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

Emily E. Petersen, MD; Nicole L. Davis, PhD; David Goodman, PhD; Shanna Cox, MSPH; Carla Syverson, MSN; Kristi Seed; Carrie Shapiro-Mendoza, PhD; William M. Callaghan, MD; Wanda Barfield, MD


Morbidity and Mortality Weekly Report. 2019;68(35):762-765. 

In This Article

Abstract and Introduction


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.

PMSS was established in 1986 by CDC and the American College of Obstetricians and Gynecologists to better understand the causes of death and risk factors associated with pregnancy-related deaths. Methodology of PMSS has been described previously.[2] Briefly, CDC requests that all states, the District of Columbia, and New York City identify deaths during or within 1 year of pregnancy and send corresponding death certificates, linked birth or fetal death certificates, and additional data when available. Medically trained epidemiologists review information and determine the relatedness to pregnancy and cause for each death. A death was considered pregnancy-related if it occurred during or within 1 year of pregnancy and was caused by a pregnancy complication, a chain of events initiated by pregnancy, or aggravation of an unrelated condition by the physiologic effects of pregnancy. U.S. natality files were the source of live birth data.[3]

PRMRs were analyzed by age group, highest level of education, and calendar year for women who were non-Hispanic white, black, AI/AN, Asian or Pacific Islander (A/PI), and Hispanic. Per the PMSS assurance of confidentiality, state-specific data are not authorized to be released. States were anonymously classified by PRMR and grouped into lowest, middle, and highest tertiles by PRMR; the PRMR was calculated by race/ethnicity per state tertile. Disparity ratios (comparisons of PRMR between two racial/ethnic groups) were calculated by five 2-year intervals, demographic characteristics, and state PRMR tertiles. White decedents were the referent group because they represented the largest racial/ethnic group. Cause-specific proportionate mortality was classified in 10 mutually exclusive categories,* and differences by race/ethnicity were identified using chi-squared tests. SAS statistical software (version 9.4; SAS Institute) was used for the analyses.

During 2007–2016, a total of 6,765 pregnancy-related deaths occurred in the United States (PRMR = 16.7 per 100,000 births). PRMRs were highest among black (40.8) and AI/AN (29.7) women; these rates were 3.2 and 2.3 times the PRMR for white women (12.7) (Table 1). From 2007–2008 to 2015–2016, the overall PRMR increased slightly from 15.0 to 17.0. The disparity ratios did not change significantly over time.

PRMR increased with maternal age; the black:white disparity was lowest among women aged <20 years (1.5) and highest among those aged 30–34 years (4.3); the AI/AN:white disparity was lowest among women aged 20–24 years (1.2) and was highest among women aged 35–39 years (5.1). Racial/ethnic disparities were present at all education levels. The PRMR among black women with a completed college education or higher was 1.6 times that of white women with less than a high school diploma. Among women with a college education or higher, the PRMR for black women was 5.2 times that of their white counterparts. The black:white disparity ratio in the PRMR for the states in the lowest, middle, and highest tertiles was 3.0, 3.3, and 2.8, respectively.

Cardiovascular conditions (including cardiomyopathy, other cardiovascular conditions, and cerebrovascular accidents), other noncardiovascular medical conditions, and infection were leading causes of pregnancy-related deaths. The proportion of pregnancy-related deaths attributed to each of 10 mutually exclusive causes varied by race/ethnicity (Table 2). Cardiomyopathy, thrombotic pulmonary embolism, and hypertensive disorders of pregnancy contributed to a significantly higher proportion of pregnancy-related deaths among black women than among white women. Hemorrhage and hypertensive disorders of pregnancy contributed to a higher proportion of pregnancy-related deaths among AI/AN women than among white women.

* Cause of death coding includes the following 10 mutually exclusive categories: hemorrhage; infection; amniotic fluid embolism; thrombotic pulmonary or other embolism (i.e., air, septic, or fat); hypertensive disorders of pregnancy (i.e., preeclampsia or eclampsia); anesthesia complications; cerebrovascular accidents; cardiomyopathy; other cardiovascular conditions (e.g., congenital heart disease, ischemic heart disease, cardiac valvular disease, hypertensive heart disease, and congestive heart failure); and other noncardiovascular medical conditions (e.g., endocrine, hematologic, immunologic, and renal). Deaths caused by hypertension that were not preeclampsia, eclampsia, or gestational hypertension were categorized in the "other cardiovascular conditions" category. Deaths caused by cerebrovascular accidents that were a result of preeclampsia or eclampsia were classified in the "hypertensive disorders of pregnancy" category; otherwise, deaths were classified in the "cerebrovascular accidents" category.