Park Robin Y, Bilinski Alyssa, Parks Robbie M, Flaxman Seth
Department of Engineering, University of Oxford, Oxford, United Kingdom.
Departments of Health Services, Policy & Practice and Biostatistics, Brown University School of Public Health, Providence, Rhode Island.
JAMA Pediatr. 2025 Apr 28. doi: 10.1001/jamapediatrics.2025.0440.
Accurately measuring maternal mortality trends has been challenging due to changes in data collection. This work disambiguates trends from the effects of introducing the pregnancy checkbox on death certificates and also analyzes closely related fetal and infant mortality.
To describe trends in maternal, fetal, and infant deaths since 2000, including the impact of the COVID-19 pandemic.
DESIGN, SETTING, AND PARTICIPANTS: A national, population-level, epidemiological, cross-sectional analysis during 2000 to 2023 was conducted as well as a staggered difference-in-differences analysis on the pregnancy checkbox, using the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database on underlying causes of death in the US to identify maternal, infant, and fetal deaths. Study population was restricted to mothers aged 15 to 44 years for all definitions of maternal mortality.
Staggered introduction of the pregnancy checkbox on death certificates across different states.
Longitudinal study (2000-2023) reporting crude rates per 100 000 population for adjusted maternal mortality and per 1000 population for fetal and infant mortality at the national level and by US Census Bureau-designated main census regions, age groups, and race and ethnicity. Staggered difference-in-differences counterfactuals (1999-2023) on impact of pregnancy checkbox.
The introduction of the pregnancy checkbox was associated with 6.78 (95% CI, 1.47-12.09) deaths per 100 000 live births increase in reported maternal mortality, 66% (95% CI, 14%-117%) of the total increase from 2000 to 2019, with a smaller impact on maternal mortality excluding cause unspecified (adjusted maternal death rates). Adjusted maternal death rates remained consistently between 6.75 (95% CI, 5.97-7.61) to 10.24 (95% CI, 9.22-11.34) per 100 000 live births from 2000 until 2021, when it peaked at 18.86 (95% CI, 17.48-20.32); the rate dropped to 10.23 (95% CI, 9.22-11.32) in 2022. The death rates of Native American or Alaska Native women increased the most during the COVID-19 period, almost tripling from 2011 to 2019 (10.70 per 100 000 live births; 95% CI, 7.64-14.57) to the 2020 to 2022 period (27.47 per 100 000 live births; 95% CI, 18.39-39.45). The death rates of non-Hispanic Black women were highest across time-approximately triple the rate of non-Hispanic White women in each time period. Infant death rates per 1000 live births dropped from 6.93 (95% CI, 6.85-7.01) in 2000 to 5.44 (95% CI, 5.36-5.51) in 2020, increasing slightly to 2018 levels in 2021 to 2023. Fetal death rates per 1000 live births decreased from 6.28 (95% CI, 6.16-6.31) in 2005 to 5.53 (95% CI, 5.45-5.60) in 2022.
Using difference-in-differences analyses, results of this study reveal that the pregnancy checkbox explained much of the observed increase in maternal mortality before the COVID-19 pandemic. Nevertheless, results of this cross-sectional study suggest that, even adjusting for pregnancy checkbox effects, most groups saw increases from 2011 to 2019 to the 2020 to 2022 period, indicating that the COVID-19 pandemic led to worse outcomes. The findings demonstrate the relevance of public health emergencies to maternal health outcomes.
由于数据收集方式的变化，准确衡量孕产妇死亡率趋势一直具有挑战性。这项工作消除了引入死亡证明上的怀孕复选框对趋势的影响，并分析了密切相关的胎儿和婴儿死亡率。
描述2000年以来孕产妇、胎儿和婴儿死亡的趋势，包括COVID-19大流行的影响。
设计、背景和参与者：对2000年至2023年进行了一项全国性、人口水平的流行病学横断面分析，并对怀孕复选框进行了交错差分分析，使用美国疾病控制与预防中心的广泛在线流行病学研究数据（WONDER）数据库中美国潜在死因来识别孕产妇、婴儿和胎儿死亡。所有孕产妇死亡率定义的研究人群仅限于15至44岁的母亲。
不同州在死亡证明上交错引入怀孕复选框。
纵向研究（2000 - 2023年）报告全国层面以及按美国人口普查局指定的主要普查区域、年龄组、种族和族裔划分的每10万人口的调整后孕产妇死亡率以及每1000人口的胎儿和婴儿死亡率的粗率。对怀孕复选框影响的交错差分反事实分析（1999 - 2023年）。
引入怀孕复选框与报告的孕产妇死亡率每10万活产增加6.78例（95%可信区间，1.47 - 12.09）相关，占2000年至2019年总增加量的66%（95%可信区间，14% - 117%），对未指定原因的孕产妇死亡率（调整后的孕产妇死亡率）影响较小。从2000年到2021年，调整后的孕产妇死亡率始终保持在每1万活产6.75例（95%可信区间，5.97 - 7.61）至10.24例（95%可信区间，9.22 - 11.34）之间，2021年达到峰值18.86例（95%可信区间，17.48 - 20.32）；2022年降至10.23例（95%可信区间，9.22 - 11.32）。在COVID - 19期间，美国原住民或阿拉斯加原住民妇女的死亡率上升幅度最大，从2011年到2019年几乎增加了两倍（每10万活产10.70例；95%可信区间，7.64 - 14.57）到2020年至2022年期间（每10万活产27.47例；95%可信区间，18.39 - 39.45）。非西班牙裔黑人妇女的死亡率在各时间段均最高，约为每个时间段非西班牙裔白人妇女死亡率的三倍。每1000活产的婴儿死亡率从2000年的6.93例（95%可信区间，6.85 - 7.01）降至2020年的5.44例（95%可信区间，5.36 - 5.51），在2021年至2023年略有上升至2018年的水平。每1000活产的胎儿死亡率从2005年的6.28例（95%可信区间，6.16 - 6.3）降至2022年的5.53例（95%可信区间，5.45 - 5.6）。
使用差分分析，本研究结果表明，怀孕复选框解释了COVID - 19大流行之前观察到的孕产妇死亡率增加的大部分原因。然而，这项横断面研究的结果表明，即使调整了怀孕复选框的影响，大多数群体在2011年至2019年到2020年至2022年期间仍有所增加，这表明COVID - 19大流行导致了更糟糕的结果。研究结果证明了公共卫生紧急情况与孕产妇健康结果的相关性。
