US maternal deaths more than doubled over two decades in unequal proportions for race and geography

The rate of maternal deaths in the United States has more than doubled over a period of two decades, revealing significant disparities in terms of race and geography. These distressing findings were presented in a recent study published in the Journal of the American Medical Association. The researchers examined maternal mortality data from 1999 to 2019, excluding the impact of the pandemic, across all states and five racial and ethnic groups.

The study serves as a call to action, urging a comprehensive understanding of the underlying causes contributing to this alarming trend. While limited access to healthcare is a factor, the study highlights that structural racism and existing policies and procedures play a significant role in preventing people from maintaining good health. Dr. Allison Bryant, one of the authors of the study and a senior medical director for health equity at Mass General Brigham, emphasized the need to address these root causes.

Among affluent nations, the United States has the highest rate of maternal mortality, defined as death during pregnancy or up to one year postpartum. Causes of these deaths include complications such as excessive bleeding, infection, heart disease, suicide, and drug overdose.

The researchers, from Mass General Brigham and the Institute for Health Metrics and Evaluation at the University of Washington, utilized national vital statistics data on deaths and live births, employing modeling techniques to estimate maternal mortality per 100,000 live births. The study revealed pervasive and widening disparities. High rates of maternal mortality were observed not only in the South but also in regions such as the Midwest, as well as states like Wyoming and Montana, which recorded high rates for multiple racial and ethnic groups in 2019.

Comparing the first and second decades of the study, researchers identified the five states with the largest increases in maternal mortality. The increases were as follows:

• 162% for American Indian and Alaska Native mothers in Florida, Illinois, Kansas, Rhode Island, and Wisconsin
• 135% for white mothers in Georgia, Indiana, Louisiana, Missouri, and Tennessee
• 105% for Hispanic mothers in Georgia, Illinois, Indiana, Minnesota, and Tennessee
• 93% for Black mothers in Arkansas, Georgia, Louisiana, New Jersey, and Texas
• 83% for Asian and Pacific Islander mothers in Georgia, Illinois, Kansas, Michigan, and Missouri

Dr. Karen Joynt Maddox, a health services and policy researcher at Washington University School of Medicine in St. Louis who was not involved in the study, expressed her lack of surprise at the findings. She emphasized the need to investigate the underlying causes and take immediate action to address this issue.

Maddox highlighted the underinvestment in social services, primary care, and mental health in the United States compared to other wealthy nations. Additionally, she pointed out the inadequate funding of public health in Missouri and the lack of Medicaid expansion during the study period. However, Missouri has since expanded Medicaid and passed legislation providing new mothers with a year of Medicaid health coverage.

Disparities in maternal mortality are also evident in neighboring Arkansas, where Black women are twice as likely to experience pregnancy-associated deaths compared to white women, according to a 2021 state report. Dr. William Greenfield, the medical director for family health at the Arkansas Department of Health, acknowledged the persistence of this significant disparity and emphasized the need for further investigation to determine the reasons behind the increase in maternal mortality rates for Black mothers in the state.

The COVID-19 pandemic likely exacerbated existing demographic and geographic trends, which should be explored further in future studies. Preliminary federal data suggests that maternal mortality rates declined in 2022 after reaching a six-decade high in 2021, primarily due to the impact of COVID-19. Efforts to bring the 2022 rate closer to pre-pandemic levels, which were already alarmingly high, are underway.

To address these disparities, it is crucial to gain a deeper understanding of the underlying causes and prioritize community-based solutions. Arkansas has already implemented telemedicine and is working on various initiatives to improve access to care. The state has also established a perinatal quality collaborative to assist healthcare providers in adopting best practices for reducing cesarean sections, managing complications related to hypertensive disorders, and preventing injuries or severe complications during childbirth.

Dr. Greenfield emphasized that many of the reviewed deaths, both in Arkansas and elsewhere, were preventable.

This report was prepared by the AP Public Health Collaborations Editor Erica Hunzinger, with support from the Howard Hughes Medical Institute’s Science and Educational Media Group and the Robert Wood Johnson Foundation. The AP takes sole responsibility for the content.

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More about maternal mortality

• Study: US maternal deaths more than doubled over two decades
• Journal of the American Medical Association (JAMA)
• Maternal mortality in the United States: A Primer
• Structural Racism and Maternal Health: A Call to Action
• Racial and Ethnic Disparities in Maternal Mortality