The Epidemiology of Maternal Mortality in the United States: Trends, Structural Determinants, and Individual Risk Factors.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

State-based maternal death reviews: assessing opportunities to alter outcomes

Background: In 2021 there were 1205 maternal deaths in the United States, translating to a maternal mortality rate of 32.9 deaths per 100,000 live births. The National Vital Statistics System reports this was nearly double the 17.4 death rate in 2018. With 754 maternal deaths in 2019 and 861 in 2020, it was not until 2022 that maternal deaths unexplainably dropped to 817. The Healthy Woman 2000 Goal projected a steep decline in maternal deaths, yet two decades later maternal mortality was at an all-time high. These rates do not capture the 50,000+ women who face life-endangering pregnancy complications or “near misses” each year. The increasing US maternal mortality rate becomes even more alarming when compared to declining maternal mortality rates in other industrialized countries. There are a variety of risk factors and system-level barriers which have been proposed as contributing factors to apparent escalation of maternal mortality within the United States. Examples range from racial disparities to conflicting definitions and inaccurate reporting methods. Some argue that the introduction of the pregnancy checkbox to the death certificate has contributed to an overestimate of maternal deaths in recent years. Nevertheless, maternal deaths are occurring at an unacceptable level and the public is demanding change. Actionable steps toward improving maternal mortality and morbidity include ensuring accuracy of data, utilization of Maternal Mortality Review Committees (MMRCs), health policy changes, and the education of medical trainees early in their career. Educational Problem: Most medical students arrive with limited exposure to the field of maternal health. The typical medical school curriculum provides minimal education on specific maternal death epidemiology and intervention strategies. Pre-clinical education on this topic is typically limited to abbreviated reproductive pathology or general public health lectures. Specific women’s health related education occurs during the clinical phases, either in an OBGYN clerkship or other OBGYN-related elective. Additionally, many medical students do not have an opportunity to learn about their regional MMRC and may not know they exist. Medical students have little to no training in completing death certificates and are not privy to the impact of the pregnancy checkbox. This gap in knowledge and exposure is problematic because accurate completion of vital statistic records impacts all specialties. Review of maternal mortality data indicates that a significant number of maternal deaths are preventable, providing an opportunity for early education and awareness. Advocating for additional educational content is always challenging with an already full medical curriculum. In a rural state where perhaps less than two maternal deaths occur in a year, it may be even more of a challenge to secure dedicated educational contact hours for this subject. However, the community impact of even one maternal death is devastating, and even more unacceptable if this death was preventable. We propose introducing early maternal mortality and morbidity education to medical students in our rural state. There is virtually no published data on any other US medical schools taking this approach to ensure accuracy of vital statistics. Intervention: We propose the development of a pathology learning module, centered on maternal morbidity and mortality, that will be integrated into the pre-clerkship phase of medical education. The goal of the module is to educate students on the significance of maternal health vital statistics reporting and emphasize their future role in improving patient outcomes regardless of their eventual chosen specialty. Students will also learn about the role of the MMRC and its impact on maternal health data. This curriculum will be a partnership between the Departments of Pathology and Obstetrics and Gynecology and will be implemented in 2025. Initial training will take the form of an educational module taught in the Reproductive Unit before clinical rotations begin. Lectures will be led by academic faculty involved in the state-wide MMRC. Information presented will include traditional didactic learning on the epidemiology, etiology, and pathology of maternal mortality, as well as case-based learning. Once aware of the significance of maternal health, students will take on the role of medical certifier and complete death certificates based on fictional cases, as well as discuss whether or not they deem the deaths preventable and potential intervention strategies. Outcomes of this module will be measured over several curricular periods. Data collection will include student course evaluation surveys, both quantitative and qualitative responses, and standardized assessment of students’ knowledge and perceptions regarding maternal care. Information presented will be eligible material for students’ end-of-unit course exams. Outcomes will be compared to the goals of the module annually. Conclusion: Maternal mortality persists at an unacceptable level in the United States, and novel educational approaches are needed to produce impacts in this area. We propose a pre-clinical pathology training module to educate all medical students on the importance of accurately completing vital statistic forms regardless of their eventual specialty.

Background:This study examines trends and inequalities in US maternal mortality from indirect obstetric causes (ICD-10 codes: O98-O99) and specific chronic conditions by maternal race/ethnicity, socioeconomic status, nativity/immigrant status, marital status, place and region of residence, and cause of death.Methods:National vital statistics data from 1999 to 2017 were used to compute maternal mortality rates by sociodemographic factors. Rate ratios and log-linear regression were used to model mortality trends and differentials.Results:During 1999-2017, maternal mortality from indirect causes showed an upward trend; the annual rates increased by 11.2% for the overall population, 12.9% for non-Hispanic Whites, and 9.4% for non-Hispanic Blacks. The proportion of all maternal deaths due to indirect causes increased from 12.0% in 1999 to 26.9% in 2017. Maternal mortality from CVD increased sharply over time, from 0.40/100,000 live births in 1999 to 1.82 in 2017. During 2013-2017, compared to non-Hispanic Whites, non-Hispanic Blacks had 83% higher, Hispanics 51% lower, and Asian/Pacific Islanders 55% lower mortality from indirect causes. Non-Hispanic White women with <12 years of education had 4.4 times higher mortality than those with a college degree. Unmarried, US-born, and women living in rural areas and deprived areas had 90%, 80%, 60%, and 97% higher maternal mortality risks than married, immigrant, and women in urban areas and affluent areas, respectively. Maternal mortality from infectious diseases, including HIV, was 4.1 times greater and from respiratory diseases 2.9 greater among non-Hispanic Black women compared to non-Hispanic White women.Conclusions and Global Health Implications:While maternal mortality from direct obstetric causes has declined during the past two decades, maternal deaths due to indirect causes, particularly from pre-existing medical conditions, including CVD and metabolic disorders, have increased. Understanding complex interactions among social determinants, indirect causes, and proximate/direct causes is important to reducing maternal mortality and improving maternal health.

Color lines: Disparities in pharmacy treatment, education, and practice

Challenges of reducing maternal and neonatal mortality in Indonesia: Ways forward.

Objectives: Given that pregnancy health information seeking is common and considered impactful on health outcomes, the potential lack of fair and clear information within media may be an impediment towards women developing their own agency and working towards the transformation and betterment of their own outcomes. Setting: The USA has the worst maternal mortality rate of any developed country. Women’s opinions are shaped and informed by public media and discourse; therefore, a critical look at how public media texts support women’s agency is of significance. Method: Reducing maternal mortality requires more than just effective health interventions. This paper uses critical discourse analysis to examine two samples of widely viewed public discourse around the issue of US maternal mortality and reveals the murky and polarised dialogue contained in each. Results: The two samples may be representative of a larger lack of clarity in US discourse about maternal mortality, a body of discourse which – to the detriment of women’s maternal morbidity and mortality outcomes – subtly but powerfully either declines to admit mistakes or uses polarising, overly simplified language. Conclusion: Recognising the polarised dialogue surrounding maternal mortality and working towards a more reasoned discussion of the issue at hand may promote women’s advocacy and provide potentially better outcomes.

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

BackgroundRates of preterm birth, low birth weight, and Neonatal Intensive Care Unit (NICU) admissions continue to rise in the United States (US). Social determinants of health (SDOH) are recognized as significant contributors to infant and maternal health, underscoring the need for use of research frameworks that incorporate SDOH concepts. The Restoring Our Own Through Transformation (ROOTT) theoretical framework is rooted in reproductive justice (i.e. reproductive rights and social justice-based framework) and emphasizes both structural and social determinants as root causes of health inequities. The impact of SDOH on maternal and infant mortality and morbidity can often be traced to structural determinants unique to the US, including slavery, Jim Crow laws, redlining, and the GI Bill.AimsUsing data from the Pregnancy Risk Assessment Monitoring System (PRAMS) 8 database, we aimed to evaluate relationships between SDOH (as guided by the ROOTT Framework) and maternal and infant health outcomes.MethodsData were analyzed from 11 states that included the SDOH supplement in their PRAMS 8 data collection. We used bivariate analyses to examine relationships between SDOH measures guided by the ROOTT framework (e.g. abuse during pregnancy, access to prenatal care, housing stability and education) and maternal morbidity (i.e., gestational hypertension and gestational diabetes) and infant outcomes (i.e., preterm birth, NICU admission, breastfeeding). Pre-identified covariates were controlled for in the logistic and linear regression models.ResultsPreterm birth, NICU admission, breastfeeding, and maternal morbidities were significantly associated with SDOH measures linked to structural determinants in the US. Abuse during pregnancy, access to prenatal care, housing, and education were all significantly associated with poorer infant health outcomes in the final regression models. Women who received prenatal care beginning in the 3rd trimester were twice as likely to develop gestational hypertension.ConclusionsSDOHs rooted in structural determinants are important predictors of poorer maternal and infant health outcomes. Evaluating health outcomes using a reproductive justice framework reveals modifiable risk factors, including access to stable healthcare, safety, and housing. Comprehensive healthcare provision must ensure early and consistent access to healthcare and resources for safety and housing stability to support maternal and infant health.

Periconception care of the infertile patient: Are we doing enough?

Changes in data collection and processing of US maternal mortality data across states over time have led to inconsistencies in maternal death reporting. Our purpose was to identify possible misclassification of maternal deaths and to apply alternative coding methods to improve specificity of maternal causes. We analyzed 2016–2017 US vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We developed an alternative coding strategy to code the “primary cause of death” defined as the most likely cause that led to death. We recoded deaths with or without literal pregnancy mentions to maternal and non-maternal causes, respectively. Originally coded and recoded data were compared for overall maternal deaths and for a subset of deaths originally coded to ill-defined causes. Among 1691 originally coded maternal deaths, 597 (35.3%) remained a maternal death upon recoding and 1094 (64.7%) were recoded to non-maternal causes. The most common maternal causes were eclampsia and preeclampsia, obstetric embolism, postpartum cardiomyopathy, and obstetric hemorrhage. The most common non-maternal causes were diseases of the circulatory system and cancer, similar to the leading causes of death among all reproductive-age women (excluding injuries). Among 735 records originally coded to ill-defined causes, 94% were recoded to more specific, informative causes from literal text. Eighteen deaths originally coded as non-maternal mentioned pregnancy in the literals and were recoded as maternal deaths. Literal text provides more detailed information on cause of death which is often lost during coding. We found evidence of both underreporting and overreporting of maternal deaths, with possible overreporting predominant. Accurate data is essential for measuring the effectiveness of maternal mortality reduction programs.

This special issue of Public Health Reports (PHR) focuses on innovations and advances in incorporating a social-determinants-of-health (SDH) framework for addressing the interrelated epidemics of human immunodeficiency virus (HIV), viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB) in the United States and globally. This focus is particularly timely given the evidence of increasing burden and worsening health disparities for these conditions, the evolution in our understanding of the social and structural influences on disease epidemiology, and the far-reaching implications of the global economic downturn. The global trends and adverse health impact of HIV, viral hepatitis, STIs, and TB remain among the major and urgent public health challenges of our time.1 These conditions account for substantial morbidity and mortality, with devastating fiscal and emotional costs to individuals, families, and societies. Despite decades of investment and support, the U.S. still experiences a disproportionate burden of these conditions compared with other Western industrialized nations, with substantial health disparities being observed across population subgroups and geographic regions.2 The reasons for these inequities are multifaceted and complex. It is true that individual-level determinants, including high-risk behaviors such as unsafe sexual and drug-injecting practices, are major drivers of disease transmission and acquisition risk. However, it is also clear that the patterns and distribution of these infectious diseases in the population are further influenced by a dynamic interplay among the prevalence of the infectious agent, the effectiveness of preventive and control interventions, and a range of social and structural environmental factors.3,4 Many of these conditions arise because of the circumstances in which people grow, live, work, socialize, and form relationships, and because of the systems put in place to deal with illness, all of which are, in turn, shaped by political, social, and economic forces. Understanding the multilevel and overlapping nature of these epidemics, and their social and structural determinants, is key to designing and implementing more effective prevention programs.5 Individual risk behaviors influence the probability of contact with other infected or infectious individuals. However, these behaviors do not occur in a vacuum. With respect to STIs, an individual's sexual risk behavior occurs within the context of a sexual partnership or partnerships, which are, in turn, located within a wider sexual network. For other infectious diseases, including TB, the built or physical environment can influence patterns and opportunities for interpersonal contact, social mixing, and probability of onward transmission of the infectious agent.6 These more proximal determinants of transmission risk also occur within the context of wider social and structural determinants.7,8 Structural factors include those physical, social, cultural, organizational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid disease transmission. Social factors include the economic and social conditions that influence the health of people and communities as a whole, and include conditions for early childhood development, education, employment, income and job security, food security, health services, and access to services, housing, social exclusion, and stigma. Our understanding of the connections between these determinants, and their relative importance to each other, has evolved over time. Earlier models for infectious disease transmission highlighted the primacy of the interactions among the individual, the infectious agent, and the environment, with infectious disease prevention and control programs being focused predominantly on targeting interventions toward the individual—e.g., individual-level counseling, testing, screening, and treatment interventions. Thus, HIV prevention has been dominated by individual-level behavioral interventions that seek to influence knowledge, attitudes, and behaviors, such as promotion of condom use, education about sexual health, and education of injecting drug users about the dangers of sharing equipment.4 While there has been some success with this approach, public health programs have failed to achieve sustained reductions in incidence or achieve elimination of these conditions and their associated inequities. There is also a growing appreciation that although some individually oriented interventions have shown results in reducing risk behavior, their success is substantially improved when HIV prevention addresses the broader structural factors that shape or constrain individual behavior, such as poverty and wealth, gender, age, policy, and power.9 The growing recognition of the social and structural barriers to prevention and control efforts for HIV, viral hepatitis, STIs, and TB have allowed prevention experts to employ more comprehensive approaches to their interventions. Such structural approaches include actions implemented as single policies or programs that aim to change the conditions in which people live, multiple structural actions of this type implemented simultaneously, or community processes that catalyze social and political change (e.g., social mobilization to oppose a harmful traditional practice). They also include policy or legal interventions (e.g., legal actions to combat or reform a discriminatory practice), interventions to influence the way services are delivered through promoting collaboration and integration,10 contingent funding, and economic and educational interventions.11 These approaches can be applied in combination with behavioral or medical interventions targeted at individuals, and aim to address factors affecting individual behavior, rather than targeting the behavior itself. It is within this context that this special issue of PHR has been brought together to reflect upon the influences, opportunities, and impact of SDH on the transmission of HIV, viral hepatitis, STIs, and TB. Major strategic priorities for the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC)12 are promoting health equity and reducing health disparities through adopting a social-determinants approach to our prevention activities. NCHHSTP also intends to place more emphasis on structural and contextual determinants of health, particularly health policy and legislation, economic and social interventions, and cross-sectoral collaboration.

Background: Among developed countries, the United States has the highest maternal mortality rate. Between 1987 and 2011, the US maternal mortality rate more than doubled from 7.2 to 17.8 deaths per 100,000 live births. More than 1,300 pregnancy-related deaths occurred in the United States in 2011-2012. Additionally, an increasing number of women have chronic health conditions, such as hypertension, diabetes, and chronic heart disease, that increase their risk of pregnancy complications, including maternal mortality. Reducing the prevalence of these diseases may be an important step toward reducing maternal mortality. To examine the current state of maternal mortality and chronic diseases in the United States, the geographical variation of these factors was examined. Methodology: State-level prevalence estimates were calculated for diabetes, heart disease, and hypertension awareness among women of reproductive age (18 to 44 years) using data from the 2013-2014 Behavioral Risk Factor Surveillance System. State-level maternal mortality rates were calculated using CDC’s 2010-2014 National Vital Statistics System. Maternal mortality was defined as the number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births. Results: The maternal mortality rate is 6.8 times higher in Georgia (39.3 deaths per 100,000 live births) than in Massachusetts (5.8 deaths per 100,000 live births). Nationally, there are an estimated 19.9 maternal deaths per 100,000 live births. The prevalence of chronic diseases that increase risk of pregnancy complications also vary by state. For example, diabetes (excluding gestational diabetes) ranges from a low of 1.9% of women aged 18 to 44 in Alaska, Minnesota, and Wisconsin to a high of 4.8% in Alabama. Nationally, an estimated 3.1% of women aged 18 to 44 have been told by a doctor that they have diabetes. Conclusion: The prevalence of chronic diseases in women of reproductive age vary based on state of residence, as does the maternal mortality rate. Raising awareness about the variation in these measures is an important step toward identifying what strategies are being utilized in states with a low prevalence of diabetes, heart disease, and hypertension, and determining how their public health efforts may help those states facing challenges in these areas.

Black women in the United States (U.S.) disproportionately experience adverse pregnancy outcomes, including maternal mortality, compared to women of other racial and ethnic groups. Historical legacies of institutionalized racism and bias in medicine compound this problem. The disproportionate impact of COVID-19 on communities of color may further worsen existing racial disparities in maternal morbidity and mortality. This paper discusses structural and social determinants of racial disparities with a focus on the Black maternal mortality crisis in the United States. We explore how structural racism contributes to a greater risk of adverse obstetric outcomes among Black women in the U.S. We also propose public health, healthcare systems, and community-engaged approaches to decrease racial disparities in maternal morbidity and mortality.

Increasing rates of maternal morbidity and mortality is a growing concern in many industrialized countries. Data from US maternal mortality review committees indicate that more than 80% of these deaths are preventable (Trost et al., 2019). Various factors contributing to this issue include advancing maternal age, increased adults living with congenital disease that may affect outcomes and increased prevalence of comorbidities such as diabetes and hypertension (Fink et al., 2023). In the United States, black women are disproportionately affected by maternal mortality and severe maternal morbidity, facing rates almost three times higher than those of white women (Hoyert, 2023). Few Canadian studies exist, but they echo similar findings. Research by McKinnon and colleagues (2016) found that Black women were more likely to have premature babies and have their pain experiences discounted. A more recent qualitative study based in Toronto reported pervasive obstetric racism experienced by Black women (Boakye et al., 2023). These disparities stem from a complex interplay of factors, including systemic racism, socio-economic disparities, and unequal access to quality healthcare. Unfortunately, research on Black maternal mortality and morbidity is limited in Canada, and we lack a much-needed national system to track these outcomes. Unlike the United States, few Canadian health agencies collect racial statistics. However, disaggregated race-based data is critical for informing targeted interventions and policy changes. This infographic was created under the umbrella of The Newcomer Health Hub, a Canadian medical student-run organization that seeks to increase awareness of health-care disparities in order to improve medical training. Infographics play a crucial role in enhancing comprehension, increasing engagement, and promoting health literacy. Together, through education, advocacy, and community engagement, we can work towards ensuring that every mother receives the support, resources, and care they need to have a safe and healthy pregnancy and childbirth experience, regardless of race or ethnicity.