Examining Disparities in Maternal Health

Maternal Health refers to a pregnant woman’s health and wellbeing before, during, and after pregnancy and encompasses aspects of physical, mental, emotional, and social health. Maternal health also includes the absence of maternal morbidity (health conditions that complicate pregnancy and childbirth or that have a negative impact on a person’s health and wellbeing), severe maternal morbidity (outcomes of labor and birth that result in significant negative short- or long-term consequences to a woman's health), and maternal mortality (the death of a woman directly related to complications of pregnancy, birth, or within 12 months of giving birth).

The disparities related to maternal health and mortality are likely related to patients’ ability (or inability) to access maternal care services. According to the March of Dimes, 1,117 counties in the United States (35.57%) lack access to any maternal care services, including hospitals and birth centers offering obstetric care or obstetric providers (OBs, OB/GYNs, or Certified Nurse Midwife [CNM]) per 10,000 birthday), and another 373 counties (11.88%) have low access to maternity care services (Figure 1; Bignance et al., 2022).

Figure 1 - America’s Maternity Care Deserts

Note - Data from Bignance et al., 2022. Dashboard available at: https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/march-of-dimes-maternity-care-deserts-dashboard.html

The United States has the worst maternal mortality rate out of any high-income country (Gunja, Gumas, & Williams, 2022). While maternal mortality rates in the United States have seen significant annual increases across all racial groups since 2018, when 658 women died at a rate of 17.4 deaths (per 100k live births), and peaking in 2021, when 1,205 women died at a rate of 32.9 (per 100k live births; Hoyert, 2023), recent data indicate that 817 women died in 2023, at a rate of 22.3. Maternal mortality rates decreased significantly among Black, White, and Hispanic Women, and decreased marginally for Asian Women (Hoyert, 2024). These decreases were seen across all age groups, as well.

Despite these decreases, Black Women continue to bear a disproportionate burden compared to their peers with a maternal mortality rate of 49.5 (per 100k live births) in 2022, compared to White Women (19.0), Hispanic Women (16.9), and Asian Women (13.2).

Older women continued to have the highest rates of maternal mortality, at 87.1, compared to 21.1 in women aged 25-39 and 14.4 in women younger than 25.

As we noted in 2023’s Disparities Statement, little research has been conducted to examine the correlational or causal relationship between income levels and maternal mortality. Somewhat paradoxically, women with higher incomes may be at risk of experiencing complications or mortality during pregnancy. This appears to be because women with higher levels of income are more likely than those with lower incomes to wait to attempt pregnancies until later in life, which increases the risk of complications and mortality, and are more likely to have multiple birth pregnancies, which may be the result of fertilization treatments used to get pregnant. Women with lower incomes are more likely to become pregnant much earlier in life, which may mean they have fewer complications and lower rates of infant or mother mortality.

What can be observed, however, is that Black families, regardless of their income levels, have worse infant and maternal health outcomes than the very poorest White families (Kennedy-Moulton et al., 2022).

Women living in the American South (i.e., Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee) experienced the highest rates of maternal mortality from 2018-2020, with Arkansas having the highest rate at 40.4, compared to the national rate of 20.4 (Figure 2; KFF, n.d.). However, data were suppressed for 20 states and the District of Columbia, painting an uneven picture of maternal mortality rates across the U.S.

Figure 2 - Maternal Mortality Rates by State, 2018-2020

Note - Data from KFF, n.d.

Considerations and Discussion: The Potential Impacts of the Dobbs Decision on Maternal Health Outcomes

While maternal mortality rates saw significant decreases from 2021 to 2022, it is unknown whether or not this decline will become a continuing trend, particularly due to the recent overturning of Roe v. Wade by the Supreme Court in 2022 in their Dobbs v. Jackson Women’s Health Organizations ruling. Since that time, several states have moved to severely limit or eliminate access to abortion services and medications. This has already resulted in obstetricians leaving those states, further worsening a field already beleaguered by a limited number of physicians and too many patients per physician (Weiner, 2023).

A qualitative study published in JAMA Network Open surveyed 54 OB-GYNs practicing under abortion bans in 13 states about their perceptions on the impacts on the OB-GYN field and patient outcomes (Sabbath, McKetchnie, Arora, & Buchbinder, 2024). Physicians raised concerns that these laws may result in delayed medically necessary care until patients were at risk of death or permanent impairment in order to comply with state laws. They were also concerned about what types of counseling they could provide without running afoul of those laws, and about their inability to provide care under the statutes without the risk of losing their licenses. 6 of surveyed OB-GYNs indicated that they had already relocated their practices out of their respective states and reopened in states with stronger abortion protections, while another 29 reported wanting to leave the state but being unable to do so due to personal ties. The OB-GYNs surveyed also reported that these laws were likely to make recruiting new physicians or students more difficult.

A prime example of this is the state of Idaho, where 21 of Idaho’s 44 counties (47.73%) are designated as Maternal Care Deserts (Bignance, et al., 2022). Since the passage of a near-total abortion ban in August 2022, the number of obstetricians decreased from 227 in 2022 to 176 in 2023 (Associated Press, 2024). In addition, three facilities in Idaho have closed their maternity services since August 2022—Bonner General Hospital (Campoamor, 2023), Valor Health Hospital (Tabachnick, 2023), and West Valley Medical Center (Moseley-Morris, 2024).

These closures and the loss of maternal health providers are not isolated to Idaho, nor does it appear that the issues of critical understaffing and new blood entering the field in states with abortion restrictions or bans will be abating any time soon. Moreover, because we are only two years past the Dobbs decision, it is difficult to definitively quantify how these state-level bans will impact maternal health outcomes.

Because many of the states who have already passed or are rushing to pass abortion restrictions are located in states where the majority of counties already have low- to no-access to maternal care services, these restrictions may make accessing maternal care even more difficult, should physicians continue to leave without applicants willing to risk their licenses by practices in legislatively hostile states. This may further exacerbate maternal mortality rates, particularly among Black Women living in Southern states.

PlusInc will continue to monitor disparities in maternal health outcomes.

Health Disparities Portfolio Expanded to Include More Chronic Health Conditions

In 2022, PlusInc launched its national campaign to raise awareness about health disparities among marginalized communities in the United States. Health Equity can only be achieved by addressing and changing the systemic institutional and societal barriers that result in health disparities. Initially, our health disparities portfolio focused on COVID-19, Escherichia coli Pyomyositis (ExPEC), HIV/AIDS, Mental Health, Respiratory Syncytial Virus (RSV), Substance Use Disorder (opioids, stimulants), and Viral Hepatitis (HBV, HCV). Next year, we will expand our reach into seven additional chronic health conditions to complement the work we’re already doing.

In 2023, PlusInc’s expanded health disparities portfolio will include:

1. Behavioral Health

2. Cancer - Colon

3. Cancer - Melanoma

4. Cardiovascular Disease

5. Maternal Health & Mortality

6. Respiratory - Asthma

7. Respiratory - Chronic Obstructive Pulmonary Disease (COPD)

The additions represent a broad array of the health issues long plaguing marginalized communities in the United States, as well as others emerging as incident rates increase and more data becomes available on them. For example, we have known for quite some time that poor maternal health outcomes disproportionately impact communities of color. According to the U.S. Centers for Disease Control & Prevention (CDC), black mothers are three times more likely than white mothers to die from maternal health complications, and many of them avoidable with better care. Additionally, a federal study on maternal deaths yielded a very troubling statistic: most (like, 90%) maternal deaths among Indigenous mothers were preventable. More troubling is pregnant mothers are now being threatened by a new trend in the United States, namely maternity care ‘deserts’ are on the rise.

But there are other deserts impacting quality healthcare. There are significant care gaps in behavioral health. Fortunately, there is a new behavioral health data mapping tool, which could remedy the problem. Change won’t happen unless such tools are accompanied by heightened awareness, additional resources, and better community outreach. PlusInc exists to help in this effort.

Moving forward into next year, PlusInc will build upon our momentum we started this year by not only taking a deeper dive into the health disparities surrounding these chronic health conditions, but also evaluating how they’re impacting local communities.