Author : SRT Date : April 14, 2026

The Most Preventable Cause of Poor Health—The Missed Diagnosis

When Jasmine, a 29-year-old new mother, returned to the emergency room one week after delivery, she complained of shortness of breath and fatigue. She was sent home twice with reassurance that it was “just the stress of new motherhood.” Then she collapsed in her living room and was admitted to the hospital. The diagnosis—postpartum cardiomyopathy (heart failure).

Stories like Jasmine’s are heartbreaking, and not rare enough. In thinking about how to reduce our too high maternal mortality rates, we have recognized delayed or missed diagnosis is one of the most preventable contributors to maternal mortality.

The Reality Behind the Numbers

  • The U.S. has one of the highest maternal mortality rates among high-income countries.¹
  • Black women and Native American women are nearly three times more likely to die from pregnancy-related causes than white women.²
  • Reviews of maternal deaths consistently find that delayed recognition and missed opportunities for diagnosis are common threads.³

Why Missed Diagnoses Happen

  • Symptoms are dismissed as “normal postpartum recovery” or “stress.”
  • Providers are under time pressure, leading to incomplete histories.
  • Care is fragmented across multiple settings—ER, OB clinic, primary care—with no unifying diagnostic process.

What Providers and Students Can Do

  • Take every postpartum complaint seriously—especially chest pain, shortness of breath, severe headache, or heavy bleeding.
  • Use structured frameworks: ask thorough history questions, consider broad differentials, and filter carefully.
  • Remember that normal tests do not always mean no disease. Clinical reasoning must come first.

If we want to lower maternal deaths, we must stop missing what’s right in front of us. That’s why I built Access Diagnosis—an AI-powered tool that helps clinicians:

  • Ask the right history questions up front
  • Build broad differential diagnoses
  • Use exam findings, labs, and imaging to refine—not replace—clinical judgment

Because the most preventable cause of maternal death is the diagnosis we didn’t make in time.

References

  1. Hoyert DL. Maternal Mortality Rates in the United States, 2021. NCHS Health E-Stats. 2023. National Center for Health Statistics.
  2. Centers for Disease Control and Prevention. Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68:762–765. doi:10.15585/mmwr.mm6835a3
  3. Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423–429. doi:10.15585/mmwr.mm6818e1