The rapidly rising rate of maternal mortality in the United States may be in part related to recent changes in data collection and statistical modeling for death during or after pregnancy, according to a new study published Wednesday in the American Journal of Obstetrics and Gynecology.
Researchers argue that the discrepancy may be due to the recording of deaths of women who coincidentally were pregnant as deaths caused by pregnancy itself. Their findings suggest that maternal mortality is largely stable and that deaths due to obstetric complications have decreased in recent years.
Lead study author K.S. Joseph from the University of British Columbia and his colleagues that this conflation of pregnancy-caused death and death while pregnant may be responsible for an overestimate of maternal mortality of upwards of 300%.
The problem appears to have arisen after the National Center for Health Statistics recommended adding a “pregnancy checkbox” to U.S. death certificates in 2003 to address the problem of underestimating the number of deaths due to pregnancy complications. By 2018, all 50 states had implemented this change on their death certificates to note whether a woman either was pregnant at the time of death or experienced a pregnancy up to one year before her death.
To distill the data, Joseph and his colleagues separated the statistics into “maternal death,” or death due to pregnancy and its management, and “pregnancy-associated death,” or death while pregnant from any other cause.
Based upon this distinction, the researchers found that the rate of maternal deaths remained relatively stable between the periods of 1999-2002 and 2018-2022, increasing from 10.2 deaths to 10.4 deaths per 100,000 live births.
This significantly differs from the methodology used by the National Vital Statistics System from the Centers for Disease Control and Prevention, which estimates an increase from 9.7 deaths to 23.6 deaths per 100,000 live births during the same time period.
Joseph and his colleagues found that deaths from certain complications of pregnancy, such as preeclampsia, eclampsia labor, and delivery complications, decreased during the study period. Other causes of death indirectly related to pregnancy, such as preexisting hypertension and cardiomyopathy, increased between 1999 and 2022.
“Although the pregnancy checkbox has the potential to improve the sensitivity of maternal mortality surveillance, it has to be used as a first-step screen, with an assessment of the clinical circumstances required before such deaths are deemed to be maternal deaths,” wrote Joseph and his colleagues in their study.
CDC Chief of Mortality Statistics Robert Anderson told CNN that, despite discrepancies in surveillance methods, he is very confident that there has been an increase in maternal mortality, especially during the COVID-19 pandemic.
“We went from underestimating to overestimating, so we had to make that correction,” said Anderson. “But I feel fairly confident that the increases since 2018 are real.”
Even in light of these new findings, the United States still has the highest maternal mortality rate in the developed world, especially for black women, who are more likely to die during or after pregnancy than other racial or ethnic groups.
The maternal mortality rate for black women, according to Joseph and his colleagues, decreased from 25.7 deaths in 1999-2002 to 23.8 deaths per 100,000 live births in 2018-2022. Both figures are double the overall rates, largely because black women are more likely to experience preexisting conditions that are worsened during pregnancy, including hypertension and cardiovascular problems.
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Joseph and his colleagues suggest that a cause-specific method of maternal death data collection would provide “a clear agenda for clinical and public health action,” providing a better strategy for prevention.
Addressing the maternal mortality crisis has been a top priority of the Biden administration, with Pres. Joe Biden proposing a $376 million investment in the fiscal 2025 budget for the implementation of the White House Blueprint for Addressing the Maternal Health Crisis. The project was first launched in 2022.
