Maternal mortality rates in the USA remain high, with persistent racial and socioeconomic disparities. We identified 207,016 hospital admissions for pregnant women in Maryland, from 2017 to 2019. Logistic regression was used to identity factors associated with maternal death. The health outcome for black women was more prone to give rise to maternal mortality than for white women. Our study revealed numerous racial and age discrepancies in gestational health outcomes, which opioid use disorder exacerbated. Our findings elaborate on the importance of identifying the drivers of adverse pregnancy outcomes, to help inform policy, and resource allocations.
Keywords: Maternal mortality, racial disparities, age disparities, miscarriage, public health
IntroductionDespite the increased spending on prenatal care and efforts to improve reproductive health care access for women, maternal mortality rates in the USA remain high, with persistent racial and socioeconomic disparities [1]. Several studies he provided data demonstrating the risks women of color undergo because of lesser healthcare access and quality. The USA has a significantly higher maternal mortality rate than other comparable countries. Approximately 700 women die in the USA each year because of pregnancy or its complications [1]. According to the Centers for Disease Control and Prevention (CDC), cardiomyopathy, thrombotic pulmonary embolism, and hypertensive disorders of pregnancy were among the key factors that contributed to a significantly higher proportion of pregnancy-related deaths among black women compared to white women [1].
Furthermore, it should also be noted that women of color he been reported to experience inequalities based on their age and level of education. As for the educational level, it has been reported that the pregnancy-related mortality rate for black women with a completed college education or higher is 1.6 times higher than the rate for white women with less than a high school diploma [1]. Therefore, these acts of discrimination in the healthcare sector are present and persist regardless of one’s educational level and socioeconomic status. Most of these deaths are preventable, which has been mentioned on several accounts. However, due to the racism, black women are more likely to die from complications of pregnancy than white women [2]. For instance, the risk of cardiomyopathy, leading cause of late maternal death, in black women is six times higher than in white women [3]. During a study carried out in 2007–2016, pregnancy-related deaths for all US women were reported to be 16.7 deaths per 100,000 live births. When taking a closer look at these numbers among different ethnic groups, the difference in the death rate among black women becomes noticeable. The deaths among white women were reported to be 12.7 deaths per 100,000 live births, while those among black women reached 40.8 deaths per 100,000 live births [1].
In addition, women with opioid use disorder (OUD) suffer from increased pregnancy complication risks. In fact, the number of pregnant women with OUD has increased four times in the past decade [4]. This can be explained by the fact that there has been a decrease in the administration of the OUD treatment in the general population because of shortages, insufficient insurance funds, stigma, and a general miscomprehension of the disorder [5,6]. However, when considering smaller and more specific racial/ethnic populations such as the black communities, it has been observed that there is less access to the OUD treatment, buprenorphine, than in white non-Hispanic, non-Black people, along with a less timely administration of the medication [7,8]. In parallel, OUD complications he not spared pregnant women, thus possibly contributing to this high maternal mortality rates [1]. These trends are especially noted in Maryland [4], thus, it is important to identify the drivers of adverse pregnancy outcomes to help inform policy and resource allocations.
This study aimed to identify and assess determinants of maternal mortality or miscarriage using inpatient discharge data from all Maryland hospitals between 2017 and 2019.
MethodsWe extracted data using a patient-level dataset ailable through the Hospital Data and Reporting system in Maryland [9]. The dataset contains discharge medical record abstract and billing data from all acute care hospitals and licensed specialty hospitals in the state. We identified 207,016 hospital admissions in Maryland for pregnant women ages 14–45 years from January 2017, through December 2019. We categorized our predictor variables under three main categories: comorbidities, clinical factors, and demographics. The primary outcome was maternal mortality or miscarriage. All diagnoses were identified through ICD-10 codes. To identify pregnant patients, we used ICD-10 codes Z34 and Z33.1. For comorbidities, we examined OUD (ICD-10 codes: F11.1 and F11.2), high-risk pregnancy (ICD-10 code: O09), preexisting hypertension (ICD-10 codes: O10–O16), and diabetes (O24). For clinical factors, we looked at the nature of admission such as delivery, scheduled, emergency and urgent, other type of admissions, and major hospital service to which patients were assigned, including psychiatric and other types of services. We examined age, race, patient residency in Maryland, and primary payer for demographic variables. Due to the very low prevalence of maternal mortality, we used a composite outcome of maternal mortality and miscarriage.
We performed a bivariate analysis on all predictor variables using logistic regression to explore any association between each characteristic and maternal mortality or miscarriage. Variables that showed a statistically significant association with the outcome, in addition to age as an important confounder, were selected as candidate variables for the multivariate analysis to detect risk factors of maternal mortality or miscarriage after adjusting for other covariates. P < 0.05 was considered to be statistically significant, and all statistical analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC).
ResultsBetween 2017 and 2019, out of 207,016 hospital admissions, there were 66,311 (32%) hospital admissions for black women and 3014 (1.46%) hospital admissions for women with OUD. About 16% of 207,016 hospital admissions were for women aged 35 years or older and 4% for women 14–19 years old (Table 1). There were 587 hospital admissions where pregnant women either died or had a miscarriage (28 per 10,000 hospital admissions).
Table 1.Hospital admissions by age group, race and opioid use disorder status
Demographic Hospital Admissions n (%)(N = 207016) Age 14–19 years old 8443 (4.1) 20–35 years old 164,309 (79.4) 35–45 years old 34,264 (17.5) Race White 91,381 (44.1) Black 66,311 (32) Asian 12,527 (6.1) Other 36,797 (17.8) Opioid Use Disorder (OUD) Status No 204,002 (98.5) Yes 3014 (1.5) Open in a new tabThe findings of the multivariate-adjusted model indicated that among comorbidities examined in this study, diabetes (OR = 0.42, 95%CI: 0.27–0.65), preexisting hypertension (OR = 0.30, 95%CI: 0.22–0.41), and OUD (OR = 2.61, 95%CI: 1.71–3.99) were significantly associated with maternal mortality or miscarriage. High-risk pregnancy was not associated with adverse maternal health outcomes (p = 0.23).
Patients with Medicaid insurance (OR = 0.82, 95%CI: 0.68–1) were at a higher risk of maternal mortality or miscarriage than those with commercial insurance. Moreover, we found that after controlling for residency status, nature of hospital admissions, major hospital service assigned, and comorbidities (high-risk pregnancy, hypertension, diabetes, and OUD) there were still substantial racial and age disparities in hospital admissions, with adverse pregnancy-related outcomes. Hospital admissions for Black women were more likely to result in maternal mortality and miscarriage (OR = 2.16, 95%CI: 1.76–2.65) than for White women. Likewise, advanced maternal age (35–45 years old) (OR = 1.79, 95%CI: 1.45–2.20) was associated with adverse outcomes (Table 2).
Table 2.Factors associated with maternal mortality and miscarriages among hospital admissions of pregnant women between 2017 and 2019
Variables Number (%) of visits with maternal mortality or miscarriage Univariate model Multivariable model Crude odds ratio (OR) (95%CI) p-value Adjusted odds ratio (OR) (95%CI) p-value Comorbidities Opioid use disorder No 562 (0.28%) 1 1 Yes 25 (0.83%) 3.03 (2.03–4.53)