• Pregnancy
• Hypertension
• Epidemiology

While global maternal mortality has decreased in the last three decades, pregnancy-related deaths remain prevalent in the USA,1 even after accounting for possible over-reporting based on changes in death certificates.2 In 2017, approximately 17 US mothers per 100 000 live births died due to complications related to pregnancy or childbirth; in contrast, only 7 UK mothers per 100 000 live births died that year.3 Up to two-thirds of US maternal deaths may have been preventable.4

Cardiovascular disease has emerged as the driving cause of current maternal mortality rates, causing or related to over one-third of US maternal deaths, with most deaths occurring during or after delivery.4 Recent studies worldwide have also begun to elucidate the long-term consequences of pregnancy-related cardiovascular conditions such as gestational hypertension or pre-eclampsia5 6 ; for instance, a large-scale population study in the UK found hypertensive disorders of pregnancy increased risk across a multitude of cardiovascular disorders with the impact starting soon after pregnancy.7 In the USA, pre-eclampsia-related deaths have decreased in the last two decades, while deaths associated with or due to chronic hypertension have been increasing.2

However, one striking difference between the USA and similarly wealthy countries, which may contribute to rising maternal mortality, is its fragmented insurance coverage. Marschner et al give readers a revealing snapshot of the intersection between …