Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016

Racial/ethnic disparities in pregnancy-related mortality were evident in 2007 and continued through 2016, with significantly higher PRMRs among black and AI/AN women than among white, A/PI, and Hispanic women. The PRMR for black and AI/AN women aged ≥30 years was approximately four to five times that of their white counterparts. Even in states with the lowest PRMRs, and among groups with higher levels of education, significant disparities persisted, demonstrating that the disparity in pregnancy-related mortality for black and AI/AN women is a complex national problem.

Multiple factors contribute to pregnancy-related mortality and to racial/ethnic disparities. Previous analyses found that for each pregnancy-related death, an average of three to four contributing factors were identified at multiple levels, including community, health facility, patient/family, provider, and system (1). Thirteen state maternal mortality review committees reported 60% of pregnancy-related deaths were preventable, and there were no significant differences in preventability by race/ethnicity (1). Differences in proportionate causes of death among black and AI/AN women might reflect differences in access to care, quality of care, and prevalence of chronic diseases (4).

Chronic diseases associated with increased risk for pregnancy-related mortality (e.g., hypertension) are more prevalent and less well controlled in black women (5). Ensuring access to quality care, including specialist providers, during preconception, pregnancy, and the postpartum period is crucial for all women to identify and manage chronic medical conditions (4). Systemic factors (e.g., gaps in health care coverage and preventive care, lack of coordinated health care, and social services) and community factors (e.g., securing transportation for medical visits and inadequate housing) have also been identified as contributors to pregnancy-related deaths (1). Addressing these factors and ensuring that pregnant women at high risk for complications receive care in facilities prepared to provide the required level of specialized care can improve outcomes.^†,§ In addition, innovative delivery of care models in the preconception, pregnancy, and postpartum periods might be further evaluated for their potential to reduce maternal disparities.

Quality of care likely has a role in pregnancy-related deaths and associated racial disparities. A national study of five specific pregnancy complications found a similar prevalence of complications among black and white women, but a significantly higher case-fatality rate among black women (6). Studies have suggested that black women are more likely than are white women to receive obstetric care in hospitals that provide lower quality of care (7). Hospitals and health care systems can implement standardized protocols and training in quality improvement initiatives, ensuring implementation in facilities that serve disproportionately affected communities. Quality improvement efforts, such as perinatal quality collaboratives^¶ that facilitate a change in the culture of care provision, implement standards of care,** and rapidly use data to identify opportunities for improvement, can improve the quality of care received by all pregnant and postpartum women.

Implicit racial bias has been reported in the health care system and can affect patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient health outcomes (8). This report’s findings demonstrate that black and AI/AN women have a more accelerated trajectory in age-specific PRMRs compared with white women. This might be related to the “weathering” hypothesis, which proposed that black women experience earlier deterioration of health because of the cumulative impact of exposure to psychosocial, economic, and environmental stressors (9). Identifying and addressing implicit bias and structural racism in health care and community settings, engaging communities in prevention efforts, and supporting community-based programs that build social support and resiliency would likely improve patient-provider interactions, health communication, and health outcomes (4).

Reducing disparities in pregnancy-related mortality requires addressing multifaceted contributors. Ensuring robust comprehensive data collection and analysis through state and local maternal mortality review committees, which thoroughly review pregnancy-related deaths and make actionable prevention recommendations, offer the best opportunity for identifying priority strategies to reduce disparities in pregnancy-related mortality.^††

The findings in this report are subject to at least three limitations. First, PMSS predominantly uses death certificates and linked birth or fetal death certificates to determine the pregnancy-relatedness of each death. Errors in reported pregnancy status on death certificates have been described, potentially leading to overestimation of the number of pregnancy-related deaths (10). Second, pregnancy-relatedness cannot generally be determined in PMSS for cancer-related deaths or injury deaths such as drug overdoses, suicides, or homicides, and thus, these are often not included in the PRMR calculated from PMSS data. Finally, small cohort sizes precluded the reporting of some factors by race/ethnicity; in addition, there might be inconsistencies in the reporting of race/ethnicity when death certificates were used for classification.^§§

Most pregnancy-related deaths can be prevented, and significant racial/ethnic disparities in pregnancy-related mortality need to be addressed. Further identification and evaluation of factors contributing to racial/ethnic disparities are crucial to inform and implement prevention strategies that will effectively reduce disparities in pregnancy-related mortality, including strategies to improve women’s health and access to quality care in the preconception, pregnancy, and postpartum periods. Addressing this complex national problem requires coordination and collaboration among community organizations, health facilities, patients and families, health care providers, and health systems.