Trends and Racial/Ethnic, Socioeconomic, and Geographic Disparities in Maternal Mortality from Indirect Obstetric Causes in the United States, 1999-2017.

Gopal K Singh,Hyunjung Lee

doi:10.21106/ijma.448

Abstract

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.

Highlights

Maternal mortality from indirect causes showed an upward trend during 1999-2017, with the rate increasing by 11.2% annually for the overall population, 12.9% for non-Hispanic Whites, and 9.4% for non-Hispanic Blacks (Figure 1)
The proportion of all maternal deaths due to indirect causes rose from 12.0% in 1999 to 26.9% in 2017 (Figure 2)
Of 12,135 maternal deaths that occurred during 1999-2017, 3184 deaths were from indirect causes, including 173 deaths from maternal infectious and parasitic diseases, 3011 deaths from all chronic conditions, 993 deaths from cardiovascular disease (CVD), 178 deaths from mental disorders, 191 deaths from respiratory diseases, 48 deaths from digestive diseases, 26 deaths from endocrine/ metabolic disorders, and 30 deaths from HIV (Table 1)

Summary

Introduction

The leading causes of maternal deaths in the United States are hemorrhage, pregnancyrelated hypertension, embolism, and obstetric infection, maternal deaths due to indirect obstetric causes, including chronic medical conditions such as cardiovascular disease (CVD), diabetes, respiratory disorders, and mental health conditions, have increased substantially in the past two decades.[1,2] Globally, including the United States, 25-30% of all maternal deaths are attributed to these indirect causes.[3,4,5] Recent trends and socioeconomic and demographic disparities in US maternal mortality from indirect causes have not been well studied, the proportionate share of various indirect causes to overall mortality and racial/ethnic patterns have been examined using death certificate-based maternal mortality and Pregnancy Mortality Surveillance System data.[6,7,8,9] To our knowledge, none of the US studies have analyzed inequalities in maternal mortality from indirect causes by a wide range of social determinants, including maternal education, marital status, nativity/immigrant status, place of residence, geographic region, and area deprivation. To address the aforementioned gaps in research, we analyzed racial/ethnic, socioeconomic, demographic, rural-urban, and regional variations in US maternal mortality from indirect obstetric causes and specific chronic conditions (ICD-10 codes O98-O99) occurring during or within 42 days after the end of pregnancy.[1,2,10]. 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

Results

Discussion

Conclusion