Maternal Mortality as a Public Health Challenge

Gene Declercq, PhD

Community Health Sciences Dept.

www.birthbythenumbers.org

USC Health Journalism Webinar

October 4, 2017

Definitions (in the U.S.) • Maternal Mortality Ratio – the death of a woman while pregnant or

within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Typically reported as a ratio per 100,000 births.

• Pregnancy Related Death – the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

• Pregnancy Associated Death – The death of a women while pregnant or within one year of termination of pregnancy, irrespective of cause. (WHO calls these “pregnancy related”)

Is there a problem in the U.S.?

Is there a problem in the U.S.?

Yes

U.S. Maternal Mortality (per 100,000 live births),

1951-2007

0

10

20

30

40

50

60

70

80

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

Source: NCHS. Deaths: Final Data. Annual Reports.

U.S. Maternal Mortality (per 100,000 live births),

1951-2007

0

10

20

30

40

50

60

70

80

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

1951-198289% decline (75.0 to 7.9)

Source: NCHS. Deaths: Final Data. Annual Reports.

U.S. Maternal Mortality (per 100,000 live births),

1951-2007

0

10

20

30

40

50

60

70

80

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

1982-1998Basically no change

7.9 to 7.1

Source: NCHS. Deaths: Final Data. Annual Reports.

U.S. Maternal Mortality (per 100,000 live births),

1951-2007

0

10

20

30

40

50

60

70

80

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

1997-200778% increase (7.1 to 12.7)

Source: NCHS. Deaths: Final Data. Annual Reports.

U.S. Maternal Mortality (per 100,000 live births),

1951-2007

0

10

20

30

40

50

60

70

80

Note: The U.S. NCHS hasn’t reported and official maternal mortality rate since 2007 –Is there any more recent measure?

???

Source: NCHS. Deaths: Final Data. Annual Reports.

Pregnancy Related Mortality, U.S., 1987-2013

Source: CDC. Pregnancy Mortality Surveillance

Systemhttps://www.cdc.gov/reproductivehealt

h/maternalinfanthealth/pmss.html

Pregnancy Related Mortality, U.S., 1987-2013

Source: CDC. Pregnancy Mortality Surveillance

Systemhttps://www.cdc.gov/reproductivehealt

h/maternalinfanthealth/pmss.html

NOTE: This isn’t a measure of

maternal mortality and hence not comparable to

other countries.

So can we compare the U.S. to other countries?

Estimated MMRs, 48 states* and DC, 2000-2014

0

5

10

15

20

25

30

2000 2005 2010

18.8

23.8R

ate

pe

r 1

00

,00

0 li

ve b

irth

s

2014

*Excludes California and Texas.

27% increase 2000-2014

How might the U.S. compare internationally?

Maternal Mortality Ratios, OECD* Countries, 2014

0 5 10 15 20 25

United States^

Chile*

Turkey

New Zealand#

Korea

Austria

Denmark*

Estonia*

United Kingdom

Hungary

Czech Republic

Portugal*

Canada#

France*

Belgium#

Israel*

Germany

Slovak Republic

Sweden

Finland#

Japan

Norway

Ireland

Netherlands

Switzerland*

Italy#

Spain

Australia*

Poland*

Greece#

Iceland

Luxembourg

Source: OECD Health Data 2016* 2013# 2012^U.S. from MacDorman et al.

* Organization for Economic and Cooperation and Development

Using a more conservative estimateAdjusting the CDC Pregnancy Related Mortality data

to reflect a maternal mortality rate

Estimated for 2011-2013 (per 100,000 live births):

•All women 14.8•Non-Hispanic white women 11.3•Non-Hispanic black women 36.2•Hispanic women 10.0

• Black-white disparity 3.2

U.S. Maternal Mortality (per 100,000 live births),

1951-2007 by Race

0

50

100

150

200

250

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

All White Black

U.S. Maternal Mortality Ratio of Black to White Rates 1951-2007

0

1

2

3

4

5

6

1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

U.S. Infant & Maternal Mortality Black to White Ratios of 1980-2014

0

1

2

3

4

5

6

Infant

Maternal

Why is disparity greater for maternal mortality than infant mortality?

Using the more conservative measure in an international

comparison

Estimated for 2011-2013 (per 100,000 live births):All women 14.8Non-Hispanic white women 11.3Non-Hispanic black women 36.2Hispanic women 10.0

U.S. MMR* Compared to Countries with 300,000+ births, 2014, using WHO Estimates

14.8

11

9

8

7

6

6

5

5

4

0 2 4 6 8 10 12 14 16

U.S.

Korea

U.K.

France

Canada

Germany

Australia

Japan

Spain

Italy

* Maternal Mortality per 100,000 birthsSource: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015.

U.S. MMR* Compared to Countries with 300,000+ births, 2014, using WHO Estimates

14.8

11.3

11

9

8

7

6

6

5

5

4

0 2 4 6 8 10 12 14 16

U.S.

U.S. White

Korea

U.K.

France

Canada

Germany

Australia

Japan

Spain

Italy

* Maternal Mortality per 100,000 birthsSource: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015.

If we limited the US ratio to white mothers (estimated 11.3) only, the U.S. would still rank behind all other countries including South Korea

Interracial Differences

Hispanic 10.0 (Lithuania 10/Portugal 10)

Where would estimated rates leave the U.S. in international comparisons?

Interracial Differences

Hispanic 10.0 (Lithuania 10/Portugal 10)

NH White 11.3 (Bulgaria 11/S. Korea 11)

Where would estimated rates leave the U.S. in international comparisons?

Interracial Differences

Hispanic 10.0 (Lithuania 10/Portugal 10)

NH White 11.3 (Bulgaria 11/S. Korea 11)

NH Black 36.2 (Uzbekistan 36/ Mexico 38)

Where would estimated rates leave the U.S. in international comparisons?

So, by even a conservative standard the US fares poorly in

international comparisons.

What can be done?

Key is a combined clinical, public health and policy response.

Dr. Main will describe the exceptional efforts underway to deal with the clinical challenges.

Why a public health response is also needed.Timing of Maternal Deaths

30.5%

16.8%18.2%

21.3%

13.2% Before Delivery

Day of Delivery

42-365 Days PPM

7-41 Days PPM

1-6 Days PPM

Source: Creanga A et al. Pregnancy Related Mortality in the U.S., 2011-2013. Obstet & Gynec 2017.

Why a public health response is also needed.Timing of Maternal Deaths

30.5%

16.8%18.2%

21.3%

13.2% Before Delivery

Day of Delivery

42-365 Days PPM

7-41 Days PPM

1-6 Days PPM

Source: Creanga A et al. Pregnancy Related Mortality in the U.S., 2011-2013. Obstet & Gynec 2017.

What’s the policy response needed?

• Investment in the public health infrastructure so we can better determine just who is dying, when and how they are dying.

• More importantly there needs to be an investment in ………

WOMEN’S HEALTH WHEN THEY ARE NOT PREGNANT

Infant & Maternal Mortality Black to White Ratios of 1980-2014

0

1

2

3

4

5

6

Infant

Maternal

Level of Coverage:Variation in

Medicaid Eligibility by Pregnancy

Status

As of January, 2017 Medicaid Eligibility

Pregnancy Parents Familyof 3

U.S. Average 203% 107%

Connecticut 263% 155%

Maine 214% 105%

Massachusetts 214% 138%

New Hampshire 205% 138%

Alabama 146% 18%

California 213% 138%

Florida 196% 33%

Iowa 380% 138%

New York 223% 138%

Texas 203% 18%Source: Kaiser FF. https://www.kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/

Source: Daw J. Health Affairs2017; 36:598-606

Note:Data is all pre-ACA

Period covered by pregnancy related mortality

Timing of Coverage

Maternal Mortality is the tip of the iceberg on women’s health.

Maternal deaths account for about 1% of all deaths to women 15-49 in the U.S.

The death rate for women 15-49 has not improved.

Focusing only on pregnancy will not solve the problem of maternal mortality in the U.S.

FACEBOOK: www.facebook.com/BirthByTheNumbers

Twitter: @BirthNumbers

Email: birthbynumbers@gmail.com

Slides will also be posted here.

Extra slides if there are questions

Death rates, by age, females: United States,

1955–2014Number of female

deaths, 15-49 in 2014 75,192.

Maternal deaths = ~1% of all those.

Source: NCHS. Deaths, Final Data for 2014