Is US maternal mortality rising? Maybe not.

Tombstone Mother

I’ve been writing about the issue of US maternal mortality for years, and for years I’ve argued that most of the supposed increase is a result of improved reporting of maternal deaths, not more deaths.

That view was confirmed by the recent paper Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues by MacDorman et al.

“The overall picture is not consistent with any serious deterioration in maternal health or maternal health services in the United States.”

Studies based on data from the 1980s and 1990s identified significant underreporting of maternal deaths… To improve ascertainment, a pregnancy question was added to the 2003 revision of the U.S. standard death certificate…

However, there were delays in states’ adoption of the revised death certificate … This created a situation where, in any given data year, some states were using the U.S. standard question, others were using questions incompatible with the U.S. standard, and still others had no pregnancy question on their death certificates.

Due in part to the difficulties in disentangling these effects, the United States has not published an official maternal mortality rate since 2007…

While raw data suggested that US maternal mortality had more than doubled since 2000, MacDorman and colleagues found that the real increase was only 26.4%, a much smaller increase, but an increase nonetheless.

Now a new paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States by Joseph et al., questions even the smaller increase.

The authors note:

Recent publications on global trends in maternal mortality have reported substantial increases in maternal deaths in the United States … The maternal mortality ratio in the United States in 2013 was higher than that in Azerbaijan, Iran, Kazakhstan, Libya, Saudi Arabia, and Uruguay (among others)… Such reports have led to considerable dismay in the United States and pleas for prompt clinical action to reduce maternal deaths.

It is difficult to reconcile the maternal mortality ratios in the United States with the lower estimates of these rates in less industrialized countries. Several explanations have been offered to explain the observed temporal increase in maternal mortality including an increase in chronic diseases among reproductive-aged women (especially obesity) and increasing rates of cesarean delivery. However, an alternative narrative, which views the rising rates of maternal mortality in the United States as an artifact of improved surveillance, implicates several different changes in maternal death surveillance …

The authors analyzed changes in both the overall rate of maternal mortality from 1999-2014 and cause specific mortality rates. They found that deaths from traditional causes actually DECLINED while deaths in new categories increased substantially.

Maternal mortality ratios (excluding late maternal deaths) increased from 9.88 in 1999 to 21.5 per 100,000 live births in 2014 (RR 2.17, 95% CI 1.93–2.45). However, maternal deaths resulting from complications of labor and delivery declined significantly over the same period (RR 0.43, 95% CI 0.27–0.68). There was no significant change in maternal deaths resulting from abortive outcomes (O00–O07), edema, proteinuria and hypertensive disorders, maternal care related to the fetus and amniotic cavity, and complications predominantly related to the puerperium. However, deaths resulting from other maternal disorders predominantly related to pregnancy and deaths resulting from other obstetric problems not elsewhere classified increased substantially between 1999 and 2014 (RR 10.0, 95% CI 6.85–14.7 and 5.88, 95% CI 4.38–7.89).

The difference was even more pronounced for late maternal deaths, many of which were not captured before the changes in reporting requirements;

Late maternal deaths, that is, obstetric deaths greater than 42 days and less than 1 year after delivery and deaths from sequelae of obstetric causes, increased from 0.38 in 1999 to 6.69 per 100,000 live births in 2014 (RR 17.7, 95% CI 10.5–29.7). Exclusion of codes O26.8 (other specified pregnancy-related conditions) and O99 (other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium) and late maternal deaths (O96 and O97) abolished the temporal increase in these maternal mortality ratios.

The authors explain:

Our study suggests that the reported substantial increase in maternal mortality in the United States between 1993 and 2014 was likely a consequence of improvements in maternal death surveillance and changes in the coding of maternal deaths. Regression adjustment for the separate pregnancy question on death certificates, ICD-10 codes, and the standard pregnancy checkbox on death certificates eliminated the increase in maternal mortality rates between 1993 and 2014. Exclusion of maternal deaths associated with the four new ICD-10 codes that identified late maternal deaths (O96, O97), other specified pregnancy-related conditions (O26.8), and other maternal diseases classifiable elsewhere (O99) also abolished the temporal increase in maternal mortality between 1999 and 2014.

Most other countries have not instituted new maternal mortality guidelines. Therefore it is hardly surprising that US maternal mortality ranking has dropped in relation to other countries that aren’t recording all maternal deaths.

The authors conclude:

Although there may have been some increase in maternal deaths resulting from chronic diseases (such as diseases of the circulatory system, diabetes, and liver disease) and definite reductions in maternal death resulting from obstetric causes (such as preeclampsia, eclampsia, and complications of labor and delivery), the overall picture is not consistent with any serious deterioration in maternal health or maternal health services in the United States.

Which is what I have been saying all along.

  • Cestrum Nocturnum

    Maternal death rates went up in Texas after they shuttered a bunch of Planned Parenthoods.

  • DrSelina

    So, now the republicans are trying to eliminate maternity care. Prior to 2011, in Oregon, I saw many women who went to home birth midwives for care because they could not afford maternity care, and did not know that the state Medicaid party covered maternity costs. Since the ACA was enacted, the number of women who are coming in for comprehensive prenatal care has increased. I have seen so many women who have told me they only went to home birth midwives because they could not afford to deliver in the hospital, prior to the ACA, due to insurance premiums. I want to know when these republicans are going to take responsibility for the babies and mothers damaged beyond repair by home birth because they could not afford to safely deliver in a hospital.

  • The Computer Ate My Nym

    I’m not altogether convinced. At least, for the US as a whole, it’s probably accurate, but some parts of the US have been seeing more concerning trends. Specifically, Texas. Texas’ maternal mortality is about 36/100,000 right now and there is a plausible mechanism for the increase: conservative harassment of providers and shutting of clinics where poor women receive care resulting in some women not receiving care, with the related risks of not receiving care. So I’d look at subpopulations before dismissing it all as due to changes in definition.

    • The Bofa on the Sofa

      Doesn’t this only look at the change up to 2014? I think the major uptick in Texas is since then.

  • MaineJen

    Meanwhile in Congress, the question of the day is “Why should men have to pay for maternity care???”

    Yes, really.

    • Azuran

      Yea, I mean, no man was ever born on this earth and women just fall pregnant on their own. Men have absolutely nothing to do with pregnancy.

      Don’t they even realize that maternity care is also foetal care? Do they not care about the health of their own babies and their SO?

      • MaineJen

        Maybe that should be the counter argument. “If the mother dies, the fetus dies!” Nothing else has worked…

        • Who?

          Would that be a problem though? In the headspace where women exist for the use, benefit and enjoyment of men, if one dies in the course of that, well so what?

          It’s the inevitable next step after ‘what’s a few dead babies’ in the pursuit of a natural approach to pregnancy and childbirth.

    • Empress of the Iguana People

      Um because the woman’s child is also a man’s child? Certainly can’t be because women shouldn’t have to pay for men’s viagra or prostate exams, or because being nice to our fellow humans is a good idea, even if that human *is* an icky girl

      • Mel

        I told a rather annoying cousin of mine that men could stop paying for maternity care as soon as humans can reproduce through parthenogenesis.

    • Sheven

      If that’s the tone they’re going to take, why should non-pregnant women have to pay for maternity care?

      • MaineJen

        Because apparently being a woman means being in a constant state of “I might be pregnant!” While being a man means being in a constant state of “I’m off the hook! But I still want my viagra!”

        • BeatriceC

          Slight point of contention: most insurance policies don’t cover viagra for erectile disfunction. They will cover sildenafil when it’s prescribed for pulmonary hypertension, but not when prescribed for erectile disfunction. Looking at just the raw numbers of how much insurance companies pay for that specific drug doesn’t give you the whole picture, because ED isn’t the only thing it’s used for, nor are adult men the only people it’s prescribed to.

          • Merrie

            The sildenafil prescribed for pulmonary hypertension is typically a different strength under a different brand name.

            In my experience (12 years in pharmacy) erectile dysfunction drugs are sometimes covered for a few pills per month (usually between 3 and 6), and fairly frequently not covered at all. The new Cialis For Daily Use hasn’t really caught on since most plans don’t cover it.

    • Sean Jungian

      Hey, they want to let your employer do a DNA screening before hiring you, too! Preemptive eugenics comin’ atcha.

  • myrewyn

    Can I ask a potentially stupid OT question? I have mentioned here that I bought a case (eight bottles) of ready-to-feed newborn formula to take to the hospital just in case my baby needs supplementation and I’m not up for fighting the nurses. I opened the case to pack the bottles into my hospital bag this week and noticed it comes with one nipple. Can I adequately clean this nipple in the hospital if I need to use it more than once or should I go buy a few more nipples at Target? And do I assume the nipples are clean from the package, or do they need to be washed first?

    • Gene

      You can wash in between without issues. In the ED I use the nipple out of the package but you can wash first if you want.

    • LovleAnjel

      The nipple is sterile in the package.

    • Empress of the Iguana People

      I washed mine and used it for a couple months

    • Heidi_storage

      Yeah, I used the ready-to-drink formula and collected quite a lot of nipples while in the hospital with my two sons. My kids actually liked those nipples best of all the ones they tried (well, except my youngest, who only likes two nipples: Mommy’s Left and Mommy’s Right).

    • TheArtistFormerlyKnownAsYoya

      I was told to sterilize every time for the first 2 months (by our hospital) so maybe pick up a few more? He’s 4 months now and I just wash them in between now. And yes, they’re sterile from the package.

    • cookiebaker

      I bought a pack of 20 Similac disposable bottle nipples (slow flow worked best for my newborns) from Amazon for about $10. Each nipple was sterile in individual packs. My kids liked the material better than silicone; I think it felt more like skin than the clear ones. I washed and reused them for months, tossing any that showed wear with time, but the pre-sterilized packs would be useful in the hospital.

      • myrewyn

        Thanks for the tip — I just looked those up and they’re much less expensive than the silicone ones and that looks perfect if I’m just going to be supplementing and not exclusively bottle feeding.

    • Mel

      When I was in the hospital, the nurses got me a dishpan and a trial size bottle of dish soap for cleaning my pumping equipment – but I don’t know how common that is outside of a special-care ob unit.

      You might want to bring the soap and a small plastic bowl if you want to save space.

  • Sheven

    So it was a bit like the “increase” in autism? People expanded and sharpened the definition and so it looked like rates were going up when actually reporting was going up?