Advertisement

Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-Experimental Study

Published:December 16, 2019DOI:https://doi.org/10.1016/j.amepre.2019.09.012

      Introduction

      Recent increases in maternal mortality and persistent disparities have led to speculation about why the U.S. has higher rates than most high-income countries. The aim was to examine the impact of changes in state-level factors plausibly linked to maternal mortality on overall rates and by race/ethnicity.

      Methods

      This quasi-experimental, population-based, difference-in-differences study used 2007–2015 National Vital Statistics System microdata mortality files from 38 states and DC. The primary exposures were 5 state-level sexual and reproductive health indicators and 6 health and economic conditions. Maternal mortality rate was defined as number of deaths of women while pregnant or within 42 days of termination of pregnancy per 100,000 live births. A difference-in-differences zero-inflated negative binomial regression model was estimated using the race/ethnicity-age-state-year population as the denominator and adjusting for race/ethnicity, age, state, and year. Data were analyzed in 2017–2018.

      Results

      There were 4,767 deaths among women up to age 44 years, resulting in a maternal mortality rate of 17.9. Reducing the proportion of Planned Parenthood clinics by 20% from the state-year mean increased the maternal mortality rate by 8% (incidence rate ratio, 1.08; 95% CI=1.04, 1.12). States that enacted legislation to restrict abortions based on gestational age increased the maternal mortality rate by 38% (incidence rate ratio, 1.38; 95% CI=1.03, 1.84). Planned Parenthood clinic closures negatively impacted all women, increasing mortality by 6%–15% across racial/ethnic groups, whereas gestational limits primarily increased mortality among white women.

      Conclusions

      Recent fiscal and legislative changes reducing women's access to family planning and reproductive health services have contributed to rising maternal mortality rates.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • MacDorman MF
        • Declercq E
        • Cabral H
        • Morton C
        Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues.
        Obstet Gynecol. 2016; 128: 447‒455
        • 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: 5‒12
        • MacDorman MF
        • Declercq E
        • Thoma ME
        Trends in maternal mortality by sociodemographic characteristics and cause of death in 27 states and the District of Columbia.
        Obstet Gynecol. 2017; 129: 811‒818
        • Molina RL
        • Pace LE.
        A renewed focus on maternal health in the United States.
        N Engl J Med. 2017; 377: 1705‒1707
        • Hoyert DL
        Maternal mortality and related concepts.
        Vital Health Stat. 2007; 3: 1‒13
        • Joseph KS
        • Lisonkova S
        • Muraca GM
        • et al.
        Factors underlying the temporal increase in maternal mortality in the United States.
        Obstet Gynecol. 2017; 129: 91‒100
        • MacDorman MF
        • Declercq E.
        The failure of United States maternal mortality reporting and its impact on women's lives.
        Birth. 2018; 45: 105‒108
        • MacDorman MF
        • Declercq E
        • Thoma ME
        Trends in Texas maternal mortality by maternal age, race/ethnicity, and cause of death, 2006-2015.
        Birth. 2018; 45: 169‒177
        • Baeva S
        • Saxton DL
        • Ruggiero K
        • et al.
        Identifying maternal deaths in Texas using an enhanced method, 2012.
        Obstet Gynecol. 2018; 131: 762‒769
        • Robbins CL
        • Zapata LB
        • Farr SL
        • et al.
        Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009.
        MMWR Surveill Summ. 2014; 63: 1‒62
      1. U.S. Centers for Medicare & Medicaid Services. Preventive care benefits: preventive health services for women. www.healthcare.gov/preventive-care-women/. Accessed June 25, 2019.

      2. Rewire. News. Legislative tracker: admitting privileges laws. https://rewire.news/legislative-tracker/law-topic/admitting-privileges/. Accessed June 25, 2019.

      3. National Women's Law Center. State laws regulating insurance coverage of abortion have serious consequences for women's equality, health, and economic stability. nwlc.org/resources/state-bans-insurance-coverage-abortion-endanger-women%E2%80%99s-health-and-take-health-benefits-away-women/. Accessed June 25, 2019.

      4. Rewire.News. Legislative tracker: later abortion. https://rewire.news/legislative-tracker/law-topic/later-abortion/. Accessed June 25, 2019.

        • Stevenson AJ
        • Flores-Vazquez IM
        • Allgeyer RL
        • Schenkkan P
        • Potter JE
        Effect of removal of Planned Parenthood from the Texas women's health program.
        N Engl J Med. 2016; 374: 853‒860
      5. National Center for Health Statistics. Mortality data 2005‒2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. www.cdc.gov/nchs/nvss/deaths.htm. Accessed September 12, 2019.

        • WHO
        International Statistical Classification of Diseases and Related Health Problems, 10th Revision.
        WHO, Geneva, Switzerland1992
      6. CDC. CDC WONDER: natality information. https://wonder.cdc.gov/natality.html. Accessed June 25, 2019.

      7. Review to Action. Maternal mortality review committees map. www.reviewtoaction.org/content/mmr-map. Accessed June 25, 2019.

        • Heron M.
        Deaths: leading causes for 2017.
        Natl Vital Stat Rep. 2019; 68 (Accessed September 25, 2019): 1-76
        • Marchi J
        • Berg M
        • Dencker A
        • Olander EK
        • Begley C
        Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews.
        Obes Rev. 2015; 16: 621‒638
      8. CDC. Obesity among women of childbearing age (18–44 years): behavioral risk factor surveillance system. www.marchofdimes.org/peristats. Accessed June 25, 2019.

        • Souza JP
        • Gülmezoglu A
        • Lumbiganon P
        • et al.
        Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health.
        BMC Med. 2010; 8: 71
      9. National Center for Health Statistics. Final natality data: total cesarean deliveries. www.marchofdimes.org/peristats. Accessed June 25, 2019.

      10. U.S. Department of Labor. Geographic profile of employment and unemployment. www.bls.gov/opub/geographic-profile/home.htm. Accessed June 28, 2019.

      11. U.S. Census Bureau. Current population survey, annual social and economic supplements 2005‒2007. www.census.gov/programs-surveys/saipe/data/tables.html. Accessed June 25, 2019.

      12. U.S. Census Bureau. 1-year American Community Surveys 2008‒2015.www.census.gov/data/tables/time-series/demo/health-insurance/historical-series/hic.html. Accessed June 25, 2019.

      13. The Henry J Kaiser Family Foundation. Status of state action on the Medicaid expansion decision; 2017.www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed June 25, 2019.

      14. Trust for America's Health. Investing in America's health: a state-by-state look at public health funding and key health facts 2008‒2016.www.tfah.org/wp-content/uploads/archive/assets/files/TFAH-2016-InvestInAmericaRpt-FINAL%20REVISED.pdf. Accessed June 25, 2019.

        • Dimick JB
        • Ryan AM.
        Methods for evaluating changes in health care policy: the difference-in-differences approach.
        JAMA. 2014; 312: 2401‒2402
        • Martin JAH
        • Hamilton BE
        • Osterman MJK
        • Driscoll AK
        • Mathews TJ
        Births: final data for 2015.
        Natl Vital Stat Rep. 2017; 66: 1
        • Currie J
        • Duque V
        • Garfinkel I
        The Great Recession and mother's health.
        Econ J (London). 2015; 125: F311‒F346
        • Finer LB
        • Zolna MR.
        Declines in unintended pregnancy in the United States, 2008-2011.
        N Engl J Med. 2016; 374: 843‒852
        • Kost K
        • Lindberg L.
        Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis.
        Demography. 2015; 52: 83‒111
        • Raymond EG
        • Grimes DA.
        The comparative safety of legal induced abortion and childbirth in the United States.
        Obstet Gynecol. 2012; 119: 215‒219
        • Lai KKR
        Abortion bans: 9 states have passed bills to limit the procedure this year.
        New York Times, May 29, 2019 (Updated)

      Linked Article