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Am J Perinatol
DOI: 10.1055/a-2295-4058
Original Article

Factors Associated with Maternal Morbidity among Black Women in the United States

Catrine Ibrahim Sous 
1   Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
,
William Moravec
1   Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
,
Emily DeFranco
1   Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
,
Elizabeth A. Kelly
1   Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
,
Robert M. Rossi
1   Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio
› Author Affiliations Funding None.
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Abstract

Objective Non-Hispanic Black people (NHBP) have a three-fold higher rate of maternal mortality compared to other racial groups. Racial disparities in maternal morbidity are well-described; however, there are substantial differences in cultural, economic, and social determinants of health among racial groups. We thus sought to study the at-risk, non-Hispanic Black population as its own cohort to identify factors most associated with severe maternal morbidity (SMM).

Study Design This is a population-based retrospective case–control study of all live births in the United States between 2017 and 2019 using birth records obtained from the National Center for Health Statistics. The primary outcome for this study was to determine demographic, social, medical, and obstetric factors associated with maternal morbidity among NHBP who did and did not experience an SMM event. Multivariable logistic regression was used to estimate the adjusted odds ratio between each individual factor and the outcome of SMM among NHBP.

Results Of the 1,624,744 NHBP who delivered between 2017 and 2019, 1.1% experienced an SMM event defined as a composite of blood product transfusion, eclamptic seizure, intensive care unit admission, unplanned hysterectomy, and uterine rupture. The rates of these individual SMM events per 10,000 deliveries were 50, 40, 20, 5, and 4 among NHBP, respectively. Among NHBP, factors associated in multivariable regression analysis with SMM in order of strength of association included cesarean delivery, earlier gestational age at delivery, preeclampsia, induction of labor, chronic hypertension, prior preterm birth, lower educational attainment, multifetal gestation, advanced maternal age, pregestational diabetes, and cigarette smoking. The population attributable fraction for cesarean delivery, preterm birth, and pregnancy-induced hypertensive disease for the outcome of SMM were 0.46, 0.23, and 0.07, respectively.

Conclusion The three factors most associated with SMM among NHBP are potentially avoidable or modifiable by aggressive screening, prevention, and treatment of preeclampsia and preterm birth as well as reducing cesarean rates in this population.

Key Points

  • The rate of SMM in NHBP may be modifiable.

  • NHBP have a three-fold higher rate of maternal mortality.

  • Preeclampsia, preterm birth, and cesarean sections are most associated with maternal morbidity.

Keywords

severe maternal morbidity - preeclampsia - preterm birth - black pregnancy outcomes

Note

Cesarean delivery, preterm birth, and pregnancy-induced hypertensive disease are associated with increased risk of SMM among the contemporary non-Hispanic Black population in the United States.


Supplementary Material



Publication History

Received: 23 September 2023

Accepted: 24 March 2024

Accepted Manuscript online:
26 March 2024

Article published online:
19 April 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Petersen EE, Davis NL, Goodman D. et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2019; 68 (35) 762-765
    CrossrefPubMedGoogle Scholar
  • 2 Fingar KR, Hambrick MM, Heslin KC. et al. Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal morbidity, 2006–2015. HCUP Statistical Brief #243. 2018. Rockville, MD: Agency for Healthcare Research and Quality; . Accessed April 2, 2024 at: https://hcup-us.ahrq.gov/reports/statbriefs/sb243-Severe-Maternal-Morbidity-Delivery-Trends-Disparities.jsp
    Google Scholar
  • 3 Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015. Obstet Gynecol 2018; 132 (05) 1158-1166
    CrossrefPubMedGoogle Scholar
  • 4 Leonard SA, Main EK, Scott KA, Profit J, Carmichael SL. Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Ann Epidemiol 2019; 33: 30-36
    CrossrefPubMedGoogle Scholar
  • 5 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
    CrossrefPubMedGoogle Scholar
  • 6 Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007; 97 (02) 247-251
    CrossrefPubMedGoogle Scholar
  • 7 Schieve LA, Handler A. Preterm delivery and perinatal death among black and white infants in a Chicago-area perinatal registry. Obstet Gynecol 1996; 88 (03) 356-363
    CrossrefPubMedGoogle Scholar
  • 8 Shen JJ, Tymkow C, MacMullen N. Disparities in maternal outcomes among four ethnic populations. Ethn Dis 2005; 15 (03) 492-497
    PubMedGoogle Scholar
  • 9 Cabacungan ET, Ngui EM, McGinley EL. Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin. Matern Child Health J 2012; 16 (07) 1455-1467
    CrossrefPubMedGoogle Scholar
  • 10 Caughey AB, Stotland NE, Washington AE, Escobar GJ. Maternal ethnicity, paternal ethnicity, and parental ethnic discordance: predictors of preeclampsia. Obstet Gynecol 2005; 106 (01) 156-161
    CrossrefPubMedGoogle Scholar
  • 11 Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol 2018; 61 (02) 387-399
    CrossrefPubMedGoogle Scholar
  • 12 Rosenberg D, Geller SE, Studee L, Cox SM. Disparities in mortality among high risk pregnant women in Illinois: a population based study. Ann Epidemiol 2006; 16 (01) 26-32
    CrossrefPubMedGoogle Scholar
  • 13 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 729. Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol 2018; 131: e43-e48
    CrossrefPubMedGoogle Scholar
  • 14 Centers for Disease Control and Prevention. National Center for Health Statistics. Revisions of the U.S. Standard Certificates of Live Birth. Hyattsville, MD: US Department of Health and Human Services; 2003. Accessed August 15, 2016 at: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf
    Google Scholar
  • 15 National Center for Health Statistics. Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death (2003 Revision). . Accessed August 15, 2016 at: https://www.cdc.gov/nchs/nvss/facility-worksheets-guide.htm
    PubMedGoogle Scholar
  • 16 Rossi RM, DeFranco EA. Maternal complications associated with periviable birth. Obstet Gynecol 2018; 132 (01) 107-114
    CrossrefPubMedGoogle Scholar
  • 17 Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986; 51 (06) 1173-1182
    CrossrefPubMedGoogle Scholar
  • 18 Iacobucci D, Saldanha N, Deng X. A meditation on mediation: evidence that structural equations models perform better than regressions. J Consum Psychol 2008; 17 (02) 139-153
    CrossrefPubMedGoogle Scholar
  • 19 Mehmetoglu M. medsem: a Stata package for statistical mediation analysis. Int. J. Computational Economics and Econometrics 2018; 8 (01) 63-78
    CrossrefPubMedGoogle Scholar
  • 20 Newson R. PUNAFCC: Stata module to compute population attributable fractions for case-control and survival studies. Statistical Software Components S457354, Boston College Department of Economics. 2011 . Revised February 6, 2023
    PubMedGoogle Scholar
  • 21 MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016‒2017. Am J Public Health 2021; 111 (09) 1673-1681
    CrossrefPubMedGoogle Scholar
  • 22 Leonard SA, Main EK, Carmichael SL. The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC Pregnancy Childbirth 2019; 19 (01) 16
    CrossrefPubMedGoogle Scholar
  • 23 Debbink MP, Ugwu LG, Grobman WA. et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic inequities in cesarean birth and maternal morbidity in a low-risk, nulliparous cohort. Obstet Gynecol 2022; 139 (01) 73-82
    CrossrefPubMedGoogle Scholar
  • 24 Petersen EE, Davis NL, Goodman D. et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep 2019; 68 (18) 423-429
    CrossrefPubMedGoogle Scholar
  • 25 Moaddab A, Dildy GA, Brown HL. et al. Health care disparity and state-specific pregnancy-related mortality in the United States, 2005-2014. Obstet Gynecol 2016; 128 (04) 869-875
    CrossrefPubMedGoogle Scholar
  • 26 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (01) 5-12
    CrossrefPubMedGoogle Scholar
  • 27 Louis JM, Menard MK, Gee RE. Racial and ethnic disparities in maternal morbidity and mortality. Obstet Gynecol 2015; 125 (03) 690-694
    CrossrefPubMedGoogle Scholar
  • 28 Burris HH, Passarella M, Handley SC, Srinivas SK, Lorch SA. Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status. Am J Obstet Gynecol 2021; 225 (01) 83.e1-83.e9
    CrossrefPubMedGoogle Scholar
  • 29 Chang J, Elam-Evans LD, Berg CJ. et al. Pregnancy-related mortality surveillance–United States, 1991–1999. MMWR Surveill Summ 2003; 52 (02) 1-8
    PubMedGoogle Scholar
  • 30 Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012; 36 (01) 2-6
    CrossrefPubMedGoogle Scholar
  • 31 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. How Does CDC Identify Severe Maternal Morbidity?. (Appendix 2. Severe Morbidity Indicators and Corresponding ICD-9-CM/ICD-10-CM/PCS Codes during Delivery Hospitalizations). Accessed April 23, 2022 at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm
    PubMedGoogle Scholar