Issues and focus points for maternal mortality tracking

Maternal mortality tracking trends have shifted over time, highlighting focus points with a need for improvement.¹ In this article, we discuss inequities in maternal health, changes in maternal mortality tracking, and how methods of tracking from the Centers for Disease Control and Prevention (CDC) have led to overestimations of maternal death.

Inequities in maternal health care were revealed by Wanda Barfield, MD, MPH, FAAP, director of the Division of Reproductive Health within the CDC’s National Center for Chronic Disease Prevention and Health Promotion, in a recent interview.² This included a 3-fold increased risk of maternal mortality among Black women vs White women and a 2-fold increased risk among Alaskan Native women.

Barfield highlighted how the CDC is improving maternal health with data and surveillance. Maternal mortality review committees have been developed to obtain data surrounding deaths and share these data in a common language that allows doctors to understand the circumstances around maternal mortality.

Despite these efforts, current estimates for maternal mortality may be overestimated, according to Cande Ananth, PhD, MPH, vice chair for academic affairs at Rutgers Robert Wood Johnson Medical School.³ In an interview with Contemporary OB/GYN Ananth discussed a study evaluating the reasons for high and increasing rates of maternal mortality despite available resources for health care.

The introduction of the pregnancy checkbox on death certificates was the primary reported source of overestimated maternal deaths. While the checkbox was introduced in response to the undercapture of maternal death, it has often been used incorrectly, such as maternal death being reported among many women aged over 85 years.

Maternal mortality rates were significantly lower when the cause of death fields on death certificates were used rather than the pregnancy checkbox, indicating a link between the checkbox and overestimating deaths. In 2004, the CDC stopped producing national maternal mortality estimates to address these issues, but this practice was reintroduced in 2018.

According to Mark Simon, MD, chief medical officer at OB Hospitalist Group, a recent study evaluating maternal mortality tracking also found overestimation from the introduction of the checkbox.¹ Simon was surprised that the number of deaths partly connected to maternal care, especially from mental health and substance abuse, were not reported.

Pregnant patients are at increased risk of mental health and substance abuse issues, and failure to report them leads to underestimation of the impact pregnancy may have on maternal mortality. Whether a death is directly or indirectly linked to pregnancy, the outcome of death among young individuals should be given focus and prevented, Simon noted.

Ananth noted the sharp increase in maternal mortality numbers when the checkbox was reintroduced, from 17 per 100,000 deaths in 2018 to 32.8 per 100,000 deaths in the 2021 estimate.³ Maternal mortality is presented through 2 CDC reports, including the National Vital Statistics System (NVSS) and the National Center for Health Statistics report.

The NVSS reports correcting maternal mortality rates for potential errors. However, even after correction for errors, the disparities in maternal mortality remain.

Improving maternal care is a collective effort among health care providers in the US, with challenges such as bias and racism being systemic.² Barfield suggested improving the quality of perinatal care to ensure equity.

The CDC is working to improve access to quality care through efforts such as Perinatal Quality Collaboratives, which identify methods for reducing disparities in access to care and implementation of care.

The Hear Her campaign is another effort for addressing maternal mortality by identifying warning signs such as concerns expressed by mothers. Identifying these signs allows patients to receive the care they need as soon as possible. Information about patients from multiple backgrounds is available through the campaign.

Rates of obstetrically related maternal deaths such as pregnancy-related hypertension have been improved over time, and Simon believes this means any provider caring for pregnant patients should prioritize best practices for significant maternal disease processes.¹ Following appropriate protocols can minimize and prevent maternal deaths when possible.

Expecting mothers can also reduce their risk of death through clear and open communication with their health care provider. Patients should be able to openly discuss their health history, mental health concerns, substance abuse, and external environment in a nonjudgmental environment to achieve optimal outcomes.

To improve tracking, individual states should come together and report their data to the CDC, according to Ananth.³ Clinicians have begun to address issues of maternal death and maternal morbidity women may face during pregnancy, but additional effort is needed. More concerted efforts toward timely care can help protect women before and during pregnancy.

Recently, a decline in maternal mortality rates was reported by the CDC, from 32.9 per 100,000 live births in 2021 to 22.3 per 100,000 in 2022.⁴ Significant reductions were observed for non-Hispanic Black, non-Hispanic White, and Hispanic individuals. However, Asian women did not experience a significant decrease.

The racial disparity in maternal mortality remained significant in 2022, according to the CDC data. Black women had a rate of 49.5 deaths per 100,000 live births, compared with 19 per 100,000 in White women, 16.9 per 100,000 in Hispanic women, and 13.2 per 100,000 in Asian women.

All age groups experienced significant reduction in maternal mortality, though significant differences in rates were observed across age groups. This included rates as low as 14.4 deaths per 100,000 live births in women aged under 25 years vs 87.1 per 100,000 for those 40 years and older.

Simon highlighted the importance of teams working together when caring for pregnant patients.¹ The process can involve multiple health care professionals as well as the patient and family, all working to ensure that the best possible outcomes are achieved.

Based on studies tracking maternal mortality, Simon believes many maternal deaths are preventable and that they can be prevented when providers work together.

“All of us have a role to play in preventing pregnancy-related deaths,” Barfield said, noting that multiple resources are available on the CDC website.² These resources can be used to prevent maternal deaths that Barfield described as “unacceptable.”

REFERENCES

1. Krewson C. Study unveils maternal mortality tracking trends. Contemporary OB/GYN. March 20, 2024. Accessed June 26, 2024. https://www.contemporaryobgyn.net/view/study-unveils-maternal-mortality-tracking-trends
2. Krewson C. Addressing maternal health inequities: insights from CDC's Wanda Barfield. Contemporary OB/GYN. May 31, 2024. Accessed June 26, 2024. https://www.contemporaryobgyn.net/view/addressing-maternal-health-inequities-insights-from-cdc-s-wanda-barfield
3. Krewson C. CDC estimates of maternal mortality found overestimated. Contemporary OB/GYN. March 29, 2024. Accessed June 26, 2024. https://www.contemporaryobgyn.net/view/cdc-estimates-of-maternal-mortality-found-overestimated
4. Hoyert DL. Maternal mortality rates in the United States, 2022. NCHS Health E-Stats. National Center for Health Statistics; 2024. Accessed June 26, 2024. https://stacks.cdc.gov/view/cdc/152992