How does maternal mortality vary by state and race and ethnicity over time in the US?
Long-term trends in maternal mortality ratios from vital registration and census data were estimated. Increases in maternal mortality ratios in specific states were identified and showed previously unmeasured inequities for specific subpopulations.
Previous research has focused on trends at the national level or in selected states. Comprehensive reporting of disparities in maternal mortality provides evidence to guide intervention policies and benchmark progress for the prevention of maternal deaths.
Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated.
To quantify trends in MMRs (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups using a bayesian extension of the generalized linear model network.
Design, Setting, and Participants
Observational study using vital registration and census data from 1999 to 2019 in the US. Pregnant or recently pregnant individuals aged 10 to 54 years were included.
Main Outcomes and Measures
In 2019, MMRs in most states were higher among American Indian and Alaska Native and Black populations than among Asian, Native Hawaiian, or Other Pacific Islander; Hispanic; and White populations. Between 1999 and 2019, observed median state MMRs increased from 14.0 (IQR, 5.7-23.9) to 49.2 (IQR, 14.4-88.0) among the American Indian and Alaska Native population, 26.7 (IQR, 18.3-32.9) to 55.4 (IQR, 31.6-74.5) among the Black population, 9.6 (IQR, 5.7-12.6) to 20.9 (IQR, 12.1-32.8) among the Asian, Native Hawaiian, or Other Pacific Islander population, 9.6 (IQR, 6.9-11.6) to 19.1 (IQR, 11.6-24.9) among the Hispanic population, and 9.4 (IQR, 7.4-11.4) to 26.3 (IQR, 20.3-33.3) among the White population. In each year between 1999 and 2019, the Black population had the highest median state MMR. The American Indian and Alaska Native population had the largest increases in median state MMRs between 1999 and 2019. Since 1999, the median of state MMRs has increased for all racial and ethnic groups in the US and the American Indian and Alaska Native; Asian, Native Hawaiian, or Other Pacific Islander; and Black populations each observed their highest median state MMRs in 2019.
Conclusion and Relevance
While maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: May 9, 2023.
Corresponding Author: Gregory A. Roth, MD, MPH, Institute for Health Metrics and Evaluation, UW Box 351615, University of Washington, 3980 15th Ave NE, Seattle, WA 98195 (firstname.lastname@example.org).
Author Contributions: Ms Fleszar and Dr Roth had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Fleszar and Dr Bryant were co–first authors.
Concept and design: Bryant, Johnson, Zheng, Roth.
Acquisition, analysis, or interpretation of data: Fleszar, Johnson, Blacker, Aravkin, Baumann, Dwyer-Lindgren, Kelly, Maass, Roth.
Drafting of the manuscript: Fleszar, Bryant, Johnson.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Fleszar, Johnson, Aravkin, Zheng.
Obtained funding: Roth.
Administrative, technical, or material support: Fleszar, Blacker, Maass.
Supervision: Bryant, Johnson, Roth.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in part by grants from the National Heart, Lung, and Blood Institute (R01HL136868), the National Institutes of Health (75N94019C00016), and Gates Ventures LLC.
Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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