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Current Psychiatry Reports Apr 2022Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and... (Review)
Review
PURPOSE OF REVIEW
Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.
RECENT FINDINGS
Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.
Topics: Female; Humans; Maternal Mortality; Parturition; Postpartum Period; Pregnancy; Pregnancy Complications; Suicide, Attempted
PubMed: 35366195
DOI: 10.1007/s11920-022-01334-3 -
NeoReviews Oct 2019The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths...
The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.
Topics: Female; Healthcare Disparities; Humans; Maternal Health Services; Maternal Mortality; United States
PubMed: 31575778
DOI: 10.1542/neo.20-10-e561 -
Annual Review of Medicine Jan 2023Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and... (Review)
Review
Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.
Topics: Pregnancy; Humans; Female; United States; Maternal Mortality; Risk Factors; Ethnicity
PubMed: 36706746
DOI: 10.1146/annurev-med-042921-123851 -
JAMA Jul 2023Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for... (Observational Study)
Observational Study
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.
Topics: Female; Humans; Pregnancy; Bayes Theorem; Ethnicity; Maternal Mortality; Racial Groups; United States; Child; Adolescent; Young Adult; Adult; Middle Aged
PubMed: 37395772
DOI: 10.1001/jama.2023.9043 -
Obstetrics and Gynecology May 2021Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were...
Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were an artifact of changes in surveillance. The pregnancy checkbox, introduced in the revised 2003 death certificate and implemented by the states in a staggered manner, resulted in increased identification of maternal deaths and in reported maternal mortality rates. This Commentary summarizes the findings of the National Center for Health Statistics reports, describes temporal trends and the current status of maternal mortality in the United States, and discusses future concerns. Although the National Center for Health Statistics studies, based on recoding of death certificate information (after excluding information from the pregnancy checkbox), showed that crude maternal mortality rates did not change significantly between 2002 and 2018, age-adjusted analyses show a temporal reduction in the maternal mortality rate (21% decline, 95% CI 13-28). Specific causes of maternal death, which were not affected by the pregnancy checkbox, such as preeclampsia, showed substantial temporal declines. However, large racial disparities continue to exist: Non-Hispanic Black women had a 2.5-fold higher maternal mortality rate compared with non-Hispanic White women in 2018. This overview of maternal mortality underscores the need for better surveillance and more accurate identification of maternal deaths, improved clinical care, and expanded public health initiatives to address social determinants of health. Challenges with ascertaining maternal deaths notwithstanding, several causes of maternal death (unaffected by surveillance artifacts) show significant temporal declines, even though there remains substantial scope for preventing avoidable maternal death and reducing disparities.
Topics: Adolescent; Adult; Child; Death Certificates; Female; Forecasting; Healthcare Disparities; Humans; Maternal Mortality; Population Surveillance; Pregnancy; Pregnancy Complications; United States; Young Adult
PubMed: 33831914
DOI: 10.1097/AOG.0000000000004361 -
American Journal of Public Health Sep 2021To better understand racial and ethnic disparities in US maternal mortality. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual...
To better understand racial and ethnic disparities in US maternal mortality. 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. 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. 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.
Topics: Adult; Black or African American; Asian; Ethnicity; Female; Health Status Disparities; Healthcare Disparities; Hispanic or Latino; Humans; Maternal Death; Maternal Mortality; Pregnancy; Risk Factors; United States
PubMed: 34383557
DOI: 10.2105/AJPH.2021.306375 -
BJOG : An International Journal of... Mar 2022To assess national and regional trends and causes-specific distribution of maternal mortality in India.
OBJECTIVE
To assess national and regional trends and causes-specific distribution of maternal mortality in India.
DESIGN
Nationally representative cross-sectional surveys.
SETTING
All of India from 1997 to 2020.
SAMPLE
About 10 000 maternal deaths among 4.3 million live births over two decades.
METHODS
We analysed trends in the maternal mortality ratio (MMR) from 1997 through 2020, estimated absolute maternal deaths and examined the causes of maternal death using nationally representative data sources. We partitioned female deaths (aged 15-49 years) and live birth totals, based on the 2001-2014 Million Death Study to United Nations (UN) demographic totals for the country.
MAIN OUTCOME MEASURES
Maternal mortality burden and distribution of causes.
RESULTS
The MMR declined in India by about 70% from 398/100 000 live births (95% CI 378-417) in 1997-98 to 99/100 000 (90-108) in 2020. About 1.30 million (95% CI 1.26-1.35 million) maternal deaths occurred between 1997 and 2020, with about 23 800 (95% CI 21 700-26 000) in 2020, with most occurring in poorer states (63%) and among women aged 20-29 years (58%). The MMRs for Assam (215), Uttar Pradesh/Uttarakhand (192) and Madhya Pradesh/Chhattisgarh (170) were highest, surpassing India's 2016-2018 estimate of 113 (95% CI 103-123). After adjustment for education and other variables, the risks of maternal death were highest in rural and tribal areas of north-eastern and northern states. The leading causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%).
CONCLUSIONS
India could achieve the UN 2030 MMR goals if the average rate of reduction is maintained. However, without further intervention, the poorer states will not.
TWEETABLE ABSTRACT
We estimated that 1.3 million Indian women died from maternal causes over the last two decades. Although maternal mortality rates have fallen by 70% overall, the poorer states lag behind.
Topics: Adolescent; Adult; Female; Humans; India; Live Birth; Maternal Mortality; Middle Aged; Pregnancy; Young Adult
PubMed: 34455679
DOI: 10.1111/1471-0528.16888 -
American Journal of Obstetrics and... Oct 2020Maternal mortality and severe maternal morbidity are urgent issues in the United States. It is important to establish priority areas to address these public health...
Maternal mortality and severe maternal morbidity are urgent issues in the United States. It is important to establish priority areas to address these public health crises. On April 8, 2019, and May 2 to 3, 2019, the Eunice Kennedy Shriver National Institute of Child Health and Human Development organized and invited experts with varied perspectives to 2 meetings, a community engagement forum and a scientific workshop, to discuss underlying themes involved in the rising incidence of maternal mortality in the United States. Experts from diverse disciplines reviewed current data, ongoing activities, and identified research gaps focused on data measurement and reporting, obstetrical and health system factors, social determinants and disparities, and the community perspective and engagement. Key scientific opportunities to reduce maternal mortality and severe maternal morbidity include improved data quality and measurement, understanding the populations affected as well as the numerous etiologies, clinical research to confirm preventive and interventional strategies, and engagement of community participation in research that will lead to the reduction of maternal mortality in the United States. This article provides a summary of the workshop presentations and discussions.
Topics: Black or African American; Community Participation; Female; Health Status Disparities; Healthcare Disparities; Humans; Maternal Mortality; National Institute of Child Health and Human Development (U.S.); Pregnancy; Research; Social Determinants of Health; United States; White People
PubMed: 32682858
DOI: 10.1016/j.ajog.2020.07.021 -
Journal of Comparative Effectiveness... Sep 2022To evaluate the economic burden of age- and race/ethnicity-based US maternal mortality disparities. Economic burden is estimated by years of potential life lost (YPLL)...
To evaluate the economic burden of age- and race/ethnicity-based US maternal mortality disparities. Economic burden is estimated by years of potential life lost (YPLL) and value of statistical life (VSL). Maternal mortality counts (2018-2020) were obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database. Life-expectancy data were obtained from the Social Security actuarial tables. YPLL and VSL were calculated and stratified by age (classified as under 25, 25-39, and 40 and over) and race/ethnicity (classified as Hispanic, non-Hispanic White, non-Hispanic Black). Economic measures associated with maternal mortality increased by an estimated 30%, from a YPLL of 32,824 and VSL of US$7.9 billion in 2018 to a YPLL of 43,131 and VSL of US$10.4 billion in 2020. Our findings suggest that age, race and ethnicity are major drivers of the US maternal mortality economic burden.
Topics: Ethnicity; Financial Stress; Hispanic or Latino; Humans; Life Expectancy; Maternal Mortality; United States; Female
PubMed: 35833509
DOI: 10.2217/cer-2022-0056 -
Annals of Epidemiology May 2019Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of...
PURPOSE
Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors.
METHODS
We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n = 8,252,025).
RESULTS
The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics.
CONCLUSIONS
The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.
Topics: Adult; Black or African American; Black People; California; Cohort Studies; Female; Healthcare Disparities; Humans; Maternal Health; Maternal Mortality; Minority Health; Pregnancy; Prevalence; White People; Young Adult
PubMed: 30928320
DOI: 10.1016/j.annepidem.2019.02.007