Policy Brief: Maternal Mortality in the US. A Review of States with High and Low Rates

High rates of pregnancy-related maternal deaths in the United States (U.S.) are alarming. The risk of a woman in the U.S. dying due to birth complications is higher than in any other developed country[i]. The Centers for Disease Control and Prevention (CDC) defines maternal mortality[ii] as the death of a woman while pregnant or within 42 days of termination of pregnancy. Recent data[iii] affirms that the maternal mortality rate among American women was 17.4 deaths per 100,000 live births in 2018.

This equates to an estimated 658 deaths, of which the CDC estimates 60% were preventable[iv]. Although many women and families throughout the US are affected by maternal mortality, wide racial and ethnic gaps exist and disproportionately affect non-Hispanic Black women.

Federal legislation has been enacted or is in progress to address this surmountable health crisis. At the same time, many states have developed and implemented initiatives such as Maternal Mortality Review Committees[v] (MMRCs) that aim to better understand and make recommendations to reduce maternal deaths.

State Review + High Mortality Rates

A state review from the America’s Health Ranking found that Georgia[vi] and Louisiana[vii] have the highest pregnancy-related deaths at 46.2 and 44.8 per 100,000 live births, respectively. This report highlights that Black mothers in Georgia die at a rate of 66.6 per 100,000 live births compared to 43.2 for White mothers and 18.1 for Hispanic mothers. In Louisiana, 4 Black mothers die for every 1 White mother(viii).

Of these two states, only Louisiana has expanded Medicaid, but both states have established Maternal Mortality Review Committees[ix] and Collaboratives[x] amid increasing maternal deaths and significant racial gaps. Panels from both committees have agreed that hemorrhaging[xi] is one of the leading causes of maternal deaths among cases in their states and almost half were found to be preventable. To address this issue, Louisiana is set to establish new standards[xii] beginning in 2021. The goal is to better equip hospitals to handle emergencies during childbirth and tackle preventable deaths. Most recently, Georgia has provided grants to 20 rural birthing[xiii] hospitals to implement maternal hemorrhage patient safety bundles since higher rates of postpartum hemorrhage has been found in rural hospitals[xiv].

State Review + Low Maternal Mortality Rates

California[xv] and Massachusetts[xvi] have the two lowest rates of maternal mortality in the United States, ranking at 4.5 and 6.1 deaths per 100,000 live births, respectively. Although the America’s Health Rankings report does not provide maternal mortality data by race for the state of Massachusetts, Black mothers in California were found to die at a rate of 17.4 per 100,000 live births compared to 4.7 for White mothers and 3.1 for Hispanic mothers. California’s Birth Equity Collaborative[xvii] reports that evidence points to racism as being a key cause of these birth disparities.

California[xviii] and Massachusetts[xix] have established Maternal Mortality Review Committees and both states expanded Medicaid. Access to quality healthcare positively affects health outcomes for pregnant women, which is likely to contribute to these states’ lower maternal mortality rates, compared to states who did not expand Medicaid[xx]. Additionally, in 2014 the Massachusetts Maternal Mortality and Morbidity Review Committee recommended that Massachusetts implement procedures to manage hemorrhaging[xxi] during delivery. In the last 15 years, California developed and implemented care protocols related to preeclampsia and hemorrhaging after experiencing rising maternal mortality rates. As a result, from 2006-2013 California saw a 55%[xxii] decline in maternal mortality rates.

Federal Initiatives

As states continue to grapple with high maternal mortality rates, Congress has provided some relief to address this crisis. The Maternal Deaths Act of 2018[xxiii] was recently enacted and the Helping MOMS Act of 2019[xxiv] has been introduced. The Maternal Deaths Act allows for standardized reporting and data collection including best practices of MMRCs. Meanwhile, the Helping MOMS Act seeks to provide states with the option to increase Medicaid postpartum coverage for up to one year after giving birth. Pregnant women are currently receiving only 60 days of post-delivery healthcare. In addition, the Maternal CARE Act[xxv] of 2019 seeks to allocate grants to fight racial bias in maternal health care settings and create programs to provide resources and support to high-risk pregnant women. A recent GAO report[xxvi] found that California and Georgia along with three other states, receiving funds from the U.S. Department of Health and Human Services to reduce maternal mortality, reported that, “they were beginning or continuing to address racial/ethnic health differences.”

Analysis

There is no single solution to reducing maternal mortality rates - it will require reliable and consistent data collection, along with various interventions at all levels. At the federal level, increased Medicaid coverage is critical because it covers half of all births[xxvii] in the United States. In addition, Medicaid expansion has resulted in reduced rates[xxviii] of maternal mortality and has been a critical factor to addressing racial disparities. Most importantly, federal legislators must ensure states’ funds allocated to reduce maternal deaths are effectively used to actively establish initiatives to eliminate racial bias. At the same time, at the state and local levels, specific interventions from health care systems, professionals and community organizations to undertake existing health inequities are essential. As such, continuous support and growth from the active 38 MMRCs nationwide is critical. Some successful MMRCs’ initiatives were implemented several years ago, in California and Massachusetts, whereas others were recently developed. In states where newer initiatives are being explored or developed, it is too early to tell if programs will reduce pregnancy-related deaths and will actually close the alarming racial gaps.

Sources

(i) Julia Belluz, “We finally have a new US maternal mortality estimate. It’s still terrible.,” Vox (January 30, 2020), https://www.vox.com/2020/1/30/21113782/pregnancy-deaths-us-maternal-mortality-rate

(ii) Centers for Disease Control and Prevention, “First Data Released on Maternal Mortality in Over a Decade,” Centers for Disease Control and Prevention, (January, 30, 2020), https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2020/202001_MMR.htm

(iii) Donna L. Hoyert and Arialdi M. Miniño, “Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018,” National Vital Statistics Report, (Department of Health and Human Services, January 30, 2020) https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69_02-508.pdf

(iv) Centers for Disease Control and Prevention, “Pregnancy-related deaths,” Centers for Disease Control and Prevention (May 7, 2019), https://www.cdc.gov/vitalsigns/maternal-deaths/index.html

(v) Review to Action, “Definitions,” Review to Action https://reviewtoaction.org/learn/definitions

(vi) 2018 Health of Women and Children Report, “Georgia,” America’s Health Rankings (United Health Foundation 2020), https://www.americashealthrankings.org/learn/reports/2018-health-of-women-and-children-report/state-summaries-georgia

(vii) 2018 Health of Women and Children Report, “Louisiana,” America’s Health Rankings (United Health Foundation 2020), https://www.americashealthrankings.org/learn/reports/2018-health-of-women-and-children-report/state-summaries-louisiana

(viii) Reducing Maternal Morbidity and Mortality in Louisiana: Addressing Obstetric Hemorrhage and Severe Hypertension, “Reducing Maternal Morbidity and Mortality in Louisiana: Addressing Obstetric Hemorrhage and Severe Hypertension,” (August 2018) https://www.ncsl.org/portals/1/documents/health/MCH19VGillispie_34210.pdf

(ix) Georgia Department of Public Health, “Maternal Mortality,” Georgia Department of Public Health (November 22, 2019), https://dph.georgia.gov/maternal-mortality

(x) Louisiana Department of Health, “Louisiana Pregnancy-Associated Mortality Review (LaPAMR),” Louisiana Department of Health http://ldh.la.gov/index.cfm/page/1347

(xi) Lyn Kieltyka, Pooja Mehta, Karis Schoellmann, and Chloe Lake, “Louisiana Maternal Mortality Review Report 2011-2016” (August 2018) http://ldh.la.gov/assets/oph/Center-PHCH/Center-PH/maternal/2011-2016_MMR_Report_FINAL.pdf

(xii) World Population Review, “Maternal Mortality Rate By State 2020,” World Population Review (March 30, 2020) https://worldpopulationreview.com/states/maternal-mortality-rate-by-state/

(xiii) House budget and Resource Office, “Maternal mortality in Georgia,” House Budget and Resource Office, (April 2019) http://www.house.ga.gov/budget/Documents/2019_Session/2019_Policy_Brief_Maternal_Mortality_in_Georgia.pdf

(xiv) March of Dimes, “Better data and better outcomes: Reducing maternal mortality in the U.S.” March of Dimes (September 27, 2018) https://www.marchofdimes.org/materials/Stewart%20MOD%20maternal%20mortality%20testimony%20092718.pdf

(xv) 2018 Health of Women and Children Report, “California,” America’s Health Rankings, (United Health Foundation, 2020) https://www.americashealthrankings.org/learn/reports/2018-health-of-women-and-children-report/state-summaries-california

(xvi) 2018 Health of Women and Children Report, “Massachusetts,” America’s Health Rankings, (United Health Foundation, 2020) https://www.americashealthrankings.org/learn/reports/2018-health-of-women-and-children-report/state-summaries-massachusetts

(xvii) California Maternal Mortality Care Collaborative, “California Birth Equity Collaborative

Improving Care, Experiences and Outcomes for Black Mothers,” California Maternal Mortality Care Collaborative https://www.cmqcc.org/qi-initiatives/birth-equity

(xviii) Renee Montagne, “To Keep Women From Dying In Childbirth, Look To California,” NPR (July 29, 2018) https://www.npr.org/2018/07/29/632702896/to-keep-women-from-dying-in-childbirth-look-to-california

(xix) Review to Action, “Brief Overview of State MMR or PAMR,” Review to Action https://reviewtoaction.org/content/massachusetts

(xx) Adam Searing and Donna Cohen Ross, “Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies,” Georgetown University Health Policy Institute Center for Children and Families (May 2019) https://ccf.georgetown.edu/wp-content/uploads/2019/05/Maternal-Health-3a.pdf

(xxi) Massachusetts Department of Public Health Bureau of Family Health and Nutrition, “Maternal Mortality and Morbidity Review

in Massachusetts,” Massachusetts Department of Public Health Bureau of Family Health and Nutrition, (July 2014) https://www.mass.gov/doc/2014-report-pregnancy-associated-mortality-2000-2007/download

(xxii) California Maternal Quality Care Collaborative, “Who We Are,” California Maternal Quality Care Collaborative https://www.cmqcc.org/who-we-are

(xxiii) U.S. Congress, House, Preventing Maternal Deaths Act of 2018, H.R.1318, 115th Cong., 2nd sess., Became Law December 21, 2018, https://www.congress.gov/bill/115th-congress/house-bill/1318/text

(xxiv) U.S. Congress, House, Helping MOMS Act of 2019, H.R. 4996, 116th Cong., 1st sess., Introduced November 20, 2019, https://www.congress.gov/bill/116th-congress/house-bill/4996/text

(xxv) U.S. Congress, Senate, Maternal Care Access and Reducing Emergencies Act, S. 1600, 1st. Sess., Introduced May 22, 2019, https://www.congress.gov/bill/116th-congress/senate-bill/1600/text

(xxvi) United States Government Accountability Office, “Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them,” United States Government Accountability Office, (March 2020) https://www.gao.gov/assets/710/705331.pdf

(xxvii) Congresswoman Robin Kelly, “How the MOMMA Act Will Help to Reverse America’s Rising Maternal Mortality Rate,” Congresswoman Robin Kelly, (June 5, 2018), https://robinkelly.house.gov/media-center/in-the-news/how-the-momma-act-will-help-to-reverse-america-s-rising-maternal-mortality

(xxviii) Adam Searing and Donna Cohen Ross, “Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies,” Georgetown University Health Policy Institute Center for Children and Families (May 2019) https://ccf.georgetown.edu/wp-content/uploads/2019/05/Maternal-Health-3a.pdf