State-Specific Maternal Mortality Among Black and White Women -- United States, 1987-1996

One of the national health objectives for 2000 is to reduce the overall maternal mortality ratio* ([MMR] i.e., number of maternal deaths per 100,000 live-born infants) to no more than 3.3 (objective 14.3) (1); however, during 1982-1996, the MMR remained at approximately 7.5 (2). In addition, the risk for maternal mortality consistently has been higher among black women than white women. This report presents state-specific MMRs for 1987-1996, focusing on persistent disparities in maternal mortality between black and white women. The findings indicate that in every state where MMRs could be reliably calculated, black women were more likely than white women to die from complications of pregnancy and that the 2000 objective will not be met; however, for white women, it has been met in three states.

MMRs were calculated using information from birth and death certificates filed in state vital statistics offices and compiled by CDC's National Center for Health Statistics (3,4). Maternal deaths were defined as deaths that occurred during pregnancy or within 42 days after pregnancy termination, regardless of pregnancy duration and site, from any cause related to or aggravated by the pregnancy, but not from accidental** or incidental causes.*** Cause of death is recorded on the death certificate by the attending physician, medical examiner, or coroner. For the denominator (live-born infants), maternal race as indicated on the birth certificate was used; for the numerator (maternal deaths), maternal race as indicated on the death certificate was used. Data for racial groups other than black and white are not presented separately because numbers were too small to provide reliable estimates; however, data for other races were included in the totals for each state. Data for Hispanic women were not available from all states and were not analyzed.

Data from states with fewer than seven maternal deaths for black and white women were considered unreliable and were not reported (relative standard error [RSE]: greater than 38%). Data for states with seven-19 maternal deaths for black and white women were reported. RSE for these maternal deaths was 23%-38%; however, data were not considered as reliable as those for states with at least 20 maternal deaths. Total MMRs were presented for all states, regardless of the total number of deaths.

During 1987-1996, for black women, MMRs in 26 states ranged from 8.7 (Massachusetts) to 28.7 (New York) (Table 1); for white women, MMRs in 41 states ranged from 2.7 (Massachusetts) to 9.2 (Vermont). The MMR for black women was higher than for white women in every state where ratios could be calculated. The black:white ratio of MMRs ranged from 2.6 (Iowa, Maryland, and South Carolina) to 6.3 (Michigan).

Total MMRs ranged from 1.9 (New Hampshire) to 22.8 (District of Columbia). Eight states and the District of Columbia had significantly higher MMRs than the national MMR. Because the MMR for black women was 3-6 times higher than for white women, states with higher percentages of births to black women tended to have higher total MMRs (Table 1).

To discern possible trends in maternal mortality, data were divided into two 5-year periods (1987-1991 and 1992-1996). The national MMR was 7.7 for each time period. The MMR did not differ significantly between these periods for black women (18.8 and 20.3, respectively) or for white women (5.5 and 5.0, respectively). The difference in MMRs for the two time periods was not significant in 48 states and the District of Columbia.

Reported by: Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Vital Statistics, National Center for Health Statistics, CDC.

Editorial Note:

Although no progress has been made in achieving the 2000 objective to reduce maternal mortality, the findings in this report indicate that for white women, the goal has been achieved in three states (Massachusetts, Nebraska, and Washington) and has almost been met in eight other states (MMRs of less than 4). Therefore, in the United States, lower levels of maternal mortality can be achieved.

The proposed 2010 objective for maternal mortality using vital statistics data remains at 3.3 per 100,000 live-born infants. A focus for the 2010 objectives is to eliminate racial disparities in maternal mortality. The fourfold increase nationally in risk for maternal death among black women compared with white women is one of the largest racial disparities among major public health indicators; no improvement has occurred during 1987-1996 (2,5). Race and ethnicity are not risk factors for maternal mortality but instead may be markers of social, economic, cultural, health-care access and quality, and other interrelated factors that may increase the risk for death among pregnant women.

Black women have a higher risk than white women for dying from every pregnancy-related cause of death reported, including the three leading causes (i.e., hemorrhage, pregnancy-induced hypertension, and embolism) (6). Although prenatal care reduces the risk for maternal mortality, health-care access and use do not explain fully the disproportionate risk for maternal death for black women (7). Other factors, such as quality of prenatal, delivery, and postpartum care, and interaction between health-seeking behaviors and satisfaction with care, may explain part of this difference. Epidemiologic, sociologic, health-care delivery, and program research are needed to identify key factors that may contribute to the disparity between black and white women in maternal health whether at the individual, clinic, community, or health systems level.

The wide disparity that exists among states for both black and white MMRs is not attributable solely to small numbers. However, vital statistics data do not include information necessary to assess risk factors and case-fatality rates that may have contributed to these state-to-state disparities.

The findings in this report are subject to at least two limitations. First, although U.S. vital statistics data during 1987-1996 indicated that 3086 women died because of pregnancy complications, these data are underestimates because of misclassification on death certificates. Misclassification occurs when the cause of death on the death certificate does not reflect the relation between a woman's pregnancy and her death. The estimated number of maternal deaths is 1.3-3.0 times higher than that reported in vital statistics records (6). If a maternal mortality review discovers that the cause of death on the death certificate is reported incorrectly, the certifying physician should be contacted to file an amended record. Second, misclassification of race on death certificates may vary among the states and are not known.

To identify interventions that may reduce maternal mortality, 25 states have reestablished maternal mortality review committees. These committees review factors that may have contributed to maternal deaths, including the quality of medical care and problems in the health-care delivery system. All states should implement such review mechanisms to help identify and investigate maternal deaths, discuss each case in a multidisciplinary process, disseminate findings, and provide recommendations for preventing future deaths. Both public health surveillance and prevention research are needed to understand the underlying causes of maternal mortality and the disparity between black and white women and to guide appropriate interventions and improvements in maternal health care.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.
2. CDC. Maternal mortality--United States, 1982-1996. MMWR 1998;47:705-7.
3. Peters KD, Kochanek KD, Murphy SL. Deaths: final data for 1996. Hyattsville, Maryland: US Department of Health and Human Services, CDC, National Center for Health Statistics, 1998. (National vital statistics reports; vol 47, no. 9).
4. Ventura SJ, Martin JA, Curtin SC, et al. Report of final natality statistics, 1996. Hyattsville, Maryland: US Department of Health and Human Services, CDC, National Center for Health Statistics, 1998. (Monthly vital statistics report; vol 46, no. 11).
5. CDC. Differences in maternal mortality among black and white women--United States, 1990. MMWR 1995;44:6-14.
6. Berg C, Atrash H, Koonin L, et al. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol 1996;88:161-7.
7. Koonin L, MacKay A, Berg C, et al. Pregnancy-related mortality surveillance--United States, 1987-1990. MMWR 1997;46(no. SS-4):17-34.

* CDC's National Center for Health Statistics uses the term "rate" when reporting this indicator of maternal mortality. The term "ratio" is used instead of rate in this report because the numerator includes some maternal deaths that were not related to live-born infants and thus were not included in the denominator.

** When a death occurs under "accidental" circumstances, the preferred term within the public health community is "unintentional injury."

*** International Classification of Diseases, Ninth Revision, codes 630-676.

TABLE 1. Maternal mortality ratios* (MMRs) for black and white women, by state -
United States, 1987-1996+
================================================================================================
                             MMR
                       --------------- Black:White                             % Births to
State                  Black    White     ratio&      Total MMR    (95% CI @)  black women
------------------------------------------------------------------------------------------
Alabama                 21.1      6.7      3.1             11.7    ( 9.2-14.7)     34.0
Alaska                    **       **       -               3.6**  ( 1.0- 9.2)      4.5
Arizona                   **      4.0       -               5.2    ( 3.7- 7.2)      3.5
Arkansas                12.4++    4.1++    3.0              6.2    ( 3.9- 9.4)     22.9
California              17.9      6.9      2.6              8.1    ( 7.3- 8.8)      7.9
Colorado                  **      6.5       -               6.9    ( 4.8- 9.4)      5.2
Connecticut               **      5.0       -               5.3    ( 3.4- 7.8)     12.5
Delaware                  **       **       -               3.8**  ( 1.0- 9.7)     23.5
District of Columbia    25.7       **       -              22.8    (16.4-34.0)     77.7
Florida                 24.8      5.3      4.7              9.7    ( 8.3-11.1)     23.1
Georgia                 20.3      5.5      3.7             10.7    ( 8.8-12.7)     35.3
Hawaii                    **       **       -               4.6++  ( 2.5- 7.7)      5.7
Idaho                     **      6.7++     -               6.1++  ( 3.3-10.2)      0.4
Illinois                21.3      4.3      5.0              7.5    ( 6.2- 8.7)     20.1
Indiana                 13.3++    4.0      3.3              4.5    ( 3.2- 6.1)      9.3
Iowa                      **      5.6++     -               5.1    ( 3.1- 7.9)      2.6
Kansas                  27.3++    5.2++    5.2              6.3    ( 4.1- 9.3)      7.3
Kentucky                  **      7.0       -               6.7    ( 4.7- 9.2)      8.4
Louisiana               18.9      6.2      3.0             11.7    ( 9.3-14.5)     41.3
Maine                     **       **       -               6.3++  ( 3.0-11.6)      0.5
Maryland                15.9      6.1      2.6              9.1    ( 7.1-11.5)     31.5
Massachusetts            8.7++    2.7      3.2              3.1    ( 2.1- 4.6)      9.4
Michigan                22.6      3.6      6.3              7.5    ( 6.0- 8.9)     19.6
Minnesota                 **      3.4++     -               3.8    ( 2.5- 5.6)      4.1
Mississippi             20.5      5.1++    4.0             12.3    ( 9.2-16.1)     47.4
Missouri                15.3++    5.8      2.7              7.4    ( 5.6- 9.6)     16.4
Montana                   **       **       -               3.5**  ( 1.0- 8.9)      0.3
Nebraska                  **      3.2++     -               3.4++  ( 1.5- 6.7)      5.4
Nevada                    **      5.9++     -               6.4++  ( 3.5-10.8)      8.9
New Hampshire             **       **       -               1.9**  ( 0.4- 5.4)      0.6
New Jersey              19.0      3.9      4.9              6.9    ( 5.4- 8.5)     19.1
New Mexico                **      7.0++     -               9.5    ( 6.2-13.9)      1.9
New York                28.7      7.6      3.8             12.0    (10.7-13.3)     21.3
North Carolina          21.2      6.3      3.4             11.9    ( 9.8-14.1)     28.4
North Dakota              **      6.1++     -               7.7++  ( 3.1-15.8)      0.9
Ohio                    16.8      4.5      3.7              6.3    ( 5.1- 7.6)     15.3
Oklahoma                18.4++    4.6++    4.0              6.2    ( 4.1- 8.9)     10.4
Oregon                    **      3.6++     -               4.6    ( 2.7- 7.1)      2.2
Pennsylvania            20.5      3.9      5.2              6.4    ( 5.2- 7.7)     14.7
Rhode Island              **       **       -               4.3**  ( 1.6- 9.3)      7.6
South Carolina          17.4      6.6      2.6             10.8    ( 8.2-14.0)     37.9
South Dakota              **       **       -               3.7**  ( 1.0- 9.4)      0.7
Tennessee               19.5      4.9      4.0              8.2    ( 6.3-10.6)     23.2
Texas                   17.4      6.3      2.7              7.7    ( 6.8- 8.7)     13.1
Utah                      **      4.5++     -               4.3++  ( 2.4- 7.0)      0.6
Vermont                   **      9.2++     -               9.1++  ( 3.7-18.7)      0.3
Virginia                12.0      3.8      3.2              5.8    ( 4.4- 7.5)     23.8
Washington                **      3.0       -               3.3    ( 2.1- 4.8)      3.9
West Virginia             **      5.7++     -               5.9++  ( 3.2-10.2)      3.7
Wisconsin               16.2++    3.9      4.1              5.3    ( 3.7- 7.3)      9.7
Wyoming                   **       **       -               5.9**  ( 1.6-15.2)      1.0

Total                   19.6      5.3      3.7              7.7    ( 7.4- 8.0)     16.0
------------------------------------------------------------------------------------------
 * Maternal deaths per 100,000 live-born infants. CDC's National Center for Health Statistics
   uses the term "rate" when reporting this indicator of maternal mortality. The term "ratio"
   is used instead of rate in this report because the numerator includes some maternal deaths
   that were not related to live-born infants and thus were not included in the denominator.
 + n=3086.
 & All ratios are significantly greater than 1.0 (p<0.02).
 @ Confidence interval.
** Point estimates for states with fewer than seven maternal deaths for 1987-1996 are
   considered unreliable (relative standard error [RSE]: >38%).
++ Point estimates for states with seven-19 maternal deaths for 1987-1996 are considered less
   reliable (RSE: 23%-38%) than estimates from states with 19 maternal deaths.
================================================================================================

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