New study challenges scale of maternal health crisis in the U.S.

CNN
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Hundreds of women die each year in the United States from complications during pregnancy, childbirth, and postpartum, and the country's maternal mortality rate is high; outlier even in developed countries.

According to federal data, maternal mortality rates have skyrocketed in the United States in recent years, especially during the COVID-19 pandemic, and experts say: concern That the problem is getting worse. In 2022, the Biden administration will plan To address the maternal health crisis facing the nation, we recognize that pregnancy and childbirth are “traumatic experiences” for many people, leading to “preventable deaths, life-altering complications, and untreated mental health problems.” He emphasized that “health and substance use disorders” continue to persist.

But new study Although this suggests that the U.S. maternal mortality rate may be lower and more stable than federal data suggests, it is still very high.

In 2003, in an effort to better track and understand maternal mortality in the United States, the National Center for Health Statistics, part of the Centers for Disease Control and Prevention, asked states to include pregnancy status on death certificates. We requested that a “pregnancy checkbox” be added to indicate the pregnancy. The deceased woman was pregnant at or around the time of death.

The analysis that inspired this strategy suggested that approximately 30% of pregnancy-related deaths were missed before the introduction of the checkbox. 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 group of researchers from the University of British Columbia in Canada and other institutions around the world found that mortality and birth rates recorded by obstetrics and gynecology We have performed a detailed analysis of the file. National Center for Health Statistics 1999-2021.

Their findings show that reliance on pregnancy checkboxes may have led to an increase in misclassified maternal deaths, resulting in an overestimation of maternal mortality rates and trends over the past several decades in the United States. It suggests that.

“The pregnancy checkbox was introduced as a way to correct for underestimation of maternal mortality, but it went from underestimating maternal mortality by 30% to increasing it by 300%, which is a significant overestimation.” says Dr. KS Joseph. He is a professor in the Department of Obstetrics and Gynecology and Population and Public Health at the University of British Columbia and the study's lead author.

A new study shows that 38% of direct obstetric deaths and 87% of indirect obstetric deaths from 2018 to 2021 were identified as a result of a positive pregnancy checkbox, and that these deaths were “less specific.'' “Increased incidence of accidental causes of death.'' However, when researchers used a “definition-based approach” to identify maternal deaths and mentioned pregnancy as at least one cause of death, the results were much different.

Using National Vital Statistics System methodology, maternal mortality rates will increase from about 9.7 deaths per 100,000 live births from 1999 to 2002 to This increased to 23.6 deaths per person. However, using the researchers' alternative method, the maternal mortality rate changed only slightly over the same period, from 10.2 to 10.4 deaths per 100,000 live births. They found that deaths from direct obstetric causes, such as pre-eclampsia, actually decreased.

Including some previous studies, 2020 Report Published by CDC, found that maternal mortality appeared to increase significantly after the introduction of these checkboxes. However, surveillance methods continue to improve, and the National Center for Health Statistics' recent report did not compare maternal mortality trends with data from before 2018.

The new study presents maternal mortality rates as averages from 2018 to 2021, which also does not take into account potential short-term trends, including the impact of the COVID-19 pandemic.

Latest report According to the National Center for Health Statistics, 1,205 women died from maternal causes in the United States in 2021. The maternal mortality rate has increased by more than 60% in two years, from about 20 deaths per 100,000 live births in 2019 to about 20 now. In 2021, there will be 33 deaths per 100,000 live births.

Experts agree that surveillance methods are not perfect, but stress that high maternal mortality rates remain an important problem to address in the United States.

“We're pretty confident that we're seeing an increase. [in maternal mortality]Especially during a pandemic,” said Robert Anderson, CDC's chief of mortality statistics. “We went from underestimating to overestimating, so we had to correct. But we're pretty confident that the increase since 2018 is real.”

He said there may be some variation in the quality of the reports over the years, but it would be “non-statistical variation.”

The pregnancy checkbox on U.S. death certificates asks if the person was pregnant or recently became pregnant, but does not say whether pregnancy contributed to the death. Experts say clarifying the purpose of the checkboxes in a more direct way could help improve the quality of data collection.

Regarding the use of checkboxes in maternal mortality numbers, Dr. Elliot Mayne said: “While a pregnancy checkbox should not be considered evidence of pregnancy, the case needs further consideration before being added to the total.” Stated. He is a professor of obstetrics and gynecology at Stanford University School of Medicine and former medical director of the California Maternal Care Collaborative, but was not involved in the new study.

In March 2022, CDC sent additional guidance to death certifiers, resulting in some states implementing processes for certifiers to verify additional information about maternal deaths. Efforts are also underway to link maternal deaths with birth and fetal death records to confirm cases, and to flag discrepant records for further review by death certifiers.

“What we really want to do is improve the data on the front end, rather than trying to create workarounds to improve the information on the back end,” Anderson said.

Texas has made significant efforts to improve the data it collects on maternal mortality, developing a four-part Enhanced Methodology for Identifying Maternal Deaths that has been in place for many years. I'm here.

The pregnancy checkbox has helped identify some maternal deaths that might have been missed in the past, but “it has also proven to be error-prone,” according to the Texas Department of State Health Services' Maternal Mortality and Morbidity. said Epidemiology Manager Savannah Larimore.

Maternal mortality rates have remained generally stable in Texas in recent years, a new study suggests.

“From 2013 to 2019, we've seen a swing from 17 deaths per 100,000 live births to 20.7 deaths per 100,000 live births,” Larimore said, citing the latest data. said. report. “While we do see an increase in 2020 and 2021, we conducted a supplementary analysis showing that some of this may be due to COVID-19-specific mortality.”

Overall, Mayne said, “It's easy to identify direct maternal deaths. Deaths from bleeding or high blood pressure, deaths from blood clots, those are clearly related to pregnancy. But directly related to pregnancy. If you include non-indirect causes of maternal death, such as cancer, heart disease, and overdose, there is considerable variation.”

Over the past decade, many studies have shown that direct maternal deaths before and after childbirth have decreased, Mayne said. for example, Research published last year Researchers found that from 2008 to 2021, the proportion of pregnant women who died in hospitals from childbirth-related causes appears to have significantly decreased by more than 50% across the United States.

“We and many others have done a lot of work to address the obstacles of perinatal bleeding and hypertension, and I think that has helped directly reduce maternal mortality,” Mayne said. spoke about his work at the California Maternal Care Cooperative.

“Where we've been doing less work is in the postpartum period, where there are more challenges,” he says. “CDC data shows that the greatest increase in maternal deaths occurs in the year following birth, but the postpartum period is also a time when data are more confusing and interventions are much more difficult.”

“Gross health disparities” remain

The U.S. maternal mortality rate is lower than other high-income countries around the world, even though a new study suggests the country's overall maternal mortality rate is not rising as much as previous data showed. seems to still be high. It’s terrible,” Mayne said.

The study also highlights findings consistent with federal data showing large disparities in maternal mortality rates, particularly among black women in the United States.

“Many of the deaths detected through the checkbox are correct,” said Dr. Emre Seri, chief scientific advisor at the March of Dimes, a maternal and child health nonprofit. He was not involved in this new study.

“We agree that we should invest in researchers to better monitor maternal mortality,” he said. “However, the indisputable conclusion of this publication is that today's maternal mortality scenario is no better than it was 20 years ago, and there are enormous health inequalities in this problem. Sho.”

Seri said there is still much work to do to reduce maternal mortality rates and better track maternal deaths in the United States.

“Monitoring is critical so that we can consistently measure how effective interventions and policies are working. We know from our own report – March of Dimes” A report titledWhere you live matters“About obstetric care deserts and the access and equity crisis, we know that more than 5 million women live in counties with no or limited access to obstetric care services,” said Seri. he said.

“We know that obstetric care overall in the United States is not where it should be,” he said. “And we know that black women are much more likely to die during pregnancy than white women, and this is also shown in the current paper, even when we remove the use of the checkbox.” So we really think there's a lot of work to do to make maternal care available to everyone across the country. ”