Marian F MacDorman1, Eugene Declercq, Marie E Thoma. 1. Maryland Population Research Center, University of Maryland, and the Department of Family Science, University of Maryland School of Public Health, College Park, Maryland; and the Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.
Abstract
OBJECTIVE: To analyze recent trends in maternal mortality by sociodemographic characteristics and cause of death and to evaluate data quality. METHODS: This observational study compared data from 2008-2009 with 2013-2014 for 27 states and the District of Columbia that had comparable reporting of maternal mortality throughout the period. Maternal mortality rates were computed per 100,000 live births. Statistical significance of trends and differentials was evaluated using a two-proportion z-test. RESULTS: The study population included 1,687 maternal deaths and 7,369,966 live births. The maternal mortality rate increased by 23% from 20.6 maternal deaths per 100,000 live births in 2008-2009 to 25.4 in 2013-2014. However, most of the increase was among women aged 40 years or older and for nonspecific causes of death. From 2008-2009 to 2013-2014, maternal mortality rates increased by 90% for women 40 years of age or older but did not increase significantly for women younger than 40 years. The maternal mortality rate for nonspecific causes of death increased by 48%; however, the rate for specific causes of death did not increase significantly between 2008-2009 (13.5) and 2013-2014 (15.0). CONCLUSION: Despite the United Nations Millennium Development Goal and a 44% decline in maternal mortality worldwide from 1990 to 2015, maternal mortality has not improved in the United States and appears to be increasing. Maternal mortality rates for women 40 years or older and for nonspecific causes of death were implausibly high and increased rapidly, suggesting possible overreporting of maternal deaths, which may be increasing over time. Efforts to improve reporting for the pregnancy checkbox and to modify coding procedures to place less reliance on the checkbox are essential to improving vital statistics maternal mortality data, the official data source for maternal mortality statistics used to monitor trends, identify at-risk populations, and evaluate the success of prevention efforts.
OBJECTIVE: To analyze recent trends in maternal mortality by sociodemographic characteristics and cause of death and to evaluate data quality. METHODS: This observational study compared data from 2008-2009 with 2013-2014 for 27 states and the District of Columbia that had comparable reporting of maternal mortality throughout the period. Maternal mortality rates were computed per 100,000 live births. Statistical significance of trends and differentials was evaluated using a two-proportion z-test. RESULTS: The study population included 1,687 maternal deaths and 7,369,966 live births. The maternal mortality rate increased by 23% from 20.6 maternal deaths per 100,000 live births in 2008-2009 to 25.4 in 2013-2014. However, most of the increase was among women aged 40 years or older and for nonspecific causes of death. From 2008-2009 to 2013-2014, maternal mortality rates increased by 90% for women 40 years of age or older but did not increase significantly for women younger than 40 years. The maternal mortality rate for nonspecific causes of death increased by 48%; however, the rate for specific causes of death did not increase significantly between 2008-2009 (13.5) and 2013-2014 (15.0). CONCLUSION: Despite the United Nations Millennium Development Goal and a 44% decline in maternal mortality worldwide from 1990 to 2015, maternal mortality has not improved in the United States and appears to be increasing. Maternal mortality rates for women 40 years or older and for nonspecific causes of death were implausibly high and increased rapidly, suggesting possible overreporting of maternal deaths, which may be increasing over time. Efforts to improve reporting for the pregnancy checkbox and to modify coding procedures to place less reliance on the checkbox are essential to improving vital statistics maternal mortality data, the official data source for maternal mortality statistics used to monitor trends, identify at-risk populations, and evaluate the success of prevention efforts.
Authors: Nicholas J Kassebaum; Amelia Bertozzi-Villa; Megan S Coggeshall; Katya A Shackelford; Caitlyn Steiner; Kyle R Heuton; Diego Gonzalez-Medina; Ryan Barber; Chantal Huynh; Daniel Dicker; Tara Templin; Timothy M Wolock; Ayse Abbasoglu Ozgoren; Foad Abd-Allah; Semaw Ferede Abera; Ibrahim Abubakar; Tom Achoki; Ademola Adelekan; Zanfina Ademi; Arsène Kouablan Adou; José C Adsuar; Emilie E Agardh; Dickens Akena; Deena Alasfoor; Zewdie Aderaw Alemu; Rafael Alfonso-Cristancho; Samia Alhabib; Raghib Ali; Mazin J Al Kahbouri; François Alla; Peter J Allen; Mohammad A AlMazroa; Ubai Alsharif; Elena Alvarez; Nelson Alvis-Guzmán; Adansi A Amankwaa; Azmeraw T Amare; Hassan Amini; Walid Ammar; Carl A T Antonio; Palwasha Anwari; Johan Arnlöv; Valentina S Arsic Arsenijevic; Ali Artaman; Majed Masoud Asad; Rana J Asghar; Reza Assadi; Lydia S Atkins; Alaa Badawi; Kalpana Balakrishnan; Arindam Basu; Sanjay Basu; Justin Beardsley; Neeraj Bedi; Tolesa Bekele; Michelle L Bell; Eduardo Bernabe; Tariku J Beyene; Zulfiqar Bhutta; Aref Bin Abdulhak; Jed D Blore; Berrak Bora Basara; Dipan Bose; Nicholas Breitborde; Rosario Cárdenas; Carlos A Castañeda-Orjuela; Ruben Estanislao Castro; Ferrán Catalá-López; Alanur Cavlin; Jung-Chen Chang; Xuan Che; Costas A Christophi; Sumeet S Chugh; Massimo Cirillo; Samantha M Colquhoun; Leslie Trumbull Cooper; Cyrus Cooper; Iuri da Costa Leite; Lalit Dandona; Rakhi Dandona; Adrian Davis; Anand Dayama; Louisa Degenhardt; Diego De Leo; Borja del Pozo-Cruz; Kebede Deribe; Muluken Dessalegn; Gabrielle A deVeber; Samath D Dharmaratne; Uğur Dilmen; Eric L Ding; Rob E Dorrington; Tim R Driscoll; Sergei Petrovich Ermakov; Alireza Esteghamati; Emerito Jose A Faraon; Farshad Farzadfar; Manuela Mendonca Felicio; Seyed-Mohammad Fereshtehnejad; Graça Maria Ferreira de Lima; Mohammad H Forouzanfar; Elisabeth B França; Lynne Gaffikin; Ketevan Gambashidze; Fortuné Gbètoho Gankpé; Ana C Garcia; Johanna M Geleijnse; Katherine B Gibney; Maurice Giroud; Elizabeth L Glaser; Ketevan Goginashvili; Philimon Gona; Dinorah González-Castell; Atsushi Goto; Hebe N Gouda; Harish Chander Gugnani; Rahul Gupta; Rajeev Gupta; Nima Hafezi-Nejad; Randah Ribhi Hamadeh; Mouhanad Hammami; Graeme J Hankey; Hilda L Harb; Rasmus Havmoeller; Simon I Hay; Ileana B Heredia Pi; Hans W Hoek; H Dean Hosgood; Damian G Hoy; Abdullatif Husseini; Bulat T Idrisov; Kaire Innos; Manami Inoue; Kathryn H Jacobsen; Eiman Jahangir; Sun Ha Jee; Paul N Jensen; Vivekanand Jha; Guohong Jiang; Jost B Jonas; Knud Juel; Edmond Kato Kabagambe; Haidong Kan; Nadim E Karam; André Karch; Corine Kakizi Karema; Anil Kaul; Norito Kawakami; Konstantin Kazanjan; Dhruv S Kazi; Andrew H Kemp; Andre Pascal Kengne; Maia Kereselidze; Yousef Saleh Khader; Shams Eldin Ali Hassan Khalifa; Ejaz Ahmed Khan; Young-Ho Khang; Luke Knibbs; Yoshihiro Kokubo; Soewarta Kosen; Barthelemy Kuate Defo; Chanda Kulkarni; Veena S Kulkarni; G Anil Kumar; Kaushalendra Kumar; Ravi B Kumar; Gene Kwan; Taavi Lai; Ratilal Lalloo; Hilton Lam; Van C Lansingh; Anders Larsson; Jong-Tae Lee; James Leigh; Mall Leinsalu; Ricky Leung; Xiaohong Li; Yichong Li; Yongmei Li; Juan Liang; Xiaofeng Liang; Stephen S Lim; Hsien-Ho Lin; Steven E Lipshultz; Shiwei Liu; Yang Liu; Belinda K Lloyd; Stephanie J London; Paulo A Lotufo; Jixiang Ma; Stefan Ma; Vasco Manuel Pedro Machado; Nana Kwaku Mainoo; Marek Majdan; Christopher Chabila Mapoma; Wagner Marcenes; Melvin Barrientos Marzan; Amanda J Mason-Jones; Man Mohan Mehndiratta; Fabiola Mejia-Rodriguez; Ziad A Memish; Walter Mendoza; Ted R Miller; Edward J Mills; Ali H Mokdad; Glen Liddell Mola; Lorenzo Monasta; Jonathan de la Cruz Monis; Julio Cesar Montañez Hernandez; Ami R Moore; Maziar Moradi-Lakeh; Rintaro Mori; Ulrich O Mueller; Mitsuru Mukaigawara; Aliya Naheed; Kovin S Naidoo; Devina Nand; Vinay Nangia; Denis Nash; Chakib Nejjari; Robert G Nelson; Sudan Prasad Neupane; Charles R Newton; Marie Ng; Mark J Nieuwenhuijsen; Muhammad Imran Nisar; Sandra Nolte; Ole F Norheim; Luke Nyakarahuka; In-Hwan Oh; Takayoshi Ohkubo; Bolajoko O Olusanya; Saad B Omer; John Nelson Opio; Orish Ebere Orisakwe; Jeyaraj D Pandian; Christina Papachristou; Jae-Hyun Park; Angel J Paternina Caicedo; Scott B Patten; Vinod K Paul; Boris Igor Pavlin; Neil Pearce; David M Pereira; Konrad Pesudovs; Max Petzold; Dan Poenaru; Guilherme V Polanczyk; Suzanne Polinder; Dan Pope; Farshad Pourmalek; Dima Qato; D Alex Quistberg; Anwar Rafay; Kazem Rahimi; Vafa Rahimi-Movaghar; Sajjad ur Rahman; Murugesan Raju; Saleem M Rana; Amany Refaat; Luca Ronfani; Nobhojit Roy; Tania Georgina Sánchez Pimienta; Mohammad Ali Sahraian; Joshua A Salomon; Uchechukwu Sampson; Itamar S Santos; Monika Sawhney; Felix Sayinzoga; Ione J C Schneider; Austin Schumacher; David C Schwebel; Soraya Seedat; Sadaf G Sepanlou; Edson E Servan-Mori; Marina Shakh-Nazarova; Sara Sheikhbahaei; Kenji Shibuya; Hwashin Hyun Shin; Ivy Shiue; Inga Dora Sigfusdottir; Donald H Silberberg; Andrea P Silva; Jasvinder A Singh; Vegard Skirbekk; Karen Sliwa; Sergey S Soshnikov; Luciano A Sposato; Chandrashekhar T Sreeramareddy; Konstantinos Stroumpoulis; Lela Sturua; Bryan L Sykes; Karen M Tabb; Roberto Tchio Talongwa; Feng Tan; Carolina Maria Teixeira; Eric Yeboah Tenkorang; Abdullah Sulieman Terkawi; Andrew L Thorne-Lyman; David L Tirschwell; Jeffrey A Towbin; Bach X Tran; Miltiadis Tsilimbaris; Uche S Uchendu; Kingsley N Ukwaja; Eduardo A Undurraga; Selen Begüm Uzun; Andrew J Vallely; Coen H van Gool; Tommi J Vasankari; Monica S Vavilala; N Venketasubramanian; Salvador Villalpando; Francesco S Violante; Vasiliy Victorovich Vlassov; Theo Vos; Stephen Waller; Haidong Wang; Linhong Wang; XiaoRong Wang; Yanping Wang; Scott Weichenthal; Elisabete Weiderpass; Robert G Weintraub; Ronny Westerman; James D Wilkinson; Solomon Meseret Woldeyohannes; John Q Wong; Muluemebet Abera Wordofa; Gelin Xu; Yang C Yang; Yuichiro Yano; Gokalp Kadri Yentur; Paul Yip; Naohiro Yonemoto; Seok-Jun Yoon; Mustafa Z Younis; Chuanhua Yu; Kim Yun Jin; Maysaa El Sayed Zaki; Yong Zhao; Yingfeng Zheng; Maigeng Zhou; 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