Rural-Urban Differences in Maternal Mortality Trends in the United States, 1999-2017: Accounting for the Impact of the Pregnancy Status Checkbox.

It has been difficult to measure rural-urban differences in maternal mortality ratios (MMRs) in the United States in recent years because of the incremental adoption of a pregnancy status checkbox on the standard US death certificate. Using 1999-2017 mortality and birth data, we examined the impact of the pregnancy checkbox on MMRs according to urbanicity of residence (large urban area, medium/small urban area, or rural area), using log-binomial regression models to predict trends that would have been observed if all states had adopted the checkbox as of 1999. Implementation of the checkbox resulted in an average estimated increase of 7.5 maternal deaths per 100,000 live births (95% confidence interval (CI): 6.3, 8.8) in large urban areas (a 76% increase), 11.6 (95% CI: 9.6, 13.6) in medium/small urban areas (a 113% increase), and 16.6 (95% CI: 12.9, 20.3) in rural areas (a 107% increase), compared with MMRs prior to the checkbox. Assuming that all states had the checkbox as of 1999, demographic-factor-adjusted predicted MMRs increased in rural areas, declined in large urban areas, and did not change in medium/small urban areas. However, trends and urban-rural differences were substantially attenuated when analyses were limited to direct/specific causes of maternal death, which are probably subject to less misclassification. Accurate ascertainment of maternal deaths, particularly in rural areas, is important for reducing disparities in maternal mortality.

Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths.

Objectives-This report quantifies the impact of the inclusion of a pregnancy status checkbox item on the U.S. Standard Certificate of Death on the number of deaths classified as maternal. Maternal mortality rates calculated with and without using the checkbox information for deaths in 2015 and 2016 are presented. Methods-This report is based on cause-of-death information from 2015 and 2016 death certificates collected through the National Vital Statistics System. Records originally assigned to a specified range of ICD-10 codes (i.e., A34, O00-O99) when using information from the checkbox item were recoded without using the checkbox item. Ratios of deaths assigned as maternal deaths using checkbox item information to deaths assigned without checkbox item information were calculated to quantify the impact of the pregnancy status checkbox item on the classification of maternal deaths for 47 states and the District of Columbia. Maternal mortality rates for all jurisdictions calculated using cause-of-death information entered on the certificate with and without the checkbox were compared overall and by characteristics of the decedent. Results-Use of information from the checkbox, along with information from the cause-of-death section of the certificate, identified 1,527 deaths as maternal compared with 498 without the checkbox in 2015 and 2016 (ratio = 3.07), with the impact varying by characteristics of the decedent such as age at death. The ratio for women under age 25 was 2.15 (204 compared with 95 deaths) but was 14.14 (523 compared with 37 deaths) for women aged 40-54. Without the adoption of the checkbox item, maternal mortality rates in both 2015 and 2016 would have been reported as 8.7 deaths per 100,000 live births compared with 8.9 in 2002. With the checkbox, the maternal mortality rate would be reported as 20.9 and 21.8 deaths per 100,000 live births in 2015 and 2016.

Rates and success rates of trial of labor after cesarean delivery in the United States, 1990-2009.

This study compares rates of trial of labor after Cesarean delivery (TOLAC) and rates of successful TOLAC between 1990 and 2009. Serial cross-sectional analyses were performed using the National Hospital Discharge Survey data to compare rates of TOLAC and TOLAC success between 1990 and 2009. Joinpoint regression was used to assess trends over time, and logistic regression with marginal effects was used to examine the unadjusted and adjusted significance and magnitude of trends. The rate of TOLAC reached a high of 51.8 % (95 % CI 47.8-55.8 %) in 1995 and a low of 15.9 % (95 % CI 13.8-18.0 %) in 2006, declined, on average, 4.2 (95 % CI -4.8 to -3.9) percentage points per year between 1996 and 2005. Rates increased significantly from 1990 to 1996 and 2005 to 2009. TOLAC success was at its highest rate in 2000, 69.8 % (95 % CI 65.2-74.3 %) and its lowest in 2008, 38.5 % (95 % CI 28.1-48.8 %). The rate of TOLAC success increased significantly between 1990 and 2000, but declined thereafter an average of 3.4 % points per year (95 % CI -4.3 to -2.5). The rate of TOLAC in the US decreased between 1996 and 2005 and the rate of successful TOLAC has declined from 2000 to 2009.

The Impact of the Pregnancy Checkbox and Misclassification on Maternal Mortality Trends in the United States, 1999-2017.

Maternal mortality is a critical indicator of population health in both the United States and internationally (1-3). Monitoring maternal mortality over time is important to evaluate progress in improving maternal health in the United States, to make international comparisons, and to examine differences and inequities by demographic subgroup (3). Substantial disparities in maternal mortality exist by race and Hispanic origin and age in the United States (4-6). Maternal and pregnancy-related mortality rates for non-Hispanic black women are approximately three times the rates for non-Hispanic white women, while women aged 40 and over have the highest maternal mortality rates compared with other age groups (4,6,7).

Sports Team Participation Among US High School Girls, 1999-2015.

Sports team participation has myriad benefits for girls. We used the 1999-2015 Youth Risk Behavior Survey, a nationally representative survey of US high school students, to examine time trends in sports team participation. Data from 2015 alone were examined for current differences in participation by sex, race/ethnicity, grade, and weight status. For both analyses, unadjusted and adjusted logistic regressions, with team participation as the dependent variable, were used. In 2015, 53% of US high school girls participated in team sports. Participation was higher among non-Hispanic white (60.7%) compared to Hispanic (40.7%) and Asian (35.6%) girls, and girls with normal-weight status (58.1%) compared to overweight (50.0%) and obese (36.5%) girls ( P < .01 for all comparisons). From 1999 to 2015, the rate of increase in participation was higher among non-Hispanic black girls than non-Hispanic white girls. No increase was observed for Hispanic and Asian girls. Addressing the disparities found in team participation is imperative.

Trends in Seeing an Obstetrician-Gynecologist Compared With a General Physician Among U.S. Women, 2000-2015.

OBJECTIVE: To assess trends in the percentage of U.S. women who visit an obstetrician-gynecologist (ob-gyn) and the percentage who visit a general physician (general practitioner, family medicine, and internist). METHODS: We used data from the 2000-2015 National Health Interview Surveys, cross-sectional nationally representative surveys, to identify the percentage of U.S. women who have visited an ob-gyn and the percentage who have visited a general physician during the preceding 12 months. Unadjusted percentages, and percentages adjusted for sociodemographic and health factors, were entered into joinpoint regressions to assess unadjusted and adjusted trends over time. RESULTS: The adjusted percentage of U.S. women who saw a general physician during the preceding 12 months did not significantly change from 2000 to 2015, ranging from 70.1% in 2007 to 74.2% in 2003 (P>.05 for trend). However, although the adjusted percentage that saw an ob-gyn in the preceding 12 months did not change from 2000 to 2003 or 2007-2011 (P>.05), it declined from 45.0% to 41.2% between 2003 and 2007 and from 41.8% to 38.4% between 2011 and 2015 (P<.001 for trends). The adjusted percentage that saw both an ob-gyn and a general physician was 32.4% in 2000, reaching as high as 35.2% in 2003, but then declined to 29.8% in 2015 (P<.001 for trend). Unadjusted results were similar. CONCLUSION: The percentage of women who visit an ob-gyn has declined since 2000. To assure high-quality and coordinated care, physicians should identify whether women see both health care provider types or only one to help assure that all recommended services are being offered.