Pregnancy-Related Deaths by Hispanic Origin, United States, 2009-2018.

Objective: To describe pregnancy-related mortality among Hispanic people by place of origin (country or region of Hispanic ancestry), 2009-2018. Materials and Methods: We conducted a cross-sectional descriptive study of pregnancy-related deaths among Hispanic people, stratified by place of origin (Central or South America, Cuba, Dominican Republic, Mexico, Puerto Rico, Other and Unknown Hispanic), using Pregnancy Mortality Surveillance System data, 2009-2018. We describe distributions of pregnancy-related deaths and pregnancy-related mortality ratios (number of pregnancy-related deaths per 100,000 live births) overall and by place of origin for select demographic and clinical characteristics. Results: For 2009-2018, the overall pregnancy-related mortality ratio among Hispanic people was 11.5 pregnancy-related deaths per 100,000 live births (95% confidence intervals [CI]: 10.8-12.2). In general, pregnancy-related mortality ratios were higher among older age groups (i.e., 35 years and older) and lower among those with higher educational attainment (i.e., college degree or higher). Approximately two in five pregnancy-related deaths among Hispanic people occurred on the day of delivery through 6 days postpartum. Place of origin-specific pregnancy-related mortality ratios ranged from 9.6 (95% CI: 5.8-15.0) among people of Cuban origin to 15.3 (95% CI: 12.4-18.3) among people of Puerto Rican origin. Hemorrhage and infection were the most frequent causes of pregnancy-related deaths overall among Hispanic people. People of Puerto Rican origin had a higher proportion of deaths because of cardiomyopathy. Conclusions: We identified differences in pregnancy-related mortality by place of origin among Hispanic people that can help inform prevention of pregnancy-related deaths.

Neighborhood gentrification, displacement, and severe maternal morbidity in California.

Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.

Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States.

Importance: Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. Objective: To quantify trends in MMRs (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups using a bayesian extension of the generalized linear model network. Design, Setting, and Participants: Observational study using vital registration and census data from 1999 to 2019 in the US. Pregnant or recently pregnant individuals aged 10 to 54 years were included. Main Outcomes and Measures: MMRs. Results: In 2019, MMRs in most states were higher among American Indian and Alaska Native and Black populations than among Asian, Native Hawaiian, or Other Pacific Islander; Hispanic; and White populations. Between 1999 and 2019, observed median state MMRs increased from 14.0 (IQR, 5.7-23.9) to 49.2 (IQR, 14.4-88.0) among the American Indian and Alaska Native population, 26.7 (IQR, 18.3-32.9) to 55.4 (IQR, 31.6-74.5) among the Black population, 9.6 (IQR, 5.7-12.6) to 20.9 (IQR, 12.1-32.8) among the Asian, Native Hawaiian, or Other Pacific Islander population, 9.6 (IQR, 6.9-11.6) to 19.1 (IQR, 11.6-24.9) among the Hispanic population, and 9.4 (IQR, 7.4-11.4) to 26.3 (IQR, 20.3-33.3) among the White population. In each year between 1999 and 2019, the Black population had the highest median state MMR. The American Indian and Alaska Native population had the largest increases in median state MMRs between 1999 and 2019. Since 1999, the median of state MMRs has increased for all racial and ethnic groups in the US and the American Indian and Alaska Native; Asian, Native Hawaiian, or Other Pacific Islander; and Black populations each observed their highest median state MMRs in 2019. Conclusion and Relevance: While maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.

An in-depth analysis of perinatal related mortality among women of South Asian ethnicity in Aotearoa New Zealand.

BACKGROUND: International and national New Zealand (NZ) research has identified women of South Asian ethnicity at increased risk of perinatal mortality, in particular stillbirth, with calls for increased perinatal research among this ethnic group. We aimed to analyse differences in pregnancy outcomes and associated risk factors between South Asian, Maori, Pacific and NZ European women in Aotearoa NZ, with a focus on women of South Asian ethnicity, to ultimately understand the distinctive pathways leading to adverse events. METHODS: Clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, while national maternity and neonatal data, and singleton birth records from the same decade, were linked using the Statistics NZ Integrated Data Infrastructure for all births. Pregnancy outcomes and risk factors for stillbirth and neonatal death were compared between ethnicities with adjustment for pre-specified risk factors. RESULTS: Women of South Asian ethnicity were at increased risk of stillbirth (aOR 1.51, 95%CI 1.29-1.77), and neonatal death (aOR 1.51, 95%CI 1.17-1.92), compared with NZ European. The highest perinatal related mortality rates among South Asian women were between 20-23 weeks gestation (between 0.8 and 1.3/1,000 ongoing pregnancies; p < 0.01 compared with NZ European) and at term, although differences by ethnicity at term were not apparent until ≥ 41 weeks (p < 0.01). No major differences in commonly described risk factors for stillbirth and neonatal death were observed between ethnicities. Among perinatal deaths, South Asian women were overrepresented in a range of metabolic-related disorders, such as gestational diabetes, pre-existing thyroid disease, or maternal red blood cell disorders (all p < 0.05 compared with NZ European). CONCLUSIONS: Consistent with previous reports, women of South Asian ethnicity in Aotearoa NZ were at increased risk of stillbirth and neonatal death compared with NZ European women, although only at extremely preterm (< 24 weeks) and post-term (≥ 41 weeks) gestations. While there were no major differences in established risk factors for stillbirth and neonatal death by ethnicity, metabolic-related factors were more common among South Asian women, which may contribute to adverse pregnancy outcomes in this ethnic group.

Addressing Maternal Mortality in the US-A Pediatrics Responsibility.

This Viewpoint suggests that pediatricians' contact with the maternal-infant dyad postpartum presents an opportunity to address the US maternal mortality crisis and its inequities.

Years of life lost due to unintentional drug overdose among perinatal individuals in the United States.

BACKGROUND: The United States has one of the highest maternal mortality rates of developing countries, but the contribution of perinatal drug overdose is not known. Communities of color also have higher rates of maternal morbidity and mortality when compared to White communities, however the contribution due to overdose has not yet been examined in this population. OBJECTIVES: To quantify the years of life lost due to unintentional overdose in perinatal individuals from 2010 to 2019 and assess for disparity by race. STUDY DESIGN: This was a cross-sectional retrospective study with summary-level mortality statistics for the years 2010-2019 obtained from the Centers for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) mortality file. A total of 1,586 individuals of childbearing age (15-44 years) who died during pregnancy or six weeks postpartum (perinatal) from unintentional overdose in the United States from January 1, 2010 to December 31, 2019 were included. Total years of life lost (YLL) was calculated and summated for White, Black, Hispanic, Asian/Pacific Islander, and American Indian/Native Alaska women. Additionally, the top three overall causes of death were also identified for women in this age group for comparison. RESULTS: Unintentional drug overdose accounted for 1,586 deaths and 83,969.78 YLL in perinatal individuals from 2010 to 2019 in the United States. Perinatal American Indian/Native American individuals had a disproportionate amount of YLL when compared to other ethnic groups, with 2.39% of YLL due to overdose, while only making up 0.80% of the population. During the last two years of the study, only American Indian/Native American and Black individuals had increased rates of mortality when compared to other races. During the ten-year study period, when including the top three causes of mortality, unintentional drug overdoses made up 11.98% of the YLL overall and 46.39% of accidents. For the years 2016-2019, YLL due to unintentional overdose was the third leading cause of YLL overall for this population. CONCLUSIONS: Unintentional drug overdose is a leading cause of death for perinatal individuals in the United States, claiming nearly 84,000 years of life over a ten-year period. When examining by race, American Indian/Native American women are most disproportionately affected.

Associations Between State and Local Government Spending and Pregnancy-Related Mortality in the U.S.

INTRODUCTION: There is limited evidence on how government spending is associated with maternal death. This study investigates the associations between state and local government spending on social and healthcare services and pregnancy-related mortality among the total, non-Hispanic Black, Hispanic, and non-Hispanic White populations. METHODS: State-specific total population and race/ethnicity-specific 5-year (2015-2019) pregnancy-related mortality ratios were estimated from annual natality and mortality files provided by the National Center for Health Statistics. Data on state and local government spending and population-level characteristics were obtained from U.S. Census Bureau surveys. Generalized linear Poisson regression models with robust SEs were fitted to estimate adjusted rate ratios and 95% CIs associated with proportions of total spending allocated to social services and healthcare domains, adjusting for state-level covariates. All analyses were completed in 2021-2022. RESULTS: State and local government spending on transportation was associated with 11% lower overall pregnancy-related mortality (adjusted rate ratio=0.89, 95% CI=0.83, 0.96) and 9%-12% lower pregnancy-related mortality among the racial/ethnic groups. Among spending subdomains, expenditures on higher education, highways and roads, and parks and recreation were associated with lower pregnancy-related mortality rates in the total population (adjusted rate ratio=0.90, 95% CI=0.86, 0.94; adjusted rate ratio=0.87, 95% CI=0.81, 0.94; and adjusted rate ratio=0.68, 95% CI=0.49, 0.95, respectively). These results were consistent among the racial/ethnic groups, but patterns of associations with pregnancy-related mortality and other spending subdomains differed notably between racial/ethnic groups. CONCLUSIONS: Investing more in local- and state-targeted spending in social services may decrease the risk for pregnancy-related mortality, particularly among Black women.

"Once you get one maternal death, it's like the whole world is dropping on you": experiences of managing maternal mortality amongst obstetric care providers in Ghana.

BACKGROUND: Maternal mortality has a significant global impact, especially in low-resource settings. Little prior research has been conducted on the potential effects of poor maternal outcomes on the personal and professional well-being of healthcare providers. This study explores the in-depth experiences and perspectives of obstetric providers in Ghana who work in a setting with frequent maternal mortalities. METHODS: This is a qualitative study of semi-structured interviews conducted at the Komfo Anokye Teaching Hospital in Ghana. Participants were obstetric healthcare providers, defined as midwives, house officers currently rotating on the obstetrics/gynecology service, and obstetrician/gynecologists at any training or practice level (residents, fellows, and specialists). Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo for qualitative analysis. Using the Attride-Stirling qualitative model, an incremental and iterative process was used to code interviews with keyword phrases and develop a framework of organizing and global themes. RESULTS: Interviews were conducted with 27 participants-15 midwives and 12 physicians (three obstetrician/gynecologist residents, six obstetrician/gynecologist specialists, and three house officers), with sample size determined by data saturation. Obstetric providers' experiences in a setting with frequent maternal mortalities were dependent on their level of preparedness to manage maternal mortalities and the workplace environment. Providers' level of preparedness was dependent on both the training they had received on the medical management of obstetric emergencies, as well as a lack of training on the mental health aspects of coping with maternal mortality. The impact of the workplace environment was dependent on systems failures and limited resources, blame from colleagues and supervisors, and a lack of support in the workplace. In turn, obstetric providers' experiences managing frequent maternal mortalities impacted their clinical care performance and mental health. CONCLUSIONS: Maternal deaths have profound personal and professional impacts on the healthcare providers who manage them. A large need exists for additional institutional training and support for obstetric providers who manage maternal mortality, especially in low-resource settings like Ghana.

Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017.

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable.

Reducing Cardiovascular Maternal Mortality by Extending Medicaid for Postpartum Women.

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.

Racial and Ethnic Disparities in Peripartum Hysterectomy Risk and Outcomes.

OBJECTIVE: This study aimed to determine whether race and ethnicity contribute to risks associated with peripartum hysterectomy. STUDY DESIGN: This retrospective cross-sectional study utilized the 2000-2014 Nationwide Inpatient Sample to analyze risk of peripartum hysterectomy and associated severe maternal morbidity, mortality, surgical injury, reoperation, surgical-site complications, and mortality by maternal race and ethnicity. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log-linear regression models including patient, clinical, and hospital risk factors were performed with adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). RESULTS: Of 59,854,731 delivery hospitalizations, there were 45,369 peripartum hysterectomies (7.6 per thousand). Of these, 37.8% occurred among non-Hispanic white, 13.9% among non-Hispanic black, and 22.8% among Hispanic women. In adjusted analyses, non-Hispanic black (aRR: 1.21, 95% CI: 1.17-1.29) and Hispanic women (aRR: 1.25, 95% CI: 1.22-1.29) were at increased risk of hysterectomy compared with non-Hispanic white women. Risk for severe morbidity was increased for non-Hispanic black (aRR: 1.25, 95% CI: 1.19-1.33), but not for Hispanic (aRR: 1.02, 95% CI: 0.97-1.07) women. Between these three groups, risk for intraoperative complications was highest among non-Hispanic white women, risk for reoperation was highest among Hispanic women, and risk for surgical-site complications was highest among non-Hispanic black women. Evaluating maternal mortality, non-Hispanic black women (RR: 3.83, 95% CI: 2.65-5.53) and Hispanic women (RR: 2.49, 95% CI: 1.74-3.59) were at higher risk than non-Hispanic white women. CONCLUSION: Peripartum hysterectomy and related complications other than death differed modestly by race. In comparison, mortality differentials were large supporting that differential risk for death in the setting of this high-risk scenario may be an important cause of disparities. KEY POINTS: · Peripartum hysterectomy and related complications differed modestly by race.. · Mortality differentials in the setting of peripartum hysterectomy were large.. · Failure to rescue may be an important cause of peripartum hysterectomy disparities..

The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan.

BACKGROUND: A disproportionately high rate of maternal deaths is reported in developing and underdeveloped regions of the world. Much of this is associated with social and cultural factors, which form barriers to women utilizing appropriate maternal healthcare. A huge body of research is available on maternal mortality in developing countries. Nevertheless, there is a lack of literature on the socio-cultural factors leading to maternal mortality within the context of the Three Delays Model. The current study aims to explore socio-cultural factors leading to a delay in seeking care in maternal healthcare in South Punjab, Pakistan. METHODS: We used a qualitative method and performed three types of data collection with different target groups: (1) 60 key informant interviews with gynaecologists, (2) four focus group discussions with Lady Health Workers (LHWs), and (3) ten case studies among family members of deceased mothers. The study was conducted in Dera Ghazi Khan, situated in South Punjab, Pakistan. The data was analysed with the help of thematic analysis. RESULTS: The study identified that delay in seeking care-and the potentially resulting maternal mortality-is more likely to occur in Pakistan due to certain social and cultural factors. Poor socioeconomic status, limited knowledge about maternal care, and financial constraints among rural people were the main barriers to seeking care. The low status of women and male domination keeps women less empowered. The preference for traditional birth attendants results in maternal deaths. In addition, early marriages and lack of family planning, which are deeply entrenched in cultural values, religion and traditions-e.g., the influence of traditional or spiritual healers-prevented young girls from obtaining maternal healthcare. CONCLUSION: The prevalence of high maternal mortality is deeply alarming in Pakistan. The uphill struggle to reduce deaths among pregnant women is firmly rooted in addressing certain socio-cultural practices, which create constraints for women seeking maternal care. The focus on poverty reduction and enhancing decision-making power is essential for supporting women's right to medical care.

Round the world, many women are dying because of complications during pregnancy or in childbirth. These deaths are more frequent in developing and underdeveloped countries. Some reasons for this are related to social and cultural factors, which form barriers to women using appropriate maternal healthcare. Therefore, this study aims to explore socio-cultural factors leading to a delay in seeking maternal healthcare in South Punjab, Pakistan. We interviewed a variety of people to get an overview of this topic: (1) 60 interviews were conducted with gynaecologists, (2) we performed four focus group discussions with eight to ten Lady Health Workers providing maternal healthcare, and (3) we talked with family members of mothers who had died.The study shows that delays in seeking care are related to poor socioeconomic status, limited knowledge about maternal care, and low incomes of rural people. The low status of women and male domination keeps women less empowered. In addition, early marriages and lack of family planning due to cultural values, religion and traditions stopped young girls from getting maternal healthcare.The number of new mothers who die is very worrying in Pakistan. One of the important tasks for reducing deaths among pregnant women is to address certain socio-cultural practices. It is very important to reduce poverty and improve decision-making power to make sure women can use their right to medical care.

Urban-rural differences in pregnancy-related deaths, United States, 2011-2016.

BACKGROUND: The US pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race and ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. OBJECTIVE: We sought to compare pregnancy-related mortality across and within urban and rural counties by race and ethnicity and age. STUDY DESIGN: We conducted a descriptive analysis of 3747 pregnancy-related deaths during 2011-2016 (the most recent available data) with available zone improvement plan code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian or Alaska Native, and Asian or Pacific Islander women aged 15 to 44 years. We aggregated data by US county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. RESULTS: Of the total 3747 pregnancy-related deaths analyzed, 52% occurred in large metro counties, and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8; 95% confidence interval, 14.2-15.5), whereas noncore counties had the highest (24.1; 95% confidence interval, 21.4-27.1), including race and ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women aged 25 to 34 years and 35 to 44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women than non-Hispanic White women. Non-Hispanic American Indian or Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2 to 3 times that of non-Hispanic White women in the same areas. CONCLUSION: Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed in urban-rural categories, including by age group and race and ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths.

Racial/Ethnic Inequities in Pregnancy-Related Morbidity and Mortality.

Racism in America has deep roots that impact maternal health, particularly through pervasive inequities among Black women as compared with White, although other racial and ethnic groups also suffer. Health care providers caring for pregnant women are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their diverse skillsets and knowledge. By increasing awareness of how structural racism drives inequities in health, these providers can encourage hospitals and practices to develop and implement national bundles for patient safety, and use bias training and team-based training practices aimed at improving care for racially diverse mothers.

Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status.

BACKGROUND: Maternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known. OBJECTIVE: The aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types). STUDY DESIGN: We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis. RESULTS: There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals. CONCLUSION: Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.

The Contrast of Color: Why the Black Community Continues to Suffer Health Disparities.

The evidence of racial health disparities is profound. Much attention has been given to the disparity in maternal morbidity and mortality experienced by Black mothers. The disparity in Black lives lost from coronavirus disease 2019 (COVID-19) has further highlighted the disparity in health outcomes for Black people. Although COVID-19 is a new disease, the reason for the health disparity is the same as in maternal morbidity and mortality: implicit bias and structural racism. Implicit bias among health care professionals leads to disparities in how health care is delivered. Generations of structural racism perpetuated through racial residential segregation, economic suppression, and health care inequality have normalized the poorer health outcomes for Black Americans. It is easy to dismiss these issues as someone else's problem, because health care professionals often fail to acknowledge the effect of implicit bias in their own practices. We all need to be highly critical of our own practices and look introspectively for implicit bias to find the cure. Health care organizations must invest time and resources into investigating the structural racism that exists within our own walls.