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In the United States, hundreds of women die from complications during pregnancy, childbirth, and the postpartum period, the highest maternal mortality rate in the nation. Out Among developed countries.
According to federal data, maternal deaths have increased significantly in the United States in recent years, especially during the Covid-19 pandemic. Risk The problem is getting worse. In 2022, the Biden administration a Plan To tackle the country's maternal health crisis, it highlights that pregnancy and childbirth are “traumatic experiences” for many and “cause preventable deaths, life-changing complications and untreated mental health and substance use disorders”.
But new Research It suggests that the maternal mortality rate in the US may be low and stable — though still very high.
In the year In 2003, to better track and understand maternal deaths in the US, the National Center for Health Statistics – part of the US Centers for Disease Control and Prevention – requested that states add a “pregnancy confirmation box” to death certificates. A dead woman was pregnant at or around the time of her death.
The analysis that prompted the strategy found that 30% of pregnancy-related deaths were missed before the check box was launched. In the year By 2018, all 50 states had implemented this change on death certificates.
In a new study published Wednesday in the American Journal of Obstetrics and Gynecology, a team of researchers from the University of British Columbia in Canada and other institutions around the world conducted an in-depth analysis of mortality and birth records. National Center for Health Statistics 1999 to 2021.
Their findings suggest that reliance on the pregnancy checklist has led to an increase in misclassified maternal deaths, resulting in maternal mortality and changes in the United States over the past few decades.
“The pregnancy scorecard was proposed as a method to correct the estimate of maternal mortality, but we went from a low estimate of 30% to a 300% increase in maternal mortality, which is a significant estimate,” said Dr KS Joseph, University of British Columbia's Department of Obstetrics and Gynecology and Public and A professor at the School of Public Health, was the lead author of the study.
The new study found that between 2018 and 2021, 38% of direct perinatal deaths and 87% of indirect perinatal deaths were identified as a result of a positive pregnancy registry, and these deaths were associated with “an increase in less specific and accidental causes of death”. However, when the researchers identified a “divorce-based approach” to maternal death among the many causes of death mentioned at least once in pregnancy, the results were very different.
Maternal mortality increased from 9.7 deaths per 100,000 live births in 1999 to 23.6 deaths per 100,000 live births in 2018 to 2021. But with the researchers' alternative methods, the maternal mortality rate changed from just 10.2 deaths to 10.4 deaths per 100,000 live births. They found that deaths from direct uterine causes, such as preeclampsia, actually decreased.
Several previous studies, a 2020 report published by the CDCThey found that maternal mortality rates increased significantly after these checkboxes were introduced. But surveillance methods continue to struggle, and the latest reports from the National Center for Health Statistics don't compare maternal deaths to data from before 2018.
By averaging maternal deaths from 2018 to 2021, the new study excludes potential short-term trends – including the impact of the Covid-19 pandemic.
The latest Report According to the National Institutes of Health Statistics, 1,205 women in the United States will die from maternal causes in 2021. Maternal mortality has increased by more than 60 percent, with 20 deaths per 100,000 live births in 2019. By 2021, 33 out of 100,000 live births will die.
Experts agree that surveillance methods are not perfect, but they stress that the high maternal mortality rate in the US is an important issue that needs to be addressed.
“We are absolutely sure that progress has come [in maternal mortality]Especially during the outbreak, said Robert Anderson, chief of mortality statistics for the CDC. “We went from underestimating to overestimating, so we had to make that correction. But I feel completely confident that the increases from 2018 are real.
There could be some variation in the quality of reporting over the years, he said, but it would be “non-statistical variability.”
A pregnancy checkbox included on death certificates in the US asks if the person was pregnant or recently became pregnant, but does not state whether the pregnancy contributed to the death. Experts say that explaining the purpose of the checkbox in a more direct way can help improve the quality of data collection.
Regarding the use of tick boxes in maternal deaths, Dr. Elliot Mayne said: “The pregnancy box should not be taken as proof of pregnancy, but it should be looked at more before it becomes a general issue.” , professor of obstetrics and gynecology at Stanford University School of Medicine and former medical director of the California Maternal Quality Care Collaborative, who was not involved in the new study.
In the year In March 2022, the CDC issued additional guidance to death certifiers, indicating that some states have implemented a process for certifying additional information for maternal deaths. And there is an ongoing effort to link maternal deaths to birth records or fetal death records to prove the case, or to show records without matches for an additional round of review from death certificate issuers.
“What we really want to do is improve the data on the front end rather than trying to create a solution to improve the data on the back end,” Anderson said.
Texas made a major effort to refine data collected on maternal deaths, developing a four-part “improved method” for identifying maternal deaths that had been in place for years.
Savannah Larimore, manager of maternal mortality and morbidity epidemiology at the Texas Department of Health, said the pregnancy tick box may have helped identify some maternal deaths that may have been missed, but it is “prone to error.”
According to the new study, Texas has seen an overall stabilization in maternal mortality rates in recent years.
“From 2013 to 2019, we're looking at a shift from 17 deaths per 100,000 live births to 20.7 deaths per 100,000 live births,” Larimore said, citing the latest. Report. In the year We're seeing an increase in 2020 and 2021, and we've done further analysis to see if some of it could be due to Covid-19-related deaths.
In general, Mayne says, “It's easy to identify direct maternal deaths — like bleeding and hypertension deaths and coagulation deaths, those are clearly related to pregnancy.” But there is considerable variation in causes not directly related to pregnancy, including so-called indirect maternal deaths such as cancer, heart disease or overdose.
Over the past decade, several studies have shown that direct maternal mortality around childbirth has decreased, Maine said. For example, a The study was published last year In the year Between 2008 and 2021, more than 50 percent of pregnant women dying in the hospital from birth-related causes appear to have fallen significantly across the United States.
“We and many others have done a lot of work to address perinatal hemorrhage and hypertension, and I think that has directly helped reduce maternal mortality,” Mayne said of his own work at the California Maternal Quality Care Collaborative.
“Where we haven't put as much effort – and where there are more challenges – is in the postpartum period,” he said. “CDC data indicates that the greatest increase in maternal mortality occurs in the year after birth, but the postpartum period is also when data is skewed and interventions are most difficult.”
'Many health inequities' remain
Although the new study suggests that the country's overall maternal mortality rate is not increasing as much as previous data indicated, the United States still appears to have one of the highest maternal mortality rates in the world's high-income countries. Terrible,” said the chief
Also, the study highlighted findings consistent with federal data showing significant disparities in maternal mortality rates, particularly among black women in the US.
“Many of the deaths found in the check boxes are correct,” said Dr. Emre Celi, chief scientific advisor for the March of Dimes, a maternal and infant health nonprofit that was not involved in the new study.
“We agreed that we should invest in researchers who can better monitor maternal mortality,” he said. But the indisputable conclusion of this publication is that we are doing no better today in terms of maternal mortality than we were 20 years ago, and that there is a great deal of health inequity in this matter.
Much work remains to be done to reduce the maternal mortality rate in the United States and to better track maternal deaths, Seeley said.
Monitoring is essential to consistently measure how interventions and policies are being implemented. We know from our own reports – Dimes March report titled 'Where they live matters“On maternity care deserts and the crisis of access and equity – we know that more than 5 million women live in counties with limited access to maternity care,” Seely said.
“We know where maternity care should not be in the United States,” he said. “And we know that black women are significantly more likely to die during pregnancy than white women, even in the current paper, even when you remove the use of the check box. So we think there's a lot to do to make maternity care accessible across the country,” he said.