A new study published in the Journal of the American Medical Association (JAMA) shows that the maternal mortality rate in the U.S. more than doubled between 1999 and 2019, with Black mothers consistently bearing the highest burden.
American Indian and Alaskan Native populations, meanwhile, saw the largest increase in mortality rates.
“We were able to confirm that the rates of maternal mortality in the United States are A) unconscionably high, and B) really on the rise,” said study co-author Dr. Allison Bryant, an OB-GYN at Mass General Hospital who works with high-risk patients, and the associate chief health equity officer at Mass General Brigham. “And that there are inequities, so that those risks of maternal mortality are not borne proportionately across groups across the United States.”
The study defines maternal mortality as a death that occurs during or up to one year after the end of pregnancy. Among the most common causes of death, according to the Centers for Disease Control and Prevention, are mental health conditions, excessive bleeding, cardiac and coronary conditions, infection, blood clots, cardiomyopathy, and high blood pressure.
Bryant says she and her co-authors, who hail from the University of Washington, Seattle and its Institute for Health Metrics and Evaluation, launched the study to gain a more granular picture of which groups were most affected by rising mortality rates.
“We thought it was important to do because we know that the maternal mortality rates in the United States are on the rise, and that we don’t always have intricate or detailed data, state by state, about what’s happening in terms of race and ethnicity,” Bryant said.
Challenges to accurate tracking
One of the reasons that data has so far been lacking, Bryant says, is because some smaller states have trouble tracking mortality rates due to confidentiality issues, along with estimates that are either too unstable or too small to report.
The researchers got around this issue by using a modeling process that created accurate estimates based on data from the National Vital Statistics System of deaths and live births. Mortality rates were measured for each state and each of five racial/ethnic groups out of every 100,000 live births.
The five racial/ethnic groups that were tracked include American Indians and Alaska Natives; Asians, Native Hawaiians, or other Pacific Islanders; and Black, Hispanic, and White individuals.
The study confirmed trends that have already been observed, while also highlighting new ones.
As in past research, the South was found to have some of the highest mortality rates overall, along with the Midwest and northern Mountain states.
Black mothers fared especially poorly in Southern states — but those states weren’t alone.
“If we look at the northeast, New York and New Jersey look like they have a great deal of inequity in maternal mortality,” Bryant said.
In fact, as of 2019, several Northeastern states had some of the highest mortality rates for Black mothers, which tripled over the time of the study.
New Jersey was the second-highest for Black mortality in 2019 after Arizona, followed by New York, Washington, D.C., and Georgia.
New Jersey also saw the second-highest increase in Black mortality rates over the 20-year period after Louisiana, followed by Georgia, Arkansas, and Texas. Those increases spanned from 93.5% to 130%.
For American Indian and Alaskan Native women, maternal mortality rates were highest in the Midwest and Great Plains states. That group saw the largest percentage increases in maternal mortality rates over the two-decade period in Florida, Kansas, Illinois, Rhode Island, and Wisconsin. Those increases spanned from 162% to 254.8%.
While Pennsylvania fared better, it still showed a 31.4% increase in Black mortality rates, which were the 16th highest in the nation.
“That would suggest a greater-than-average risk of maternal mortality for Black individuals compared to others,” Bryant said.
Plateauing rates likely thwarted by Covid
Close to the end of the 20-year study period, there did seem to be some good news, Bryant says — plateauing maternal mortality rates for all groups except American Indians and Alaska Natives, whose risk continued to increase as of 2019.
“There really has been a galvanized attempt to think about, what are the root causes of maternal mortality? What are the fixes that we can apply?” Bryant said. “And maybe — it’s hard to say exactly from this study — but that sort of plateauing effect that was happening through 2019, perhaps that is reflective of some of the prevention efforts that were put into place, but clearly were not enough.”
Worse, Bryant says, CDC data indicates that COVID-19 has thwarted progress.
“What we know is, post-pandemic, we’re sort of in a worse situation than we were at the end of this study in 2019,” she said, citing CDC data for 2020 and 2021. “Not to anyone’s surprise, there was an increase across the country in terms of maternal mortality and what appears to be a widening of disparities, particularly for Black individuals.”
Bryant added that those numbers don’t include solid data for American Indians and Alaska Natives.
Among the factors that may have worsened maternal mortality during the pandemic, Bryant says, are COVID-19 itself, decreases in prenatal care, growing mistrust in the medical system, and an increase in mental health conditions and overdose deaths.
Limitations and solutions
Bryant cited several limitations to the study, including the completeness of the data on which estimates were modeled, and lack of information on causes of death.
The original data was drawn from the National Vital Statistics System, an inter-governmental system that uses state health department data in coordination with the CDC and the National Center for Health Statistics (NCHS).
“Those data are only as good as the folks who are entering them in terms of what our causes of deaths really are, these maternal mortality cases,” Bryant said. “And so our estimates may be off in some places. But also we weren’t really able to look at the actual causes of death.”
The cause of death is especially important for states looking to design interventions to decrease maternal mortality.
But, she added, there are some big-picture takeaways when it comes to what states need to look at — specifically, greater focus on the effects of interpersonal and structural racism.
“I think the story is similar in many places, which is, is there great access to high-quality care?” she said. “What is the likelihood of having excellent health status entering pregnancy? What is the likelihood of having excellent health status after pregnancy? So we oftentimes forget about the postpartum or post-pregnancy period, and making sure that people have access to care. But truly, what are the structural determinants of health that would help people to enter pregnancy healthier? And those are oftentimes inequitably distributed by population.”
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