The number of people in the US dying of pregnancy-related causes more than doubled over two decades, with Black, Native American, and Alaska Native people facing the highest risks, according to a new study in JAMA.

The US has the highest rate of maternal deaths compared to other high-income countries, despite spending far more on health care—both on a per-person and share of gross domestic product basis. And, while US maternal deaths have long been high, they’ve only gotten higher while other high-income countries have seen declines.

Still, digging into US maternal mortality data to understand the trend is difficult. States define maternal deaths differently, some have been slow to add a standard pregnancy-related question on death certificates, and some delay the release of their data.

In the new JAMA study, researchers tried to make up for those differences by modeling state-level trends in maternal mortality using national data, looking specifically at death rates by race and ethnicity for each year between 1999 and 2019. The research was led by Gregory Roth at the Institute for Health Metrics and Evaluation at the University of Washington.

The big picture findings of the study square with what we already know of maternal mortality in the US: it’s high and getting higher and particularly high for Black people in southern states. But, it also revealed widening disparities in specific states and ethnic groups that had not been previously highlighted.

Overall, the study noted that in 1999 there were an estimated 505 pregnancy-related deaths—defined as deaths related to pregnancy by medical coding that occur up to one year after the end of pregnancy. (Unintentional injuries, homicides, and suicides were excluded). By 2019, the number of pregnancy-related deaths more than doubled to 1,210. The maternal mortality rate (deaths per 100,000 live births) went from 12.7 in 2009 to 32.2 in 2019.

Trends

Among Black pregnant people, the nationwide mortality rate went from 31.4 to 67.7 in that time. For every year studied, the Black population had the highest state median for maternal mortality rate. Unsurprisingly, many of the states with the highest maternal mortality rates that got higher during the study period were in the South—but not all. New Jersey and Arizona were among the top five states that saw the largest increases in Black maternal mortality rates over the study period, along with Louisiana, Georgia, and Texas.

The American Indian and Alaska Native populations saw the largest increases in the median state mortality rates. Florida, Kansas, Illinois, Rhode Island, and Wisconsin all saw mortality rates in these populations increase by more than 162 percent during the study period. Asian maternal mortality rates, meanwhile, were high in Wyoming, Montana, and Nevada, which have high proportions of Filipino populations.

Hispanic and White populations saw lower maternal mortality rates than the other groups but still saw increases, particularly in the South and Northeast. The authors note that mental health is a leading factor in maternal deaths in these two groups, and because suicide and overdose deaths were excluded from the study, it may have masked some maternal death estimates in these groups.

Overall, the study paints a bleak picture of maternal health in the US. “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,” the authors concluded.

Moreover study period ended in 2019 before the CDC reported a pandemic-related spike in pregnancy-related deaths. Maternal morbidity and mortality are also expected to increase after the Supreme Court’s decision to overturn the constitutional right to abortion. Bans and restrictions that are now going into effect in roughly half of US states will limit abortion access and pregnancy care.

Editor’s Note: This post has been updated to correct the dates of the study.

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