Efforts to stem maternal deaths in the United States continue to fall woefully short, with the maternal mortality rate more than doubling over the past 2 decades—and with certain racial and ethnic groups being impacted more severely than others.  That is the finding of a novel state-by-state analysis of maternal deaths recently released in JAMA which aim was to quantify trends in maternal mortality ratios (MMRs; maternal deaths per 100,000 live births).

The study reveals that the death rate of women who were either pregnant or had been pregnant within the past year rose from 12.7 deaths per 100,000 live births in 1999 to 32.2 deaths per 100,000 in 2019.  In toto, maternal deaths increased from 505 to 1,210 over the 20-year timespan.  Increases in maternal mortality rates were found across nearly all states and among all racial and ethnic groups between the decades of 1999 to 2009 and 2010 to 2019.

Defining deaths

The US Centers for Disease Control and Prevention (CDC) defines maternal mortality, or maternal death, as a death during or up to 1 year after the end of pregnancy.  CDC further lists the common causes of maternal death as mental health conditions (including death by suicide, and overdose related to substance use disorder), hemorrhage, cardiac and coronary conditions, infection, thromboembolism, cardiomyopathy, and hypertensive disorders of pregnancy.

The study authors state that, typically, pregnancy-related deaths are preventable with proper medical care but that certain health conditions carry greater risks than others.

Data sources

The observational study utilized data from the National Vital Statistics System to gather data on deaths and live births from 1999 to 2019 on pregnant or recently pregnant women aged 10 to 54.  The research team from University of Washington and Mass General Brigham in Massachusetts then applied modeling to estimate maternal deaths over the 20-year period to calculate a maternal death risk for each state and each race and ethnicity out of every 100,000 live births.

In what the researchers cite as the first research to examine maternal death data by racial and ethnic groups within states over time, the team chose to rely on death certificates to gather their data because such information is collected uniformly across all states.

Across the 5 racial and ethnic groups included in the analysis, the study’s estimates show American Indian and Alaska Native females, as well as Black females, experienced the highest maternal mortality rates in 2019.  These groups of women also had the largest absolute mortality rate increases since 1999 with the national maternal mortality rate more than tripling over the 20-year timespan among American Indians and Alaska Natives from 19 deaths per 100,000 live births in 1999 to 69.3 per 100,000 in 2019.  During the same interval, maternal mortality among Black women more than doubled, from 31.4 to 67.6 per 100,000 live births.

States of risk

Among Hispanic women, median state MMRs increased from 9.6 to 19.1 (IQR, 11.6-24.9), and among white women they increased from 9.4 to 26.3.

The Black population had the highest median state MMR each year between 1999 and 2019, while the American Indian and Alaska Native population had the largest growth in median state MMRs in the same time frame.

The research team found that American Indian and Alaska Native women were in particular peril in Florida, Kansas, Illinois, Rhode Island and Wisconsin, the states which saw the largest percentage spike in these groups’ maternal mortality rate at 162%.  Louisiana, New Jersey, Georgia, Arkansas and Texas all registered increases in maternal mortality rates of greater than 93% for Black women.

Gregory Roth, MD, MPH, associate professor in the Division of Cardiology and director of the Program in Cardiovascular Health Metrics at the Institute for Health Metrics and Evaluation and co-author of the paper observes that initiatives to prevent maternal deaths have not only fallen short in chronically high-risk areas such as the South, but that now the risk is worsening in states previously thought of as having better health outcomes.

The states of New York and New Jersey saw an increase in deaths among Black and Latina mothers.  Wyoming and Montana registered deaths of more Asian mothers.  And although, statistically, white women experience lower rates of maternal mortality, these rates, too, are increasing in some areas of the US.

“We see that for white women, maternal mortality is also increasing throughout the South, in parts of New England, and throughout parts of the Midwest and Northern Mountain States,” Roth notes.

Ranking of failure

“The US has a high rate of maternal mortality, compared with other high-income countries, despite spending more per person on health care,” the study authors wrote.

Roth believes that these alarming findings represent a much larger and even more troubling reality.  That is, populations with high maternal mortality related to cardiovascular conditions also tend to happen in areas with high rates of cardiovascular disease in general, according to Roth.

“These disparities in maternal mortality are just the tip of the iceberg and tell us a lot about the health risks facing people in the states where these deaths are most likely to occur,” Roth noted in a statement released with the study’s publication.

“In the US, maternal deaths are often caused by vascular diseases like severe high blood pressure or blood clots.  So maternal deaths share many of the same drivers as heart attacks, strokes, and heart failure,” he continues.  “Our state-by-state research emphasizes where we need to focus our prevention efforts and which groups are suffering the most.”

What can be done

Roth thinks that the methodology the research team utilized for their new analysis can be used to create a database that would allow each state to track annual maternal mortality outcomes for various racial and ethnic groups.  This, in turn, could help lawmakers formulate policy decisions that can ultimately lead to improving the health of underserved populations.

This would require connecting pregnant women to health services beyond the care of their pregnancy, such as affordable primary care and mental health services.

“No woman should die during pregnancy,” stated Roth.  Addressing the rising maternal mortality rates requires “an approach that ties together the health care that women need before, during and after their pregnancy with the public health interventions that their communities need.”

Click here for a link to access the complete data, “Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States.”

The contents of this feature are not provided or reviewed by NPWH.