Pregnancy-related Mortality Ratio Research Articles

Burden and causes of pregnancy-related mortality in The Gambia: evidence from census and health and demographic surveillance data

BackgroundThe Gambia lacks capacity to estimate its burden and causes of pregnancy-related mortality (PRM) to guide reproductive health programming. We used census and Health and Demographic Surveillance System (HDSS) data...

Pregnancy-Related Deaths by Hispanic Origin, United States, 2009-2018.

Objective: To describe pregnancy-related mortality among Hispanic people by place of origin (country or region of Hispanic ancestry), 2009-2018. Materials and Methods: We conducted a cross-sectional descriptive study of pregnancy-related deaths among Hispanic people, stratified by place of origin (Central or South America, Cuba, Dominican Republic, Mexico, Puerto Rico, Other and Unknown Hispanic), using Pregnancy Mortality Surveillance System data, 2009-2018. We describe distributions of pregnancy-related deaths and pregnancy-related mortality ratios (number of pregnancy-related deaths per 100,000 live births) overall and by place of origin for select demographic and clinical characteristics. Results: For 2009-2018, the overall pregnancy-related mortality ratio among Hispanic people was 11.5 pregnancy-related deaths per 100,000 live births (95% confidence intervals [CI]: 10.8-12.2). In general, pregnancy-related mortality ratios were higher among older age groups (i.e., 35 years and older) and lower among those with higher educational attainment (i.e., college degree or higher). Approximately two in five pregnancy-related deaths among Hispanic people occurred on the day of delivery through 6 days postpartum. Place of origin-specific pregnancy-related mortality ratios ranged from 9.6 (95% CI: 5.8-15.0) among people of Cuban origin to 15.3 (95% CI: 12.4-18.3) among people of Puerto Rican origin. Hemorrhage and infection were the most frequent causes of pregnancy-related deaths overall among Hispanic people. People of Puerto Rican origin had a higher proportion of deaths because of cardiomyopathy. Conclusions: We identified differences in pregnancy-related mortality by place of origin among Hispanic people that can help inform prevention of pregnancy-related deaths.

Changes in Pregnancy-Related Mortality Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic in the United States.

To examine pregnancy-related mortality ratios before (January 2019-March 2020) and during (April 2020-December 2020 and 2021) the coronavirus disease 2019 (COVID-19) pandemic overall, by race and ethnicity, and by rural-urban classifications using vital records data. Mortality and natality data (2019-2021) were obtained from the Centers for Disease Control and Prevention's WONDER database to estimate pregnancy-related mortality ratios, which correspond to any death during pregnancy or up to 1 year after the end of a pregnancy from causes related to the pregnancy per 100,000 live births. Pregnancy-related mortality ratios were determined from International Classification of Diseases, Tenth Revision codes A34, O00-O96, and O98-O99. Overall pregnancy-related mortality ratios were partitioned by whether COVID-19 was listed as a contributory cause, and quarterly estimates were compared between 2019 and 2021. Pregnancy-related mortality ratios were compared by race and ethnicity and rural-urban residence before (2019-March 2020) and during (April 2020-December 2020 and 2021) the COVID-19 pandemic. Pregnancy-related mortality was significantly higher in 2021 (45.5/100,000 live births) compared with during the pandemic in 2020 (36.7/100,000 live births) and before the pandemic (29.0/100,000 live births). Pregnancy-related mortality ratios increased across all race and ethnicity and rural-urban residence categories in 2021. The largest increase occurred among American Indian/Alaska Native people during 2021 compared with April-December of 2020 (pregnancy-related mortality ratio 160.8 vs 79.0/100,000 live births, 104% relative change, P =.017). Medium-small metropolitan (52.4 vs 37.7/100,000 live births, 39.0% relative change, P <.001) and rural (56.2 vs 46.5/100,000 live births, 21.0% relative change, P =.05) areas had a larger increase in 2021 compared with April-December 2020 compared with large urban areas (39.1 vs 33.7/100,000 live births, 15.9% relative change, P =.009). Pregnancy-related mortality ratios increased more rapidly in 2021 than in 2020, consistent with rising rates of COVID-19-associated mortality among women of reproductive age. This further exacerbated racial and ethnic disparities, especially among American Indian/Alaska Native birthing people.

Differentials in Maternal Mortality Pattern in Sub-Saharan Africa Countries: Evidence from Demographic and Health Survey Data

Maternal mortality ratios in sub-Saharan Africa remain high and worrisome. Moreover, maternal health indicators have remained poor despite large efforts in the last two decades. This study assesses maternal mortality patterns by age and country. The demographic and health survey data were used for the study. Based on the results, countries with the lowest adult female mortality rate include Senegal, Comoros, Rwanda, Mauritania, Sao Tome and Principe, Gambia, and Ethiopia. In addition, Chad (44.7%), Niger (38.7%), the Congo Democratic Republic (34.8%), Nigeria (34.2%), Mauritania (32.0%), Senegal (29.2%), Liberia (28.8%), Benin (27.8%), and Guinea (27.5%), respectively, reported the highest female deaths that are pregnancy-related. Overall, Lesotho (1024; 95% CI: 731–1318), Liberia (913; 95% CI: 638–1189), Chad (860; 95% CI: 728–993), Congo Democratic Republic (846; 95% CI: 690–1003), Sierra Leone (796; 95% CI: 632–960) and Guinea (724; 95% CI: 531–916) had the leading pregnancy-related mortality ratio per 100,000 live births. The study found that the patterns of death vary across different countries. There is a need for concerted efforts to reduce pregnancy-related deaths in sub-Saharan countries.

Associations Between State and Local Government Spending and Pregnancy-Related Mortality in the U.S.

There is limited evidence on how government spending is associated with maternal death. This study investigates the associations between state and local government spending on social and healthcare services and pregnancy-related mortality among the total, non-Hispanic Black, Hispanic, and non-Hispanic White populations. State-specific total population and race/ethnicity-specific 5-year (2015-2019) pregnancy-related mortality ratios were estimated from annual natality and mortality files provided by the National Center for Health Statistics. Data on state and local government spending and population-level characteristics were obtained from U.S. Census Bureau surveys. Generalized linear Poisson regression models with robust SEs were fitted to estimate adjusted rate ratios and 95% CIs associated with proportions of total spending allocated to social services and healthcare domains, adjusting for state-level covariates. All analyses were completed in 2021-2022. State and local government spending on transportation was associated with 11% lower overall pregnancy-related mortality (adjusted rate ratio=0.89, 95% CI=0.83, 0.96) and 9%-12% lower pregnancy-related mortality among the racial/ethnic groups. Among spending subdomains, expenditures on higher education, highways and roads, and parks and recreation were associated with lower pregnancy-related mortality rates in the total population (adjusted rate ratio=0.90, 95% CI=0.86, 0.94; adjusted rate ratio=0.87, 95% CI=0.81, 0.94; and adjusted rate ratio=0.68, 95% CI=0.49, 0.95, respectively). These results were consistent among the racial/ethnic groups, but patterns of associations with pregnancy-related mortality and other spending subdomains differed notably between racial/ethnic groups. Investing more in local- and state-targeted spending in social services may decrease the risk for pregnancy-related mortality, particularly among Black women.

The public health exposome and pregnancy-related mortality in the United States: a high-dimensional computational analysis

BackgroundRacial inequities in maternal mortality in the U.S. continue to be stark.MethodsThe 2015–2018, 4-year total population, county-level, pregnancy-related mortality ratio (PRM; deaths per 100,000 live births; National Center for Health Statistics (NCHS), restricted use mortality file) was linked with the Public Health Exposome (PHE). Using data reduction techniques, 1591 variables were extracted from over 62,000 variables for use in this analysis, providing information on the relationships between PRM and the social, health and health care, natural, and built environments. Graph theoretical algorithms and Bayesian analysis were applied to PHE/PRM linked data to identify latent networks.ResultsPHE variables most strongly correlated with total population PRM were years of potential life lost and overall life expectancy. Population-level indicators of PRM were overall poverty, smoking, lack of exercise, heat, and lack of adequate access to food.ConclusionsIn this high-dimensional analysis, overall life expectancy, poverty indicators, and health behaviors were found to be the strongest predictors of pregnancy-related mortality. This provides strong evidence that maternal death is part of a broader constellation of both similar and unique health behaviors, social determinants and environmental exposures as other causes of death.

Women's risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa

WHO's standard definitions of pregnancy-related and maternal deaths only include deaths that occur within 42 days of delivery, termination, or abortion, with major implications for post-partum care and maternal mortality surveillance. We therefore estimated post-partum survival from childbirth up to 1 year post partum to evaluate the empirical justification for the 42-day post-partum threshold. We used prospective, longitudinal Health and Demographic Surveillance System (HDSS) data from 30 sites across 12 sub-Saharan African countries to estimate women's risk of death from childbirth until 1 year post partum from all causes. Observations were included if the childbirth occurred from 1991 onwards in the HDSS site and maternal age was 10-54 years. We calculated person-years as the time between childbirth and next birth, outmigration, death, or the end of the first year post partum, whichever occurred first. For six post-partum risk intervals (0-1 days, 2-6 days, 7-13 days, 14-41 days, 42-122 days, and 4-11 months), we calculated the adjusted rate ratios of death relative to a baseline risk of 12-17 months post partum. Between Jan 1, 1991, and Feb 24, 2020, 647 104 births occurred in the HDSS sites, contributing to 602 170 person-years of exposure time and 1967 deaths within 1 year of delivery. After adjustment for confounding, mortality was 38·82 (95% CI 33·21-45·29) times higher than baseline on days 0-1 after childbirth, 4·97 (3·94-6·21) times higher for days 2-6, 3·35 (2·64-4·20) times higher for days 7-13, and 2·06 (1·74-2·44) times higher for days 14-41. From 42 days to 4 months post partum, mortality was still 1·20 (1·03-1·39) times higher (ie, a 20% higher risk), but deaths in this interval would be excluded from measurement of pregnancy-related mortality. Extending the WHO 42-day post-partum threshold up to 4 months would increase the post-partum pregnancy-related mortality ratio by 40%. This multicountry study has implications for measurement and clinical practice. It makes the case for WHO to extend the 42-day post-partum threshold to capture the full duration of risk of pregnancy-related deaths. There is a need for a new indicator to track late pregnancy-related deaths that occur beyond 42 days, which are otherwise excluded from global maternal health surveillance efforts. Our results also emphasise the need for international agencies to disaggregate estimates by antepartum, intrapartum, postpartum, and extended post-partum periods. Additionally, the schedule and content of postnatal care packages should reflect the extended duration of post-partum risk. The UK Economic and Social Research Council.

Pregnancy-associated and pregnancy-related deaths in the United States military, 2003–2014

The Centers for Disease Control and Prevention has reported a steady increase in the US pregnancy-related mortality ratio since national surveillance began in 1987, although trends are partially induced by concurrent improvements in the identification of pregnancy-related deaths. No previous work has evaluated pregnancy-associated and pregnancy-related deaths among active-duty service members, a population with comprehensive health coverage and stable employment. This study aimed to assess trends and variations in pregnancy-associated and pregnancy-related deaths in the US military. Live births to active-duty service members were captured in Department of Defense Birth and Infant Health Research program data from 2003 to 2014. Pregnancy-associated deaths (deaths temporally related to pregnancy from any cause) were identified through 1 year after pregnancy end date using National Death Index Plus data from the Joint Department of Defense and Department of Veterans Affairs Suicide Data Repository. Pregnancy-associated deaths were classified as pregnancy-related (causally related to pregnancy) based on cause-of-death codes in the National Death Index Plus data, administrative medical encounter data, and medical record review. Pregnancy-related deaths were reported including and excluding deaths from suicide and unintentional overdose. Mortality ratios (deaths per 100,000 live births) were reported overall, triennially, and by selected characteristics; the relative contribution of each cause of death to all pregnancy-associated deaths was reported overall and by age, race and ethnicity, and marital status. Timing of death relative to pregnancy end date was assessed by cause of death. A total of 179,252 live births occurred to active-duty service members from 2003 to 2014. Pregnancy-associated and pregnancy-related mortality ratios were 41.3 (95% confidence interval, 32.4-51.8) and 18.4 (95% confidence interval, 12.7-25.9), respectively. Excluding deaths from suicide and unintentional overdose, the pregnancy-related mortality ratio was 11.2 (95% confidence interval, 6.8-17.2). Deaths from suicide and unintentional overdose composed a larger proportion of pregnancy-related deaths over time and accounted for 17.6% of all pregnancy-associated deaths. Deaths from other pregnancy-related causes accounted for a greater share of deaths among older vs younger service members (≥30 years: 41.2%; 18-29 years: 22.8%) and non-Hispanic Black vs White service members (33.3% vs 24.1%). Pregnancy-related deaths, excluding suicide and unintentional overdose, were more likely to occur within 42 days of pregnancy end date; in contrast, deaths from suicide, overdose, assault, and undetermined intent were more likely to occur between 42 days and 1 year after pregnancy. Pregnancy-associated and pregnancy-related deaths varied over time and by age and race and ethnicity. Suicide and overdose are major recent causes of pregnancy-related death among active-duty service members.

County-Level Associations Between Pregnancy-Related Mortality Ratios and Contextual Sociospatial Indicators.

To characterize county-level differences in pregnancy-related mortality as a function of sociospatial indicators. We conducted a cross-sectional multilevel analysis of all pregnancy-related deaths and all live births with available ZIP code or county data in the Pregnancy Mortality Surveillance System during 2011-2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic White women aged 15-44 years. The exposures included 31 conceptually-grounded, county-specific sociospatial indicators that were collected from publicly available data sources and categorized into domains of demographic; general, reproductive, and behavioral health; social capital and support; and socioeconomic contexts. We calculated the absolute difference of county-level pregnancy-related mortality ratios (deaths per 100,000 live births) per 1-unit increase in the median absolute difference between women living in counties with higher compared with lower levels of each sociospatial indicator overall and stratified by race and ethnicity. Pregnancy-related mortality varied across counties and by race and ethnicity. Many sociospatial indicators were associated with county-specific pregnancy-related mortality ratios independent of maternal age, population size, and Census region. Across domains, the most harmful indicators were percentage of low-birth-weight births (absolute ratio difference [RD] 6.44; 95% CI 5.36-7.51), percentage of unemployed adults (RD 4.98; 95% CI 3.91-6.05), and food insecurity (RD 4.92; 95% CI 4.14-5.70). The most protective indicators were higher median household income (RD -2.76; 95% CI -3.28 to -2.24), percentage of college-educated adults (RD -2.28; 95% CI -2.81 to -1.75), and percentage of owner-occupied households (RD -1.66; 95% CI -2.29 to -1.03). The magnitude of these associations varied by race and ethnicity. This analysis identified sociospatial indicators of pregnancy-related mortality and showed an association between pregnancy-related deaths and place of residence overall and stratified by race and ethnicity. Understanding county-level context associated with pregnancy-related mortality may be an important step towards building public health evidence to inform action to reduce pregnancy-related mortality at local levels.

A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia

BackgroundMany low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality.ObjectiveThe objective is to inform on potential options for measuring maternal mortality.MethodsThis paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS).ResultsFor Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003.ConclusionsOverall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches.ContributionRecommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant.

In this research note, I estimate one component of the mortality impact of denying all wanted induced abortions in the United States. This estimate quantifies the magnitude of an increase in pregnancy-related deaths that would occur solely because of the greater mortality risk of continuing a pregnancy rather than having a legal induced abortion. Using published statistics on pregnancy-related mortality ratios, births, and abortions, I estimate U.S. pregnancy-related deaths by race and ethnicity before and in the first and subsequent years of a hypothetical total abortion ban. The number of estimated deaths following a total abortion ban is determined by assuming three conditions: that all wanted induced abortions are denied, that each abortion denied leads to 0.8 births, and that there is a corresponding increase in exposure to pregnancy-related mortality. I find that in the first year of such a ban, estimated pregnancy-related deaths would increase from 675 to 724 (49 additional deaths, representing a 7% increase), and in subsequent years to 815 (140 additional deaths, for a 21% increase). Non-Hispanic Black people would experience the greatest increase in deaths (a 33% increase in subsequent years). Estimated pregnancy-related deaths would increase for all races and ethnicities examined. Overall, denying all wanted induced abortions in the United States would increase pregnancy-related mortality substantially, even if the rate of unsafe abortion did not increase.

Urban-rural differences in pregnancy-related deaths, United States, 2011–2016

The US pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race and ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. We sought to compare pregnancy-related mortality across and within urban and rural counties by race and ethnicity and age. We conducted a descriptive analysis of 3747 pregnancy-related deaths during 2011-2016 (the most recent available data) with available zone improvement plan code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian or Alaska Native, and Asian or Pacific Islander women aged 15 to 44 years. We aggregated data by US county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. Of the total 3747 pregnancy-related deaths analyzed, 52% occurred in large metro counties, and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8; 95% confidence interval, 14.2-15.5), whereas noncore counties had the highest (24.1; 95% confidence interval, 21.4-27.1), including race and ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women aged 25 to 34 years and 35 to 44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women than non-Hispanic White women. Non-Hispanic American Indian or Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2 to 3 times that of non-Hispanic White women in the same areas. Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed in urban-rural categories, including by age group and race and ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths.

58 PREGNANCY-RELATED DEATH (PRD) REVIEW OF TEN YEARS-FLORIDA 2009–2018

The Florida Pregnancy Associated Mortality Review (PAMR) Committee reviews all PRDs with the goal to identify opportunities for prevention. The objective is to report current Pregnancy Related Mortality Ratio (PRMR) trends 2009-2018 and recommendations for practice. PAMR identifies all pregnancy associated deaths (PADs) by linkage to multiple files. Records of possible PRDs are abstracted, reviewed, and assessed. PAMR and birth certificate records from 2009–2018 were examined for PRMR estimates, trends and risk factors. Florida had 408 PRDs for 2,191,578 live births. The PRMR fluctuated from 26.2 deaths per 100,000 live births in 2009, to 12.9 in 2016. The 2018 PRMR is 16.3 on a downward trend from 2009-2018 but not significant (p>0.05.) The overall PRMR decreased 29% from 21.8 in 2009-13 to 15.5 in 2014-18 (p=0.001). PRMRs were calculated to evaluate race/ethnicity changes during the same intervals. The Non-Hispanic (NH) Black decreased significantly 37% from 46.6 to 29.4 (p=0.002). The Hispanic 42% decrease from 12.8 to 7.41 was significant (p=0.04). The NH White 9% decrease from 15.8 to 14.5 (p=0.59) was not significant. The Black/White disparity ratio decreased from 2.9x to 2.0x (p<0.05). From 2009-2018, six causes of death accounted for 77.7% of PRDs in rank order: hemorrhage, infection, hypertensive disorders, cardiomyopathy, cardiovascular and thrombotic embolism. Risk factors all not adjusted associated with PRD were cesarean delivery (RR 3.3), age 35 or older (RR 2.7), obesity (RR 2.6), no prenatal care during the first trimester (RR 2.4), non-Hispanic black (RR 2.5), and high school or less education (RR 1.4). Florida’s PRMR trending downward and the NH Black and Hispanic rates decreasing significantly may reflect statewide efforts of PAMR, the Florida Perinatal Quality Collaborative (FPQC), ACOG District XII and other partners who release this information to practitioners in obstetrics and emergency rooms through Urgent Maternal Mortality Messages and with the FPQC who target and focus on leading causes, risks and prevention.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States.

Over the past two decades, maternal mortality rates have declined around the world. In the United States, however, 700 women die each year as a result of pregnancy or delivery complications. This represents a 50% increase in the U.S. maternal mortality rate over the same time period. According to the Centers for Disease Control and Prevention (CDC), the pregnancy-related mortality ratios vary significantly by race, with White women experiencing 13.0 deaths per 100,000 births, compared with 42.8 deaths per 100,000 births for Black women, from 2011 to 2015. Multiple studies suggest that implicit bias-defined as the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner-is most likely a contributing factor to this alarming racial health disparity. The failure to recognize the pain of African American patients, regardless of whether it is conscious or unconscious, has the potential to affect the way obstetrician/gynecologists counsel patients about treatment options when it comes to chronic conditions, contraception, vaginal birth after cesarean delivery, and the management of fibroids. In this article, we will review implicit bias and the impact it can have on health care and health disparities.

Maternal Mortality Due to Cardiac Disease in Pregnancy.

Maternal mortality worldwide has vastly improved over the last several decades. Unfortunately, maternal mortality in the United States has been increasing and now cardiovascular conditions are the leading case of maternal death. The calculation of maternal mortality ratios and pregnancy-related mortality ratios is accomplished by several different organizations and this data collection is often complex, tedious, and poorly understood. Here we review the history of maternal mortality in the United States and aim to better understand how this data are collected.

Standardized Criteria for Review of Perinatal Suicides and Accidental Drug-Related Deaths.

To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation). Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend. From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08). After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.

Severe Cardiovascular Morbidity in Women With Hypertensive Diseases During Delivery Hospitalization

(Am J Obstet Gynecol. 2019;220:582.e1–582.e11) The pregnancy-related mortality ratio in the United States has tripled between 1987 and 2014. Some studies have estimated 35% to 44% of cases of maternal mortality or severe maternal morbidity are preventable. Hypertensive disorders of pregnancy (HDP) affect 10% of pregnancies worldwide and are one of the main causes of maternal and perinatal morbidity. Cardiovascular (CV) disease is the leading cause of death in women in the United States and the leading cause of pregnancy-related death. HDP have been associated with an increased risk of CV disease 10 to 30 years after delivery, but there is a lack of data on the relationship between HDP and CV morbidity during hospitalization for delivery. This study aimed to identify the risk of CV morbidity during delivery hospitalization in pregnancies complicated by HDP.

Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016.

Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged ≥30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women's health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels.

Income inequality and racial disparities in pregnancy-related mortality in the US.

In this ecological study, we examined the associations between state-level income inequality and pregnancy-related mortality among non-Hispanic (NH) black and NH white populations across the US. We estimated total population and race-specific 5-year pregnancy-related mortality ratios in each state based on national death and live birth records from 2011 to 2015. We obtained data on Gini coefficients for income inequality and population-level characteristics from the US Census American Community Survey. Poisson regression with robust standard errors estimated pregnancy-related mortality rate ratios (RR) and 95% confidence intervals (CI) associated with a one unit increase in income inequality overall and separately within black and white populations. Adjusted linear regression models estimated the associations between income inequality and magnitude of the absolute and relative racial inequity in pregnancy-related mortality within states. Across all states, increasing contemporaneous income inequality was associated with a 15% and 5-year lagged inequality with 14% increase in pregnancy-related mortality among black women (aRR = 1.15, 95% CI = 1.05; 1.25 and aRR = 1.14, 95% CI = 1.04; 1.24, respectively) after controlling for states’ racial compositions and socio-economic conditions. In addition, both lagged and contemporaneous income inequality were associated with larger absolute and relative racial inequities in pregnancy-related mortality. These findings highlight the role of contextual factors in contributing to pregnancy-related mortality among black women and the persistent racial inequity in maternal death in the US.

Racial and Ethnic Disparities in Pregnancy-Related Mortality in Illinois, 2002-2015.

Background: Little is known about racial or ethnic differences in the potential preventability of pregnancy-related deaths, or the provider, systems, or patient factors associated with those deaths. Materials and Methods: This is a retrospective cohort study of pregnancy-related deaths among black, Hispanic, and white women between 2002 and 2015 in Illinois using Illinois Department of Public Health maternal mortality data. We compared the distribution of women's characteristics and calculated race- and ethnicity-specific pregnancy-related mortality ratios (PRMRs) per 100,000 live births. We describe the proportion of deaths that were determined to be potentially preventable by race and ethnicity and critical factors associated with pregnancy-related deaths by cause. Results: There were 130, 33, and 109 pregnancy-related deaths of black, Hispanic, and white women, respectively, in Illinois during the study period. Overall, black women's PRMR was nearly four times that of white women (32.6 vs. 8.9 per 100,000 live births). The PRMR for Hispanic women under 30 years was lower than for white women, but that advantage disappeared after age 30. Emboli and vascular accidents were the most common underlying cause of death overall. Over a third of deaths were potentially preventable. Provider factors, particularly delays in diagnosis and treatment and inappropriate treatment, were cited in 56.1%, 71.4%, and 50.0% of black, Hispanic, and white women's preventable deaths, respectively. Conclusion: Surprisingly, racial disparities in maternal mortality were not associated with statistically significant differences in the cause of death or class of contributing critical factors in this small, single-state analysis; further study in aggregate or pooled data with deeper qualitative assessment of individual cases is, therefore, required to understand how to narrow racial disparities in maternal outcome. If aggregate or pooled analysis showed systematic racial or ethnic differences in committee findings, it would be important to assess whether those differences were due to committee bias or other factors.