Alabama women die from pregnancy and childbirth complications at more than double the rate of women nationally, according to new numbers from the National Center for Health Statistics at the Centers for Disease Control and Prevention.

Alabama now ranks third highest in the nation in maternal death rates, behind Arkansas and Kentucky.

This is the first year in more than a decade that the federal government has published an official U.S. maternal mortality rate. The lag is due to a delay in states adopting standardized death certificates.

Alabama’s new rate of 36.4 maternal deaths per 100,000 live births was third-highest in the nation for 2018, the latest year for which data is available. The national rate is 17.4.

Alabama's maternal death rate of 36.4 is third-highest in the nation and more than twice the national average of 17.4, according to new data released by the National Center for Health Statistics.

“The latest maternal mortality statistics reaffirm a disturbing reality: The U.S. is in the midst of a maternal and infant health crisis,” said Dr. Rahul Gupta, senior vice president and chief medical and health officer at the March of Dimes, in a statement.

“We’re losing a shocking number of mothers each year and it’s crucial that we’re able to consistently track these deaths if we’re serious about preventing them.”

While the overall U.S. maternal death rate is 17.4 deaths per 100,000 live births, that number masks a glaring racial disparity: black women die at a rate of 37.1, more than double the rate of white women at 14.7, and Hispanic women at 11.8.

Black women die at more than double the rate of white women and Hispanic women from pregnancy-related causes, according to new data from the National Center for Health Statistics.

The new 2018 maternal death rates, though they come with caveats, are widely seen as a wakeup call. The United States ranks 55th in the world for maternal deaths, just behind Russia, and ranks worst among wealthy countries.

The U.S. rate is also higher now than it was 10 years ago, even as the global rate continues to decline.

The NCHS urges “caution” when trying to interpret the new data, however.

“The data from the NCHS report comes from the pregnancy checkbox on the death certificates,” said Dr. Rachel Sinkey, a professor in obstetrics and gynecology at the University of Alabama at Birmingham and chair of Alabama’s Maternal Mortality Review Committee.

“That is one way, although not the most accurate way, to identify a maternal death.”

The death rates are calculated based on deaths up to 42 days after delivery. Although that’s the definition used by the World Health Organization, it can miss some pregnancy-associated deaths, said Sinkey.

“Deaths resulting from pregnancy may happen more than 42 days postpartum,” she said. “For example, pregnancy can cause irreversible damage to a mother’s heart, called cardiomyopathy, and these deaths often occur more than 42 days after delivery.”

The actual number of maternal deaths reported in Alabama via the death certificate checkbox in 2018 is 31. Because it’s a slightly different way of counting maternal deaths than in previous years, it can’t easily be compared apples-to-apples with Alabama’s 41 maternal deaths in 2017.

“Even with unreliable numbers, Alabama is still doing terribly compared with other states,” said Trace Zarr, director of political development for the Medical Association of the State of Alabama, a professional organization representing Alabama doctors.

“Where we stand nationally as a state is still far behind most of the rest of the nation.”

The 31 deaths in Alabama in 2018 also do not include deaths from pregnancy-associated causes, such as suicide and drug overdose.

There’s evidence to show that using such a narrow definition of maternal death could leave out many deaths that can be positively linked to pregnancy and childbirth.

In Illinois, for example, one fifth of all deaths of pregnant women and new mothers in 2014-2016 were suicides and overdoses, according to a report from ProPublica.

One way states can get a clearer, more comprehensive picture of the causes and contributing factors of maternal deaths is through a statewide maternal mortality review committee. The CDC recommends this method since death certificate data alone has been shown to be unreliable.

Alabama recently launched its own committee, which has begun the process of reviewing maternal deaths from 2017 but operates largely as a volunteer-run organization.

“Maternal Mortality Review Committees are key to allowing stakeholders to determine if the death was related to pregnancy, like hemorrhage or hypertension, or a pregnancy-associated death, like an automobile accident,” said Sinkey. “The NCHS data don’t provide that level of detail.”

In recent months, Alabama medical and nonprofit organizations have asked the governor and state legislators to set aside nearly half a million dollars to fund the committee.

“The biggest takeaway from this report is that the checkbox and death certificates aren’t always reliable, and we need a Maternal Mortality Review Committee to actually sit down and go through those deaths,” said Zarr. “Once you confirm those deaths were related to pregnancy, you can finally start to assess the questions of why they happened, what went wrong and what we can do to fix it.”

Gov. Kay Ivey’s approved budget was sent to the legislature with a line item for $478,000 to fund the Maternal Mortality Review Committee. Now it’s up to state legislators whether that remains in the budget when it’s passed.

“It’s not a republican or Democrat issue,” said Zarr. “The death of a mother affects everyone. Our work is not done yet.”