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Maternal Mortality Doubles in One Decade, Driven by Racial Disparities

The rise in maternal mortality was driven in large part by racial disparities in mortality carried by American Indian/Alaska Native people.

The maternal mortality rate in the US more than doubled between 1999 and 2019, from a total of 505 maternal deaths to 1,210, according to a new JAMA study. But unsurprisingly, that increase affected different populations more than others, with American Indian/Alaska Native (AI/AN) and Black women seeing the steepest maternal health disparities.

These findings come as the US bemoans its unenviable title as having the worst maternal health equity in the developed world.

"Maternal mortality is a crisis in the United States. These rates have been increasing over the past several decades and were exacerbated by the pandemic," co-first author Allison Bryant, MD, MPH, senior medical director for health equity at Mass General Brigham, said in a statement. "Our study sheds light on the wide disparities within maternal mortality rates — the specter of maternal death differentially burdens some ethnic and racial populations."

Maternal mortality is defined as death that occurs during childbirth and up to one year after the end of pregnancy. Maternal mortality is commonly caused by mental health conditions as well as issues like hemorrhage, cardiac and coronary conditions, blood clots, cardiomyopathy, and hypertensive disorders.

It is well-regarded that the US has steep racial maternal health disparities. In 2021, the CDC reported that Black women were 2.6 times more likely to die from childbirth than their White peers.

This latest study, published by experts from Mass General Brigham and the Institute for Health Metrics and Evaluation (IHME), corroborates that data and provides and state-by-state breakdown of maternal mortality and maternal health equity.

Notably, it showed that even the states that perform the best in terms of maternal mortality still have inequity.

The researchers used data from the National Vital Statistics on deaths and live births in each state and broken down by racial/ethnic group. Using statistical modeling, they were able to estimate change in maternal mortality rates for each group and state, revealing a marked increase over a decade. Between 1999 and 2019, overall maternal mortality rates increased from 505 total deaths to 1,210.

But certain racial and ethnic groups bore the brunt of those increases more than others.

Certainly, Black populations have long had the highest maternal mortality rates of any racial or ethnic group. At baseline, the average maternal mortality rate for Black people across the country was 26.7 deaths per 100,000 live births, and that rose to 55.4 by 2019. The researchers noted that Black birthing people saw an outsized risk for maternal mortality at the start of the study period, but the risk plateaued around 2015.

Instead, maternal mortality among AI/AN people drove most of the overall nationwide increase. In 1999, the maternal mortality rate for this population was 14 deaths per 100,000 live births, but by 2019 that rose to 49.2.

Maternal mortality just about doubled for Asian, Native Hawaiian, or Other Pacific Islander populations, jumping from 9.6 deaths per 100,000 live births in 1999 to 20.9 in 2019. For Hispanic people, those figures were 9.6 to 19.1 deaths per 100,000 live births, and for White populations, they were 9.4 to 26.3 deaths per 100,000 live births.

Disparities were different depending on the state, the researchers added. While states located in the South did have the highest maternal mortality rates indifferent of race or ethnicity, there were still steep disparities in the states with the best maternal mortality rates.

"Often, states in the South are called out as having the worst maternal mortality rates in the nation, whereas California and Massachusetts have the best. But that doesn't tell the whole story," Bryant explained. "It's essential to look at the disparities between populations that exist even in the 'best' states.”

If nothing else, these figures can give healthcare providers and policymakers a map for implementing preventive policies, according to Greg Roth, an associate professor in the Division of Cardiology and the director of the Program in Cardiovascular Health Metrics and IHME.

"These disparities in maternal mortality are just the tip of the iceberg and tell us a lot about the health risks facing people in the states where these deaths are most likely to occur, " Roth said in a press release.

"In the U.S., maternal deaths are often caused by vascular diseases like severe high blood pressure or blood clots,” Roth added. “So maternal deaths share many of the same drivers as heart attacks, strokes, and heart failure. Our state-by-state research emphasizes where we need to focus our prevention efforts and which groups are suffering the most."

Of course, the study is limited in that it used data from before the COVID-19 pandemic, which seriously influenced clinical outcomes. Bryan said further research would look at how the pandemic affected maternal mortality rates.

“Our findings provide important insights on maternal mortality rates leading up to the pandemic, and it’s likely that we’ll see a continued increase in the risk of maternal mortality across all populations if we analyze data from subsequent years,” Bryant stated. “Black individuals would likely still have the highest rate, but there may be a higher uptick in some of the other groups in the last few years. As we emerge from the pandemic, we must renew our focus on addressing maternal mortality.”

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