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Dr. Eugene Declercq: "Maternal Mortality as a Public Health Challenge" 10.04.17

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Dr. Eugene Declercq's slides from the webinar "America's High Maternal Mortality and What Can Be Done

For info: https://www.centerforhealthjournalism.org/content/america%E2%80%99s-high-maternal-mortality-what-can-be-done

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Dr. Eugene Declercq: "Maternal Mortality as a Public Health Challenge" 10.04.17

  1. 1. Maternal Mortality as a Public Health Challenge Gene Declercq, PhD Community Health Sciences Dept. www.birthbythenumbers.org USC Health Journalism Webinar October 4, 2017
  2. 2. Definitions (in the U.S.) • Maternal Mortality Ratio – the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Typically reported as a ratio per 100,000 births. • Pregnancy Related Death – the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. • Pregnancy Associated Death – The death of a women while pregnant or within one year of termination of pregnancy, irrespective of cause. (WHO calls these “pregnancy related”)
  3. 3. Is there a problem in the U.S.?
  4. 4. Is there a problem in the U.S.? Yes
  5. 5. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 0 10 20 30 40 50 60 70 80 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 Source: NCHS. Deaths: Final Data. Annual Reports.
  6. 6. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 0 10 20 30 40 50 60 70 80 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 1951-1982 89% decline (75.0 to 7.9) Source: NCHS. Deaths: Final Data. Annual Reports.
  7. 7. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 0 10 20 30 40 50 60 70 80 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 1982-1998 Basically no change 7.9 to 7.1 Source: NCHS. Deaths: Final Data. Annual Reports.
  8. 8. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 0 10 20 30 40 50 60 70 80 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 1997-2007 78% increase (7.1 to 12.7) Source: NCHS. Deaths: Final Data. Annual Reports.
  9. 9. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 0 10 20 30 40 50 60 70 80 Note: The U.S. NCHS hasn’t reported and official maternal mortality rate since 2007 – Is there any more recent measure? ??? Source: NCHS. Deaths: Final Data. Annual Reports.
  10. 10. Pregnancy Related Mortality, U.S., 1987-2013 Source: CDC. Pregnancy Mortality Surveillance System https://www.cdc.gov/reproductivehealt h/maternalinfanthealth/pmss.html
  11. 11. Pregnancy Related Mortality, U.S., 1987-2013 Source: CDC. Pregnancy Mortality Surveillance System https://www.cdc.gov/reproductivehealt h/maternalinfanthealth/pmss.html NOTE: This isn’t a measure of maternal mortality and hence not comparable to other countries.
  12. 12. So can we compare the U.S. to other countries?
  13. 13. Estimated MMRs, 48 states* and DC, 2000-2014 0 5 10 15 20 25 30 2000 2005 2010 18.8 23.8 Rateper100,000livebirths 2014 *Excludes California and Texas. 27% increase 2000-2014 How might the U.S. compare internationally?
  14. 14. Maternal Mortality Ratios, OECD* Countries, 2014 0 5 10 15 20 25 United States^ Chile* Turkey New Zealand# Korea Austria Denmark* Estonia* United Kingdom Hungary Czech Republic Portugal* Canada# France* Belgium# Israel* Germany Slovak Republic Sweden Finland# Japan Norway Ireland Netherlands Switzerland* Italy# Spain Australia* Poland* Greece# Iceland Luxembourg Source: OECD Health Data 2016 * 2013 # 2012 ^U.S. from MacDorman et al. * Organization for Economic and Cooperation and Development
  15. 15. Using a more conservative estimate Adjusting the CDC Pregnancy Related Mortality data to reflect a maternal mortality rate Estimated for 2011-2013 (per 100,000 live births): •All women 14.8 • Non-Hispanic white women 11.3 • Non-Hispanic black women 36.2 • Hispanic women 10.0 • Black-white disparity 3.2
  16. 16. U.S. Maternal Mortality (per 100,000 live births), 1951-2007 by Race 0 50 100 150 200 250 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 All White Black
  17. 17. U.S. Maternal Mortality Ratio of Black to White Rates 1951-2007 0 1 2 3 4 5 6 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007
  18. 18. U.S. Infant & Maternal Mortality Black to White Ratios of 1980-2014 0 1 2 3 4 5 6 Infant Maternal Why is disparity greater for maternal mortality than infant mortality?
  19. 19. Using the more conservative measure in an international comparison Estimated for 2011-2013 (per 100,000 live births): All women 14.8 Non-Hispanic white women 11.3 Non-Hispanic black women 36.2 Hispanic women 10.0
  20. 20. U.S. MMR* Compared to Countries with 300,000+ births, 2014, using WHO Estimates 14.8 11 9 8 7 6 6 5 5 4 0 2 4 6 8 10 12 14 16 U.S. Korea U.K. France Canada Germany Australia Japan Spain Italy * Maternal Mortality per 100,000 births Source: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015.
  21. 21. U.S. MMR* Compared to Countries with 300,000+ births, 2014, using WHO Estimates 14.8 11.3 11 9 8 7 6 6 5 5 4 0 2 4 6 8 10 12 14 16 U.S. U.S. White Korea U.K. France Canada Germany Australia Japan Spain Italy * Maternal Mortality per 100,000 births Source: Maternal Mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, World Bank Group & UN Population Division. Geneva: 2015. If we limited the US ratio to white mothers (estimated 11.3) only, the U.S. would still rank behind all other countries including South Korea
  22. 22. Interracial Differences Hispanic 10.0 (Lithuania 10/Portugal 10) Where would estimated rates leave the U.S. in international comparisons?
  23. 23. Interracial Differences Hispanic 10.0 (Lithuania 10/Portugal 10) NH White 11.3 (Bulgaria 11/S. Korea 11) Where would estimated rates leave the U.S. in international comparisons?
  24. 24. Interracial Differences Hispanic 10.0 (Lithuania 10/Portugal 10) NH White 11.3 (Bulgaria 11/S. Korea 11) NH Black 36.2 (Uzbekistan 36/ Mexico 38) Where would estimated rates leave the U.S. in international comparisons?
  25. 25. So, by even a conservative standard the US fares poorly in international comparisons. What can be done?
  26. 26. Key is a combined clinical, public health and policy response. Dr. Main will describe the exceptional efforts underway to deal with the clinical challenges.
  27. 27. Why a public health response is also needed. Timing of Maternal Deaths 30.5% 16.8% 18.2% 21.3% 13.2% Before Delivery Day of Delivery 42-365 Days PPM 7-41 Days PPM 1-6 Days PPM Source: Creanga A et al. Pregnancy Related Mortality in the U.S., 2011-2013. Obstet & Gynec 2017.
  28. 28. Why a public health response is also needed. Timing of Maternal Deaths 30.5% 16.8% 18.2% 21.3% 13.2% Before Delivery Day of Delivery 42-365 Days PPM 7-41 Days PPM 1-6 Days PPM Source: Creanga A et al. Pregnancy Related Mortality in the U.S., 2011-2013. Obstet & Gynec 2017.
  29. 29. What’s the policy response needed? •Investment in the public health infrastructure so we can better determine just who is dying, when and how they are dying. • More importantly there needs to be an investment in ………
  30. 30. WOMEN’S HEALTH WHEN THEY ARE NOT PREGNANT Infant & Maternal Mortality Black to White Ratios of 1980-2014 0 1 2 3 4 5 6 Infant Maternal
  31. 31. Level of Coverage: Variation in Medicaid Eligibility by Pregnancy Status As of January, 2017 Medicaid Eligibility Pregnancy Parents Family of 3 U.S. Average 203% 107% Connecticut 263% 155% Maine 214% 105% Massachusetts 214% 138% New Hampshire 205% 138% Alabama 146% 18% California 213% 138% Florida 196% 33% Iowa 380% 138% New York 223% 138% Texas 203% 18% Source: Kaiser FF. https://www.kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/
  32. 32. Source: Daw J. Health Affairs 2017; 36:598-606 Note: Data is all pre-ACA Period covered by pregnancy related mortality Timing of Coverage
  33. 33. Maternal Mortality is the tip of the iceberg on women’s health. Maternal deaths account for about 1% of all deaths to women 15-49 in the U.S. The death rate for women 15-49 has not improved. Focusing only on pregnancy will not solve the problem of maternal mortality in the U.S.
  34. 34. FACEBOOK: www.facebook.com/BirthByTheNumbers Twitter: @BirthNumbers Email: birthbynumbers@gmail.com Slides will also be posted here.
  35. 35. Extra slides if there are questions
  36. 36. Death rates, by age, females: United States, 1955–2014 Number of female deaths, 15-49 in 2014 75,192. Maternal deaths = ~1% of all those. Source: NCHS. Deaths, Final Data for 2014

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