Changing the conversation: applying a health equity framework to maternal mortality reviews

Abstract

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Keywords: maternal death; maternal mortality; maternal mortality review committees; quality improvement.

FIGURE 1. US Pregnancy-related mortality ratios, United States, by race and Hispanic ethnicity, 2006–2013.

Pregnancy-related mortality ratios, United States, by race and Hispanic ethnicity, 2006–2013 Reproduced from Pregnancy Mortality Surveillance System, Centers for Disease Control and Prevention. NHW, non-Hispanic white; NHB, non-Hispanic black; AI/AN, American Indian/Alaska Native; API, Asian/Pacific Islander. Kramer. Health equity framework for maternal mortality. Am J Obstet Gynecol 2019.

FIGURE 2. Interstate variation in pregnancy-related mortality ratio, 2006–2013

Anonymized state-specific, pregnancy-related mortality ratios for 47 states and the District of Columbia. States with fewer than 10 pregnancy-related deaths between 2006 and 2013 were excluded. State-specific proportion of live births to black mothers is reflected in color gradient of points. Sensitivity analysis restricted to states adopting the pregnancy checkbox on death certificates prior to 2006 produced a similar pattern, with a 2.6-fold difference between highest and lowest state. Pregnancy-related mortality ratio was deaths per 100,000 births. Reproduced from Pregnancy Mortality Surveillance System, Centers for Disease Control and Prevention. Kramer. Health equity framework for maternal mortality. Am J Obstet Gynecol 2019.

FIGURE 3. Conceptual model for community determinants of maternal mortality

In this framework (adapted from Glass and McAtee), the pregnant woman is situated at the intersection of 2 dimensions. The horizontal dimension represents her life course social and health trajectory and recognizes that preconceptional health including accumulated and chronic psychosocial stress, prevalent chronic health conditions (such as diabetes, hypertensions, and heart disease), and adequate family planning all contribute to her health at conception, through pregnancy, and postpartum. The vertical dimension represents the multileveled causes of morbidity and mortality, ranging from biomedical conditions (such as cardiometabolic, neuroendocrine, and immune-inflammatory health), which are under the skin, up to the health service, transportation, and social support community environments. These environmental factors represent risk regulators, which constrain or influence individual behaviors, health access, exposures, and experiences. Overlaying these community environments are the fundamental social determinants of health including structural racism, segregation, and poverty concentration, which systematically determine differences between racial and economic subpopulations in life-course opportunities and exposures. Together these community and social environments may influence individual behaviors, and they may also be biologically embodied as suggested by the weathering hypothesis, which seeks to explain disparities in reproductive health as a function of the premature physiological aging of neuroendocrine and immune systems as a result of chronic and repetitive stress. Kramer. Health equity framework for maternal mortality. Am J Obstet Gynecol 2019.