Maternal mortality rates in the United States have increased significantly in nearly every state except California since 2000, and women of color have a significantly higher risk than white women, experts said during an American College of Obstetrician and Gynecologists (ACOG) news briefing. Black women fared the worst, with maternal mortality rates more than two-fold higher than those for white women.
ACOG held the briefing as a follow-up to a series of papers on worldwide maternal health published recently in The Lancet to highlight maternal health in the United States, said Barbara Levy, MD, vice president of health policy for ACOG and coauthor of one of the Lancet articles. Interventions by ACOG and other groups are focused on reducing maternal mortality rates in this country.
The rates in 48 states and Washington, DC, increased 27% from 2000 to 2014, from 18.8 to 23.8 per 100,000 live births, said Marian MacDorman, PhD, research professor at the Maryland Population Research Center in College Park, Maryland, citing work recently published in Obstetrics & Gynecology.
The researchers analyzed maternal mortality rates for Texas and California separately. Texas rates increased slowly from 17.4 to 18.6 per 100,000 live births from 2000 to 2010, then rapidly doubled to 38.6 per 100,000 live births in 2012. Although the rate has since declined a bit to 33.8 per 100,000 live births in 2014, it is still "much higher" than in any other state, Dr MacDorman said. From 2010 to 2012, the state experienced large cuts in women's health programs and clinic closings throughout the state, she said, although her research did not study potential associations.
California was the exception, with maternal mortality rates that decreased from 21.5 per 100,000 live births in 2003 to 15.1 per 100,000 in 2014.
Globally, maternal mortality has decreased by 44% worldwide from 1990 to 2015, she said. A recent World Health Organization report for 167 of 183 countries documented reductions in maternal mortality from 2000 to 2013 — a contrast to the US figures, she said. "Clearly, the United States is moving in the wrong direction."
"Maternal deaths have a large impact on society," Dr MacDorman added. "These are largely preventable deaths of young women in the prime of life, often with families and other small children needing care. Accurate measurement of maternal mortality is an essential first step in prevention efforts because it can identify [at-risk] populations and measure progress of prevention programs."
Worse for Minority Women
The picture for minority women is even worse, the panelists said. In 2014, the maternal mortality rates were 52.5 and 46.5 per 100,000 live births for non-Hispanic black and non-Hispanic Native American women, respectively. Those rates are more than twice the rate of 20.7 per 100,000 live births for non-Hispanic white women, according to statistics for 45 states and Washington, DC, Dr. MacDorman explained. Hispanic and non-Hispanic Asian/Pacific Islander women fared slightly better, with rates of 16.8 and 14.0 per 100,000 live births, respectively.
"If you're an African American woman in some parts of this country, your mortality rate with pregnancy is higher than it is in some countries in sub-Saharan Africa and South Asia," Elizabeth Howell, MD, professor and vice chair of research at Mount Sinai Icahn School of Medicine in New York City, said. She chairs an ACOG workgroup on reduction of peripartum disparities.
"If you're an African American woman in [Washington] DC, your mortality is somewhere north of 70 times what it is if you're a white woman. These are tough issues."
And Washington, DC, isn't the only city to show the exaggerated problem, according to Dr Howell. She noted that data from the New York City Department of Health and Mental Hygiene show that maternal mortality was 12 times higher among black women than non-Hispanic white women between 2006 and 2010. Moreover, the gap widened by 45%, compared with the period between 2001 and 2005.
"It's also important to remember that for every maternal death, over 100 women experience severe obstetric morbidity, a life-threatening diagnosis, or undergo a life-saving procedure during their delivery/hospitalization," Dr Howell said. This affects nearly 60,000 women annually in the United States, and rates nearly doubled over the last decade, she said. Disparities are complex and include many contributing factors, such as genetics, social determinants, patient behavior, and quality of care, she added.
ACOG and other organizations, through the Alliance for Innovation on Maternal Health (AIM), are working to reduce racial disparities in the care of pregnant women. They have developed evidence-based guidelines to improve care in areas that include obstetric hemorrhage, severe hypertension and preeclampsia, maternal prevention of venous thromboembolism, and safe reduction of primary cesarean deliveries/support for intended vaginal birth.
"Our goal is that this [safety] bundle will be utilized by healthcare systems, hospitals, and others as one of the many essential steps to reducing disparities," she said.
Improvements in California
To turn things around, it's imperative to review and determine the causes of maternal deaths, said Elliot Main, MD, medical director of the California Maternal Quality Care Collaborative and co-lead of the ACOG/Centers for Disease Control and Prevention Maternal Mortality Maternal Safety Work Group. The California Department of Public Health saw maternal mortality rates rising there and in the rest of the country and formed a maternal mortality review committee that identified care improvement opportunities in 1999, he said. Medical and public health experts, nurses, and midwives worked together to develop quality improvement toolkits for hemorrhage and preeclampsia. Those have been rolled out to some 180 hospitals since 2009.
With other partners, the California Maternal Quality Care Collaborative has developed additional obstetrics safety bundles in severe hypertension, prevention of blood clots, safe reduction of cesarean deliveries, patient and family support for these catastrophic events, and reducing racial/ethnic disparities. The toolkits are available online. The group is working with AIM to move this forward in additional states, 10 of which now have AIM state projects in place, and 9 of which are establishing programs. The collaborative is developing another toolkit on cardiovascular disease, Dr Main said.
Overall, obstetric practice in the United States varies widely, Dr Levy explained. Women and physicians/practitioners "are afraid of multiple things," she said: Women are fearful of pain or bad outcomes from vaginal birth, and healthcare practitioners fear liability and bad outcomes, which to some extent is driving the cesarean delivery rate in this country.
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Cite this: Maternal Mortality Rates Much Higher for Minorities in US - Medscape - Oct 25, 2016.