Texas Maternal Mortality Nearly Doubled During Past Decade

Tara Haelle

January 05, 2018

The maternal mortality rate in Texas has nearly doubled during the past decade, though some undetermined portion of that increase appears to be the result of over-reporting, according to a study published January 4 in Birth.

"The observed increase in maternal mortality in Texas…is likely a result of both a true increase in rates and increased overreporting of maternal deaths," write Marian F. MacDorman, PhD, from the University of Maryland in College Park, and colleagues.

They note the "implausibly high and increasing rates for women aged ≥40 years and among nonspecific causes of death" as evidence of the overreporting and call for strengthening reporting of death certificate data.

The 2006 rate of 17.5 deaths per 100,000 births remained fairly steady through 2010, with 18.6 deaths per 100,000 births. Then a dramatic climb began in 2011, reaching 30.2 deaths per 100,000 births that year and 38.7 in 2012, followed by a nonsignificant decline to 32.5 in 2015.

The authors analyzed data from the National Vital Statistics System, which relies on death certificates filled out by physicians, medical examiners, or coroners and filed in the state's vital statistics offices.  

They used the World Health Organization's definition of maternal death: "the death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes." Deaths occurring after 42 days but within a year postpartum are classified as late maternal deaths.

The study's analysis began with data from 2006, the year state death certificates first included a new pregnancy question. The question had checkboxes for whether the woman had been "not pregnant within the past year, pregnant at the time of death, not pregnant but pregnant within 42 days of death, pregnant 43 days–1 year before death, or unknown whether pregnant within the past year," Dr MacDorman and coauthor Eugene Declercq, PhD, professor, Boston University School of Public Health, Massachusetts, write in an accompanying commentary.

The researchers then computed 5-year averages for 2006 to 2010 and 2011 to 2015, divided at the start of the rapid increase. They found an 87% jump, from a rate of 18.3 during the earlier years to 34.2 during the later period. The maternal mortality rate among women at least 40 years old more than doubled during this time, with a 121% increase, but even younger women saw an increase of 55% (though increases limited to women in their 20s were nonsignificant).

Older women also had an extraordinarily higher risk for death compared with younger women during 2011 to 2015: The older women's rate of 558.8 per 100,000 births is 27 times greater than the 20.7 rate among younger women.

"The increase for the ≥40 age group accounted for 56% of the overall increase in maternal deaths between the two time periods," even after consideration of race and ethnicity, the authors report.

The rate for black women remained more than twice that of white women during all years, but the doubling of rates from the earlier to later time periods occurred in both groups. The rate for white women increased from 19.4 during the earlier period to 38 during the later years. Black women's rate increased from 41.6 to 85.6 during this time. The increase in maternal mortality was less dramatic, at 62%, among Hispanic women, who had the lowest rate of 20.5 deaths per 100,000 births during 2011 to 2015.

Nonspecific Causes of Death, Death Certificate Errors

Maternal mortality rates for nonspecific causes of death increased 132% for all women between the two periods, accounting for 65% of the increased deaths. For specific causes, the rate overall rose by 54%, with an increase of 36% for women younger than 40 years.

The increase in nonspecific causes also explained much of Texas's increased rates compared with those of 27 other states and the District of Columbia. Although the Texas rate for nonspecific causes was 74% higher than in the other states, the rate for specific causes was higher (61%) only among women at least 40 years old.

"These data collection problems are present to a certain extent in all states," Dr MacDorman told Medscape Medical News. "However, the situation in Texas appears to be worse than in other states," she added.

The authors also modeled the potential effects of overreporting related to death certificate errors on the pregnancy question.

"[A] 1% overreporting of pregnancy/ postpartum status increased reported maternal mortality rates by 14%-18% for women in their teens to early thirties, and by 30% for women aged 35-39 years," the authors write. "In contrast, the maternal mortality rate for women aged 40-54 years more than doubled (105% increase) with 1% overreporting of maternal deaths."

Maternal Mortality Rates Have Dropped in Other Nations

In the commentary, Dr MacDorman and Dr Declercq describe in detail what has led to today's situation, in which "the data system has been unable to supply accurate estimates of United States maternal mortality as a result of problems in both reporting and coding of the data."

"As a result of these data problems, there is currently no clear picture available of United States' maternal mortality levels and trends," the editorialists write. "This lack of information has a clear influence on related data systems, and on the ability of the United States to prevent these tragic deaths."

Meanwhile, the US maternal mortality rate continues to substantially outstrip those of other industrialized nations with mostly preventable deaths.

Maternal mortality rates dropped in 157 of 183 countries from 2000 to 2013, the authors report, and the global rate dropped 44% (48% among industrialized nations) from 1990 to 2015.

The authors also call for improving women's access to good-quality maternal healthcare. Of note, the 36% increase from 2006-2010 to 2011-2015 in specific-cause maternal mortality among women younger than 40 years — the group least likely to experience overreporting — indicates a worrisome trend in Texas at a time when worldwide rates are almost unilaterally declining.

"Simply put," Dr MacDorman and Dr Declerq conclude, "if accurate maternal mortality data are not available, prevention efforts are scattered and unfocused ... and more women die."

Dr MacDorman's work was partially supported by a Eunice Kennedy Shriver National Center for Child Health and Human Development grant, Maryland Population Research Center. None of the authors have disclosed any relevant financial relationships. 

Birth. Published online January 4, 2018. Full text, Commentary

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