By Kelcie Moseley and Whitney Downard
Indiana Capital Chronicle
INDIANAPOLIS — A study from the University of Washington released Monday shows maternal mortality rates more than doubled in some states between 1999 and 2019, with sharp increases for some racial and ethnic groups.
Researchers touted it as the first study to provide such maternal mortality calculations for every state. Previous reports have not included rates for states with fewer than 20 maternal deaths, which is nearly half of all states, the report shows.
In Indiana, the maternal morality rate more than doubled for both white women and Hispanic women. Indiana led the nation in maternal mortality rate increases for white women, with deaths increasing by more than 150%, and Hispanic women, with deaths increasing by more than 105%.
Though the rate for those two ethnic groups soared, Indiana still fares poorly in deaths across all populations. For Black Hoosiers, death rates are double that of white women, despite Black Hoosiers making up a significantly smaller percentage of the overall population.
The study assembled information about people who died while pregnant or up to one year afterward. Causes often include hemorrhage, heart conditions, infections and high blood pressure, all of which can develop even months post-delivery, because of the ways the body changes and reacts to carrying and birthing a baby.
Dr. Greg Roth, a cardiologist and associate professor of medicine at the University of Washington, said the study did not evaluate potential causes of deaths, but the university intends to examine those subjects in follow-up studies. He said based on his own experience in medicine, the deaths often point to the conditions in which people live and work.
“The map of maternal mortality looks like the map of social determinants of health,” Roth said. “Regardless of what the political situation is in a particular state, social determinants of health are going to drive maternal health.”
Studies over the past decade or more have often revealed large disparities between Black and white populations in maternal mortality rates, particularly in the South, where poor access to health care, gaps in insurance coverage and other social supports have historically been associated with high mortality rates.
“One of the key messages here is that we have to focus on women’s health before, during, at the time of delivery, and after pregnancy,” Roth said. “That sounds a lot like easily accessed, universal, low-cost primary care along with high-quality obstetrician care.”
Recent data in Mississippi, where a near-total abortion ban is in place, shows those trends are worsening. Doctors are expressing concern and confusion about reproductive health care laws in states like Louisiana, which is limiting essential care.
More than 150% increase for Indigenous people in five states
Researchers compiled data on deaths and live births from the National Vital Statistics System and used a special modeling method to estimate maternal deaths over the 20-year timespan and calculate a maternal death risk for each racial and ethnic group by state, which takes into account population increases over that time.
The authors said there is incomplete data around causes of death that were unable to be analyzed for this study, and a checkbox indicating the person was recently pregnant was added at different times in various states over the course of a decade.
Despite those factors, Roth said even after every state included the checkbox on death certificates, the trends continued to go up. Roth said there is early data indicating the number of deaths increased even more throughout the pandemic.
“It’s very clear from our results that this is what’s actually happening,” Roth said.
The study, published in the Journal for the American Medical Association on Monday, showed five states with a 93% increase in Black maternal mortality rates: Louisiana, New Jersey, Georgia, Arkansas and Texas.
But researchers also noted large increases of more than 162% among Indigenous people in Florida, Kansas, Illinois, Rhode Island and Wisconsin, where those spikes have not been highlighted as often. The data showed both physical conditions like hemorrhages and mental health were major contributors to their pregnancy-related deaths.
In the Asian, Native Hawaiian or Other Pacific Islander category, five states saw an increase of over 83%: Kansas, Illinois, Missouri, Michigan and Georgia.
Pregnant Hispanic people or those who’d recently given birth in Indiana, Minnesota, Georgia, Tennessee and Illinois died more than twice as often in 2019 than two decades before.
Roth said the modeling process allowed researchers to create accurate and complete results even from small amounts of data while protecting individual privacy.
“One of the challenges looking at maternal mortality within states is that it is still a relatively rare event for a woman to die during or following pregnancy,” Roth told States Newsroom. “(The model) makes use of all that information to (calculate) a risk of maternal death occurring. In any given year, there may be no maternal deaths in smaller populations, but it still gives you a risk assessment.”
High-risk OB-GYN: Abortion bans could worsen maternal death rates
Dr. Allison Bryant, a high-risk obstetrician-gynecologist for Mass General Brigham in Massachusetts, is chair of the state’s maternal mortality review committee and acted as a content expert for the study.
Bryant said the data confirms much of what was already known about trends, but it is even more important now that 15 states have near-total bans on abortion. People who become pregnant unintentionally and can’t get an abortion may become more likely to overdose or die by suicide, particularly those with existing addiction or mental health issues.
Additionally, she said more pregnancies may be carried to term that aren’t healthy and could cause death rates to rise.
One state, Idaho, failed to renew its maternal mortality review committee during its 2023 legislative session. It will become the only state without a committee that examines each maternal death in detail in July, amid doubling maternal mortality rates, specialized obstetrician-gynecologists leaving the state and clinics shutting down after the state’s new abortion restrictions.
The Indiana Supreme Court upheld Indiana’s abortion ban on Friday, determining that the state Constitution protected the right to an abortion in cases where the mother’s health or life were at risk. But health care professionals in other states have said exceptions don’t go far enough or don’t allow for nuance in medical decisions.
Additionally, only hospitals can perform the reproductive health care procedure under the state ban, though hospitals performed less than 2% of all abortions in 2021.
Maternal deaths can signal broader trends to monitor, researchers say
Nationally, the maternal mortality rate is two to four times higher for the non-Hispanic Black population than non-Hispanic whites, the research showed.
According to the study, the states of Oregon, Hawaii, Colorado, Illinois, Wisconsin, Delaware, Vermont and Rhode Island had lower 2019 maternal mortality rates across all racial and ethnic groups, “suggesting that either underlying risk factors that drive maternal deaths are lower in these states, or that prevention efforts have had some success in these locations.”
Populations with high maternal mortality related to cardiovascular conditions also tend to happen in areas with high rates of cardiovascular disease in general, according to Roth.
“We think in many ways, a maternal death is a canary in a coalmine, it’s a signal not only that there was a terrible tragedy, and we need to develop interventions, but also that we need to make sure that we are looking at the health of that population where the woman was living and understand why vascular risks are much more common there,” Roth said. “In many ways, this is not a problem of inventing new solutions, but rather making sure that the good, well-tested solutions that we know work actually get used.”
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The Indiana Capital Chronicle is an independent, nonprofit news organization dedicated to giving Hoosiers a comprehensive look inside state government, policy and elections. The site combines daily coverage with in-depth scrutiny, political awareness and insightful commentary.
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