In the July-August 2021 edition "Progress in Prevention" column, we shared a brief summary highlighting the disproportionate and inequitable burden of cardiovascular-related maternal mortality experienced by Black, Indigenous, and persons of color and summarized the status of the Black Maternal Health Momnibus Act at that time.1 Since then, new reports have indicated that maternal mortality rates have increased every year between 2018 and 2021, a rise of nearly 60%, with continued disparities.2 In 2021, the death rate for Black women was 69.9 deaths per 100 000 live births, 2.6 times higher than the death rate for White women, at 26.6 per 100 000.2 The COVID-19 pandemic worsened maternal death rates and likely exacerbated existing racial disparities, only intensifying this unacceptable and adverse trend. The United States continues to have the highest maternal mortality rate among high-income countries with an undersupply of maternity care providers and a lack of comprehensive postpartum care, despite spending more on healthcare than any other nation.3

Pregnancy-related deaths occur during pregnancy and delivery, but over half of deaths occur between 7 days and 1 year after pregnancy. Cardiovascular disease (CVD) is a leading cause of death and underlies most maternal mortality from cardiac and coronary conditions, cardiomyopathy, hypertensive disorders of pregnancy, and cerebrovascular accidents. Other leading causes include mental health conditions and hemorrhage.4 Most deaths (82%) occurred in urban areas, and over 84% of deaths were determined to be preventable.4

The Black Maternal Health Momnibus Act was first introduced to Congress in March 2020 as a series of bills to address maternal health outcomes among minority populations. Since its initial introduction, 1 bill, the Protecting Moms Who Served Act, unanimously passed in February 2021 to address maternal mortality, morbidity, and disparities among veterans. The most recent 2023 version was reintroduced on May 15, 2023, the day after Mother's Day in the United States, and encompasses 13 bills that will

* make critical investments in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition;

* extend WIC (Special Supplemental Nutrition Program for Women, Infants and Children) eligibility in the postpartum and breastfeeding periods;

* provide funding to community-based organizations that are working to improve maternal health outcomes and promote equity;

* increase funding for programs to improve maternal healthcare for veterans;

* grow and diversify the perinatal workforce to ensure that every mom in America receives maternal healthcare and support from people they trust;

* improve data collection processes and quality measures to better understand the causes of the maternal health crisis in the United States and inform solutions to address it;

* support moms with maternal mental health conditions and substance use disorders;

* improve maternal healthcare and support for incarcerated moms;

* invest in digital tools to improve maternal health outcomes in underserved areas;

* promote innovative payment models to incentivize high-quality maternity care and nonclinical support during and after pregnancy;

* invest in federal programs to address maternal and infant health risks during public health emergencies;

* invest in community-based initiatives to reduce levels of and exposure to climate change-related risks for moms and babies; and

* promote maternal vaccinations to protect the health of moms and babies.

Nurses are powerful agents to address the US maternal health crisis. By advocating for federal, state, and local legislation such as the Momnibus, nurses lead initiatives in the care environment to promote effective team communication and advocacy for patients. All women of childbearing age should have a CVD risk assessment with the objectives of (a) disease prevention through lifestyle modifications and use of medications when indicated and (b) early identification of cardiovascular conditions before pregnancy.5 Most pregnant women who die of CVD complications have no formal diagnosis of CVD, and pregnancy may be the first time that a woman formally engages with the healthcare system.6 Furthermore, many of the early warning symptoms of CVD-related complications mimic those of pregnancy and postpartum, so women's CVD symptoms are often dismissed and key opportunities to intervene are missed. Any time a woman is interacting with the healthcare environment, her pregnancy history should be assessed. Several risk assessment tools are available. The American College of Obstetricians and Gynecologists has published practice guidelines that provide guidance for risk factor identification during antepartum and postpartum periods as well as recommendations for care.7 The modified World Health Organization classification tool is a validated instrument for obtaining a cardiovascular risk assessment of pregnant women with heart disease.8 Nurses, no matter the practice environment or specialty, must be aware of urgent maternal warning signs during and after pregnancy, including the long-term health risks of having a pregnancy complicated by CVD. Ongoing postpartum and lifelong follow-up should be instituted for women with a history of hypertensive disorders of pregnancy or preeclampsia because they carry a higher risk for future CVD.9

The Centers for Disease Control and Prevention have launched the "HEAR HER" campaign to prevent pregnancy-related deaths by sharing potentially lifesaving messages about urgent warning signs (http://cdc.gov/HearHer).10 This campaign targets patients, their support networks, and health providers to improve communication around key CVD warning signs.

The proposed Momnibus legislation, the campaigns led by the Centers for Disease Control and Prevention, and many other organizations to address maternal mortality are most effective if supported, funded, and acted upon. Nurses play a key role in actualizing these initiatives. As we stressed before in the 2021 Call to Action,1 nurses can and should lead the changes necessary to address the US maternal health crisis. With 84% of maternal deaths preventable, no person should die unnecessarily related to childbirth.

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