specialist visits, such as a cardiologist or nephrologist (kidney specialist), depending on your unique needs. Telemedicine initiatives in some rural communities are making this easier for women who don’t have local access to certain specialists.

If your experts aren’t all in the same health network, be your own advocate and ask that all workups are shared with all other members of your care team. While there are initiatives under way from leading health organizations to improve maternal health, it’s important to advocate for yourself until that happens.