Abstract
Background:
The maternal mortality rate in the United States is high and disparities among non-Hispanic White and non-Hispanic Black women remain. In the State of Georgia, the pregnancy-related death rate is among the worst in the nation.
Objective:
To examine current pregnancy-related deaths in the State of Georgia using measures of timing and cause-specific mortality across maternal sociodemographic characteristics.
Design:
This cross-sectional study of pregnancy-related deaths in Georgia was based on 2016–2019 maternal mortality data obtained from the Georgia Department of Public Health.
Methods:
Our study analysis involved complete-case data of maternal deaths identified as pregnancy-related deaths (n = 129). Statistical analyses included two distinct population-level measures: (a) timing (i.e. during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum) and (b) cause-specific deaths patterned by sociodemographic groups of women and by rural and urban county of residence. Categorical variables were compared using the Chi square or Fisher’s exact test and presented as numbers and percentages. A post hoc power analysis was conducted to inform whether there was sufficient power to detect statistically significant effects given available sample sizes.
Results:
Among a total of 129 pregnancy-related deaths, 30 (23.3%) deaths occurred during pregnancy and 63 (48.8%) deaths occurred within the first 60 days postpartum. Pregnancy-related deaths were disproportionally common among non-Hispanic Black, 25 to 34 years old, and poorly educated women. Three leading underlying causes, cardiomyopathy (22.7%), hemorrhage (21.6%), and cardiovascular or coronary disease (20.4%), accounted for about 65% of all pregnancy-related deaths. Mental health conditions were common causes of death among non-Hispanic White women during pregnancy and in late postpartum.
Conclusion:
Continued monitoring, collecting and analyzing reliable data will help identify root causes and find ways to eliminate the disproportionate burden of pregnancy-related deaths in the State of Georgia.
Keywords: pregnancy-related death, State of Georgia, timing and causes of death
Introduction
Maternal mortality is one of the leading health indicators and identifying and reporting maternal deaths is well recognized. The maternal mortality rate in the United States is high (17.6 deaths per 100,000 births in 2019) 1 and the pregnancy-related death rate has been increasing over the past 2 to 3 decades. Almost 700 women die during pregnancy each year and nearly 65% of deaths occur within a year after giving birth. 2 A pregnancy-related death is defined as death of a woman that occurs during pregnancy or delivery and up to 365 days postpartum, resulting from complications initiated or aggravated by pregnancy. 2 The reasons for rising pregnancy-related death rates are unclear. However, enhanced surveillance in recent years, improvement in the identification of pregnancy-related deaths by adding a pregnancy checkbox to the revised 2003 death certificate, making changes in coding of causes of death, and linking maternal death records with birth and fetal death records produced by states, may have played a role. 3 Considerable inequities in timing and in cause-specific maternal mortality in the United States exist across race/ethnicity, socioeconomic status, and geographic location. For example, in a study of 6,765 pregnancy-related deaths in the United States between 2007 and 2016 (the overall rate of 16.7 deaths per 100,000 live births), the rate for non-Hispanic Black women was 3.2 times higher (40.8 deaths per 100,000 live births) than for non-Hispanic White women (12.7 deaths per 100,000 live births). 4 Cardiomyopathy, thrombotic pulmonary embolism, and hypertensive disorders of pregnancy were the leading causes of death contributing to a significantly higher proportion of pregnancy-related deaths among non-Hispanic Black women than among White women. 2
In 2021, the State of Georgia, after Louisiana, had the second highest maternal mortality rate in the United States of 66.3 deaths per 100,000 live births, which was about twice the national average of 32.9 deaths per 100,000 live births. 5 Georgia is a predominantly rural state. Out of 159 counties in Georgia, 108 counties are rural, 93 counties are “maternity care deserts” without a hospital labor and delivery unit, and 75 counties lack an obstetrician-gynecologist or a nurse midwife. 6 Georgia has the highest rate of rural hospital closures in the country. 7 Since 2010, among Georgia’s five hospital closures, four were critical access hospitals. 7 In Georgia, the preterm birth (PTB) rate is the seventh highest, the low birthweight (LBW) rate is the fourth highest, 6 and the cesarean section delivery rate is the ninth highest in the nation. 8 Delivering preterm out-of-hospital or in a hospital without an obstetric unit increases the risk of maternal and infant complications and the possibility of death. 6 In areas where maternity care deserts are prevalent, barriers in accessing quality prenatal and postnatal care prevent early detection, diagnosis, and treatment of conditions that may lead to unexpected short- or long-term consequences to a woman’s health. For instance, in 2013, among 79 maternal deaths and 32 pregnancy-related deaths in Georgia, 23 deaths had at least one preexisting medical condition such as hypertension, diabetes, or asthma and 17 deaths occurred among Medicaid recipients. 9 Among 25.1 deaths per 100,000 live births, non-Hispanic Black women were 2.3 times more likely to die from pregnancy-related causes than non-Hispanic White women. 10 Six hospitals in Georgia, located in Albany, Atlanta, Augusta, Columbus, Macon, and Savannah, were designated as Regional Perinatal Centers (RPCs) and supported by state and federal funding to provide advanced care for high-risk pregnancies. 11 However, these RPCs are located in large cities and are not easily accessible to women and their infants residing in remote rural areas.
The objective of this study was to provide comprehensive information regarding pregnancy-related deaths in the State of Georgia. To better understand the scope of the problem, we utilized 2016–2019 state-level maternal mortality data and applied two distinct population-level measures of timing and causes of death patterned by sociodemographic groups of women. Specifically, pregnancy-related deaths were assessed at four time-points, that is, during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum, and the leading underlying causes of death were examined according to frequency rank order across the four time-points of death. Our study findings were broadly discussed and compared for evidence with current reports and other relevant literature.
Methods
Data source and study design
Maternal mortality data (N = 349) from 2016 to 2019 were obtained from the Georgia Department of Public Health (DPH). 12 This was a cross-sectional study, and analyses were limited to data of pregnancy-related deaths (n = 129). We excluded data on pregnancy-associated but not related deaths or if pregnancy-relatedness could not be determined (n = 196), as well as deaths that were neither pregnancy-related nor pregnancy-associated (n = 20) (Figure 1). In the State of Georgia, all physicians, laboratories, and other health care providers are required by law to report within 7 days the death of a woman who was pregnant or within a year of the end of pregnancy, by filling out a certificate of death. The 2003 revision of the U.S. Standard Certificate of Death that was implemented in all 50 U.S. states by 2018 includes a checkbox to specify recent pregnancy.3,13 The reports submitted to the Georgia DPH are reviewed within two years of the date of death by the Maternal Mortality Committee (MMRC), a multidisciplinary committee at the state level.9,10 The MMRC determines whether deaths are indeed pregnancy-related and the causes of death are assigned specific code numbers (e.g. A34, O00–O95, and O98–O99) in accordance with the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10). 14 In addition, interviews with family members are conducted by the MMRC staff to learn more about the circumstances surrounding the death and whether death could have been prevented. Georgia DPH datasets are deidentified and available to researchers upon request. This study was reviewed by the Mercer University Institutional Review Board (IRB) (the IRB number is H2208186) and deemed exempt from further review. We also followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (Supplementary Table S1). 15
Figure 1.
Flow chart of the study population.
Measures
Timing and causes of pregnancy-related deaths
Pregnancy-related deaths were assessed at four time-points, that is, during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum. Because health services for pregnant women under Georgia Medicaid are covered up to 60 days postpartum, the Georgia DPH classifies timing of death as 0 to 60 days and not 0 to 42 days of the end of pregnancy. 2 Another measure of pregnancy-related death included leading underlying causes of death selected according to frequency rank order, that is, cardiomyopathy, hemorrhage, cardiovascular or coronary conditions, venous thromboembolism, mental health conditions, and preeclampsia or eclampsia.
Other variables
Basic sociodemographic characteristics associated with maternal morbidity and mortality were used in prior research.2,4,16 Race and ethnicity were categorized as non-Hispanic White, non-Hispanic Black race, other races (i.e. Asian, Pacific Islander, Alaskan native), multiracial, and Hispanic ethnicity; age was categorized as less than 25 years old, 25 to 34 years old, and 35 years old or older; education was categorized as less than high school, high school/GED, and some college or higher; urban and rural counties of residence were defined by the Federal Office of Rural Health Policy (FORHP) 17 and captured in the MMRCs classification.
Statistical analyses
SAS software version 9.4 (SAS Institute Inc., Cary, NC, USA) was used in all statistical analyses. The level of significance was set at α = 0.05. The pregnancy-related maternal mortality ratio in Georgia during 2016–2019 was calculated by dividing the number of pregnancy-related deaths (n = 129) by the total number of live births (N = 511,399) and multiplying it by 100,000 live births. Descriptive analyses compared the timing and leading underlying causes of pregnancy-related death with basic maternal sociodemographic characteristics. Categorical variables were compared using the Chi-square or Fisher’s exact test and presented as numbers and percentages. For more evidence, the distribution of causes of death was performed across four time-points of death (i.e. during pregnancy, 0 to 60 days, 61 to 180 days, and 181 to 365 days postpartum) according to maternal sociodemographic characteristics and urban/rural county of residence. In addition, a post hoc power analysis was conducted for each significant result using Python software version 3.12 (Python Software Foundation) to inform whether there was sufficient power to detect statistically significant effects given available sample sizes. The proportion of missing data was small and included race/ethnicity (0.9%), age (1.2%), education (2.6%), and urban/rural county of residence (1.2%). Complete-case data of pregnancy-related deaths were used in final analyses.
Results
In Georgia during 2016–2019, the pregnancy-related mortality ratio was 25.2 deaths per 100,000 live births. Among a total of 129 pregnancy-related deaths, 30 deaths (23.3%) occurred during pregnancy and 63 deaths (48.8%) occurred within the first 60 days of the end of pregnancy (Table 1; Figure 2). Overall, non-Hispanic Black women (56.6%) were almost twice as likely to die during pregnancy or within a year of the end of pregnancy than non-Hispanic White women (30.2%), and women who died were commonly 25 to 34 years old (46.5%) and with less than a high school education (57.4%) (Table 1). Among the six leading underlying causes of death (i.e. cardiomyopathy, hemorrhage, cardiovascular or coronary conditions, mental health conditions, venous thromboembolism, and preeclampsia or eclampsia) (Table 2), three causes, that is, cardiomyopathy, hemorrhage, and cardiovascular or coronary conditions, contributed about 65% to all pregnancy-related deaths followed by mental health conditions (14.8%), venous thromboembolism (11.4%), and preeclampsia or eclampsia (9.1%) (Table 3). Cardiovascular or coronary conditions were leading causes of death among non-Hispanic Black women and hemorrhage was a leading cause of death among both non-Hispanic Black and non-Hispanic White women. Preeclampsia or eclampsia were leading causes of death among non-Hispanic Black women, and mental health conditions among non-Hispanic White women and among women residing in urban counties. During pregnancy, women died commonly from venous thromboembolism (40.0%), hemorrhage (31.6%), cardiomyopathy (25.0%) and preeclampsia or eclampsia (25.0%) (Table 4; Figure 3). In the first 60 days postpartum, deaths frequently occurred from hemorrhage (63.1%) and cardiovascular or coronary conditions (44.5%). During 61 to 180 days, deaths occurred mostly from cardiovascular or coronary conditions (33.3%) and mental health conditions (38.4%), and during 181 to 365 days postpartum from cardiomyopathy (20.0%) and mental health conditions (23.1%; p < 0.05) (Table 4; Figure 3). There were more pregnancy-related deaths among non-Hispanic Black women in urban than in rural counties. In urban counties, non-Hispanic Black women commonly died from cardiomyopathy (28.2%), cardiovascular or coronary conditions (30.8%), and hemorrhage (15.4%), followed by venous thromboembolism (12.8%) and preeclampsia/eclampsia (12.8%), whereas non-Hispanic White women died from mental health conditions (39.1%; p < 0.05) (Table 5). In rural counties, cardiomyopathy was the leading underlying cause of death among both non-Hispanic White (57.1%) and non-Hispanic Black women (40.0%). Detailed information is presented in Tables 1–5. In a post hoc power analysis Supplementary (Table S2), the highest power across all effect sizes was detected for less than high school education categories, which remained robust even when the effect sizes decreased. The non-Hispanic Black race had high power across all effect sizes and the non-Hispanic White race had sufficient power that declined as the effect sizes decreased. For other races and Hispanic ethnicity groups of women, power was considerably low across all effect sizes. For mental health conditions, power was also low across all effect sizes due to a small sample size.
Table 1.
Timing of pregnancy-related death, State of Georgia (2016–2019).
| Characteristics | Total | During pregnancy | 0 to 60 days postpartum | 61 to 180 days postpartum | 181 to 365 days postpartum | p-value |
|---|---|---|---|---|---|---|
| Overall N (%) | 129 (100) | 30 (23.3) | 63 (48.8) | 22 (17.0) | 14 (10.9) | |
| Race/ethnicity | 0.354 | |||||
| Non-Hispanic Black | 73 (56.6) | 19 (26.1) | 32 (43.8) | 13 (17.8) | 9 (12.3) | |
| Non-Hispanic White | 39 (30.2) | 9 (23.1) | 21 (53.8) | 7 (18.0) | 2 (5.1) | |
| Hispanic | 8 (6.2) | 2 (25.0) | 3 (37.5) | 1 (12.5) | 2 (25.0) | |
| Other a | 9 (7.0) | 0 (0.0) | 7 (77.8) | 1 (11.1) | 1 (11.1) | |
| Age, years | 0.397 | |||||
| <25 | 28 (21.7) | 11 (39.3) | 12 (42.9) | 3 (10.7) | 2 (7.1) | |
| 25–34 | 60 (46.5) | 12 (20.0) | 29 (48.3) | 13 (21.7) | 6 (10.0) | |
| ⩾35 | 41 (31.8) | 7 (17.1) | 22 (53.7) | 6 (14.6) | 6 (14.6) | |
| Education | 0.032 | |||||
| Less than high school | 74 (57.4) | 21 (28.4) | 31 (41.9) | 16 (21.6) | 6 (8.1) | |
| High school/GED | 28 (21.7) | 5 (17.9) | 12 (42.8) | 5 (17.9) | 6 (21.4) | |
| Some college or higher | 27 (20.9) | 4 (14.8) | 20 (74.1) | 1 (3.7) | 2 (7.4) | |
| County of residence | 0.532 | |||||
| Rural | 24 (18.6) | 6 (25.0) | 9 (37.5) | 7 (29.2) | 2 (8.3) | |
| Urban | 105 (81.4) | 24 (22.9) | 54 (51.4) | 15 (14.3) | 12 (11.4) | |
Other: non-Hispanic Asian, American Indian Alaska Native, Native Hawaiian, Pacific Islander, multiracial.
Figure 2.
Percentage of pregnancy-related death by race and ethnicity at four time-points, State of Georgia (2016–2019).
Table 2.
Causes of pregnancy-related death, State of Georgia (2016–2019).
| All causes | Total 129 (100%) |
|---|---|
| Amniotic fluid embolism | 6 (4.6) |
| Autoimmune diseases | 1 (0.8) |
| Blood disorders | 1 (0.8) |
| Cardiomyopathy a | 20 (15.5) |
| Cardiovascular/Coronary a | 18 (14.0) |
| Cerebrovascular accidents | 5 (3.9) |
| Hemorrhage a | 19 (14.7) |
| Homicide | 2 (1.5) |
| Infection/sepsis | 7 (5.4) |
| Liver/Gastrointestinal | 1 (0.8) |
| Malignancies | 2 (1.5) |
| Mental Health a | 13 (10.1) |
| Metabolic/endocrine | 1 (0.8) |
| Preeclampsia/eclampsia a | 8 (6.2) |
| Pulmonary conditions | 4 (3.1) |
| Renal diseases | 1 (0.8) |
| Seizure Disorders | 4 (3.1) |
| Unintentional Injury | 1 (0.8) |
| Venous thromboembolism a | 10 (7.7) |
| Other/unknown | 5 (3.9) |
Leading underlying causes of pregnancy-related death.
Table 3.
Leading underlying causes of pregnancy-related death across sociodemographic characteristics.
| Characteristics | Total | Cardio- myopathy |
Hemorrhage | Cardio-vascular/ Coronary | Mental health | Venous thrombo-embolism | Pre-eclampsia/ eclampsia | p-value |
|---|---|---|---|---|---|---|---|---|
| Overall n (%) | 88 (100) | 20 (22.7) | 19 (21.6) | 18 (20.4) | 13 (14.8) | 10 (11.4) | 8 (9.1) | |
| Race/ethnicity | 0.001 | |||||||
| Non-Hispanic Black | 49 (55.7) | 15 (75.0) | 7 (36.8) | 13 (72.2) | 0 (0.0) | 7 (70.0) | 7 (87.5) | |
| Non-Hispanic White | 30 (34.1) | 5 (25.0) | 7 (36.8) | 4 (22.2) | 10 (76.9) | 3 (30.0) | 1 (12.5) | |
| Hispanic | 3 (3.4) | 0 (0.0) | 1 (5.3) | 0 (0.0) | 2 (15.4) | 0 (0.0) | 0 (0.0) | |
| Other a | 6 (6.8) | 0 (0.0) | 4 (21.1) | 1 (5.6) | 1 (7.7) | 0 (0.0) | 0 (0.0) | |
| Age, years | 0.512 | |||||||
| <25 | 19 (21.6) | 3 (15.0) | 2 (10.5) | 4 (22.2) | 4 (30.8) | 5 (50.0) | 1 (12.5) | |
| 25–34 | 41 (46.6) | 8 (40.0) | 10 (52.6) | 9 (50.0) | 7 (53.8) | 3 (30.0) | 4 (50.0) | |
| ⩾35 | 28 (31.8) | 9 (45.0) | 7 (36.9) | 5 (27.8) | 2 (15.4) | 2 (20.0) | 3 (37.5) | |
| Education | 0.549 | |||||||
| Less than high school | 50 (56.8) | 14 (70.0) | 11 (57.9) | 10 (55.5) | 7 (53.8) | 4 (40.0) | 4 (50.0) | |
| High school/GED | 19 (21.6) | 4 (20.0) | 2 (10.5) | 3 (16.7) | 4 (30.8) | 4 (40.0) | 2 (25.0) | |
| Some college or higher | 19 (21.6) | 2 (10.0) | 6 (31.6) | 5 (27.8) | 2 (15.4) | 2 (40.0) | 2 (25.0) | |
| County of residence | 0.127 | |||||||
| Rural | 18 (20.5) | 8 (40.0) | 4 (21.0) | 1 (5.6) | 1 (7.7) | 2 (20.0) | 2 (25.0) | |
| Urban | 70 (79.5) | 12 (60.0) | 15 (79.0) | 17 (94.4) | 12 (92.3) | 8 (80.0) | 6 (75.0) | |
Other: non-Hispanic Asian, American Indian Alaska Native, Native Hawaiian, Pacific Islander, multiracial.
Table 4.
Leading underlying causes of pregnancy-related death at four time-points.
| Causes | Total | During pregnancy | 0 to 60 days postpartum | 61 to 180 days postpartum | 181 to 365 days postpartum | p-value |
|---|---|---|---|---|---|---|
| Overall n (%) | 88 (100%) | 23 (26.1%) | 38 (43.2%) | 19 (21.6%) | 8 (9.1%) | |
| Cardiomyopathy | 20 (22.7) | 5 (25.0) | 6 (30.0) | 5 (25.0) | 4 (20.0) | 0.169 |
| Hemorrhage | 19 (21.6) | 6 (31.6) | 12 (63.1) | 1 (5.3) | 0 (0.0) | 0.129 |
| Cardiovascular/Coronary | 18 (20.5) | 3 (16.7) | 8 (44.5) | 6 (33.3) | 1 (5.5) | 0.288 |
| Mental health | 13 (14.8) | 3 (23.1) | 2 (15.4) | 5 (38.4) | 3 (23.1) | 0.012 |
| Venous thromboembolism | 10 (11.3) | 4 (40.0) | 4 (40.0) | 2 (20.0) | 0 (0.0) | 0.476 |
| Preeclampsia/eclampsia | 8 (9.1) | 2 (25.0) | 6 (75.0) | 0 (0.0) | 0 (0.0) | 0.497 |
Figure 3.
Percentage of leading underlying causes of pregnancy-related death at four time-points, State of Georgia (2016–2019).
Table 5.
Leading underlying causes of pregnancy-related death by urban and rural county of residence.
| Causes | Urban n = 62 |
p-value | Rural n = 17 |
p-value | ||
|---|---|---|---|---|---|---|
| NH Black 39 (63.0%) |
NH White 23 (37.0%) |
NH Black 10 (58.8%) |
NH White 7 (41.2%) |
|||
| Cardiomyopathy | 11 (28.2) | 1 (4.4) | 0.023 | 4 (40.0) | 4 (57.1) | 0.637 |
| Hemorrhage | 6 (15.4) | 5 (21.7) | 0.732 | 1 (10.0) | 2 (28.6) | 0.536 |
| Cardiovascular/Coronary | 12 (30.8) | 4 (17.4) | 0.244 | 1 (10.0) | 0 (0.0) | 1.000 |
| Mental health | 0 (0.0) | 9 (39.1) | < .001 | 0 (0.0) | 1 (14.3) | 0.411 |
| Venous thromboembolism | 5 (12.8) | 3 (13.0) | 0.979 | 2 (20.0) | 0 (0.0) | 0.485 |
| Preeclampsia/eclampsia | 5 (12.8) | 1 (4.4) | 0.398 | 2 (20.0) | 0 (0.0) | 0.485 |
NH: non-Hispanic.
Discussion
Principal findings
Our study findings add to the existing evidence that the burden of pregnancy-related maternal mortality in the State of Georgia is substantial. Analyses from this study indicate that in Georgia during 2016–2019, pregnancy-related deaths contributed about 37% to all maternal pregnancy-associated mortality. Approximately a quarter of pregnancy-related deaths occurred during pregnancy and nearly half occurred within the first 60 days postpartum. Disparities in pregnancy-related deaths were observed across all sociodemographic groups of women and urban/rural counties of residence. Non-Hispanic Black women had two-fold higher rates of death than non-Hispanic White women, and almost half of deaths occurred among 25–34-year-old and less educated women. Non-Hispanic Black women commonly died from cardiomyopathy, cardiovascular or coronary conditions, and hemorrhage, whereas non-Hispanic White women died from mental health conditions. The pregnancy-related death rate was higher in urban than in rural counties, where more than half of deaths occurred among non-Hispanic Black women. According to a recent study, 18 mortality rates in rural counties are rising with increasing rurality and with a change in distribution of population by race/ethnicity and age. There are major challenges and barriers that prevent women in Georgia from achieving good health and continuum of maternity care from preconception throughout pregnancy and into postpartum.
Findings in context of the existing literature
Findings from this study are consistent with MMRC reports (2008–2017) from 14 U.S. States 19 and from 36 U.S. States (2017–2019) 20 that included data from the State of Georgia, as well as with the 2018–2020 Georgia DPH MMRC report. 21 The 2018–2020 MMRC report shows over a 2-fold higher maternal mortality rate (48.6 deaths per 100,000 live births) for non-Hispanic Black women in Georgia than for non-Hispanic White women (22.7 deaths per 100,000 live births). 21 Notably, during that period of time, pregnancy-related deaths attributed to hemorrhage, mental health conditions, cardiomyopathy, cardiovascular/coronary conditions, and preeclampsia or eclampsia were determined preventable by the MMRC, and 83% of deaths attributed to thromboembolism were determined potentially preventable. 21 Maternal deaths are considered preventable or avoidable if the MMRC determined that there was at least some chance of death being averted by making one or more reasonable changes to patient, family, provider, facility, system, and/or community factors.21,22
The cost of maternal morbidity and mortality in the United States is billions of dollars annually. 23 Apart from 700 women who die each year from pregnancy-related complications, 60,000 women in the United States suffer serious morbidity, such as hemorrhage, infection, gestational hypertension, gestational diabetes, heart failure, or organ failure. 24 Among a total of nearly 4 million births each year in the United States, more than 12% of births occur in “maternity care deserts” with limited access to maternity care. 25 About half of women do not receive postpartum care after a pregnancy complicated by gestational diabetes or gestational hypertension. 26 Prior studies27,28 reported an independent association between non-availability of health care services, neighborhood deprivation, and disparities in maternal health, after adjusting for individual-level risk factors. The risk of dying from preeclampsia or eclampsia is about five times greater for non-Hispanic Black women (3.93 deaths per 100,000 live births) than for non-Hispanic White women (0.78 deaths per 100,000 live births). 29 Preeclampsia can continue into the postpartum period and in association with hypertension and diabetes mellitus, 30 venous thromboembolism, 31 and hemorrhage 32 can increase maternal risk of future cardiovascular disease. 33 PTB and LBW deliveries are common and recurrent among non-Hispanic Black women in Georgia. 34 These adverse birth outcomes are found to be independently predictive of peripartum cardiomyopathy. 34 Perinatal depression is highly prevalent and associated with negative birth and neonatal outcomes. 35 One in seven women in the United States experience symptoms of depression during pregnancy or in the first year after giving birth. 35 In our study, mental health conditions were associated with a large overall proportion of pregnancy-related deaths (nearly 15%), mostly among non-Hispanic White women. Although mental health services are covered by Medicaid benefits, accessing mental health care is a challenge because of the shortage of providers. According to the Health Resources and Services Administration (HRSA), 61% of areas with mental health professional shortages are rural or partially rural. 36 About 68% of pregnancy-related postpartum deaths occur among Medicaid receipients. 28 Medicaid insurance in Georgia covers nearly half of all pregnancies for low income, rural, and minority racial populations; however, benefits usually expire 2 months after giving birth. 37 Maternal morbidity and mortality rates are about three times higher for women who had cesarean section deliveries rather than vaginal deliveries. 8 Non-Hispanic Black women in Georgia have disproportionately high cesarean section delivery rates. 8 Evidence from previous research shows no further decline in the pregnancy-related maternal mortality over time and that not much progress in preventability has been made within the last decade. Racial/ethnic disparities in maternal death remain persistently high and disparities in causes of death have a differential impact on the health of women and their pregnancies.
What could be done to decrease leading underlying causes of pregnancy-related death?
Reducing maternal deaths are high public health priorities and core objectives of Healthy People 2030. 38 Various factors contribute to adverse maternal health outcomes, ranging from individual-level factors to health system-level factors. Missed opportunities to identify risk factors and treat morbidities (e.g. hypertensive disorders, diabetes, anemia, mood disorders) during prenatal care, in pregnancy, and postpartum, are common barriers in reducing pregnancy-related deaths. Assessment of risk factors may often require involvement of a multidisciplinary team of obstetricians, internists, hematologists, and neonatologists. For example, deaths from hemorrhage could be prevented by identifying high-risk pregnancies, access to skilled providers who can actively manage the third stage of labor using a prophylactic uterotonic agents to reduce blood loss, and who could manage potential placental problems (e.g. placenta accreta, placenta previa, placental abruption, or retained placenta) to prevent early/late postpartum hemorrhage. 39 According to the American College of Obstetricians and Gynecologists (ACOG), 40 mortality from cardiomyopathy and cardiovascular or coronary conditions could be prevented by pre-pregnancy counseling of women with preexisting or new onset acquired heart disease, postpartum follow-up care, and increasing awareness of cardiovascular causes of mortality among health providers. Routine screening for depression, anxiety, and mood disorders during pregnancy and postpartum, and access to mental health care can prevent maternal deaths.41,42 Venous thromboembolism (VTE) can be a serious pregnancy complication in mothers with obesity, of advanced age (>40 years), multiple gestations, and cesarean section delivery. 43 Recognizing risk factors and early interventions can prevent health consequences and recurrence of VTE. 44 Preeclampsia/eclampsia could be prevented by screening for high blood pressure, for symptoms of headache, dizziness, and rapid weight gain. 45 Simulation programs for obstetricians and gynecologists working in rural environments constrained by deficiencies will provide guidance on how to minimize the risks by stabilizing patients before transferring them to a facility that has an advanced level of care.46,47 Addressing disparities in pregnancy-related deaths requires integration of social needs in context of hospital, community and system levels, combined with public health efforts supported by local, state, and federal government. 48
Georgia MMRC reports include recommendations for reducing disparities in mortality that prioritize strategies directed toward disproportionately impacted populations. 49 The MMRC recommends case management by health providers and hospitals for high-risk women during pregnancy and postpartum; screening for perinatal mood and anxiety disorders at the first prenatal visit, in each trimester of pregnancy, and at the postpartum visit according to the American College of Obstetricians and Gynecologists (ACOG) guidelines; 50 and pre-pregnancy education and counseling to all reproductive age women focusing on modifiable risk factors, maintaining a healthy pregnancy, and family planning. 51 The MMRC reports are shared with stakeholders, such as hospitals, state and local policy-makers, and health care providers to help implement system and/or policy changes.
One of the ongoing efforts to improve maternal health in Georgia, following the MMRC recommendation, was a recently introduced extension of Medicaid coverage for eligible women until 1-year after giving birth, 37 which passed during the 2021–2022 state legislative session. Additional funds are being allocated to provide support for rural hospitals and for maternal quality improvement initiatives.
A main strength of our study was availability of State of Georgia maternal mortality data with a sufficient number of variables to analyze pregnancy-related deaths. Nevertheless, there are some limitations that should be acknowledged. First, differences in reporting and verification of pregnancy status 13 may have resulted in underestimation or overestimation of pregnancy-related deaths. Second, information was not available regarding a specific Georgia county of residence, any care provided in the Regional Perinatal Centers, as well as nature and treatment of mental health conditions (e.g. mood/anxiety disorders, depression, postpartum psychosis, risk of suicide). Data used in this study were collected before the COVID-19 pandemic and before Georgia passed an extension of Medicaid coverage for postpartum women, 37 and it is not known how these relationships may have changed the findings. Third, our findings are representative of the population of the State of Georgia and may not be generalizable to other states. Fourth, small sample sizes in certain categories had limited statistical power to provide significant estimates. In a post hoc power analysis, insufficient power to detect small to moderate effect sizes of mental health impact was a substantial limitation. Finally, a subsequent study should examine in greater detail any treatable and preventable causes of avoidable maternal death. Despite limitations, findings from our study add to the existing evidence that too many women in Georgia die from pregnancy-related causes.
Conclusion
Findings from this study will raise public awareness on the burden of pregnancy-related mortality and morbidity among reproductive age women in Georgia, inform health care providers, hospitals and state and local policy-makers to help implement needed system or policy changes. This study may prompt an interest in expanding an operative partnership between hospitals in Georgia and existing Regional Perinatal Centers and convince policy makers to prevent or reduce closures of hospitals and labor/delivery units. This research will also bring into the spotlight the need for strengthening surveillance efforts, particularly in rural areas where data are limited, and actively involve public health in documenting, collecting, and improving availability of quality maternal mortality data. Continued evidence coming from the analysis of accurately collected data will help understand the health care environment in which maternal deaths occur and to pilot interventions in the State of Georgia and in other areas across the Deep South identified as “maternity care deserts.”
Supplemental Material
Supplemental material, sj-docx-1-whe-10.1177_17455057241267103 for Pregnancy-related maternal mortality in the state of Georgia: Timing and causes of death by Anthony J Kondracki, Wei Li, Manouchehr Mokhtari, Bhuvaneshwari Muchandi, John A Ashby and Jennifer L Barkin in Women’s Health
Acknowledgments
The authors would like to thank the Georgia Department of Public Health staff and the Georgia Maternal Mortality Review Committee data collectors and reviewers. We would also like to thank the Journal Editors and anonymous reviewers for constructive suggestions on how to improve the quality of our original manuscript.
Footnotes
ORCID iD: Anthony J Kondracki 
https://orcid.org/0000-0002-7328-0248
Supplemental material: Supplemental material for this article is available online.
Declarations
Ethics approval and consent to participate: This secondary analysis of deidentified data was reviewed by the Mercer University Institutional Review Board (IRB) (the IRB number is H2208186) and was deemed exempt from further review. A waiver of consent was granted based on the following criteria: the authors were not collecting or maintaining the source material, there was no interaction with any individual, and our research involved data provided by a research repository (i.e. Georgia Department of Public Health) responsible for removing any identifiers or codes linked to identifiers prior to providing dataset to researchers.
Consent for publication: Not applicable.
Author contribution(s): Anthony J Kondracki: Conceptualization; Methodology; Formal analysis; Writing—original draft; Writing—review & editing.
Wei Li: Writing—review & editing; Formal analysis.
Manouchehr Mokhtari: Formal analysis; Writing—review & editing.
Bhuvaneshwari Muchandi: Resources.
John A Ashby: Resources.
Jennifer L Barkin: Writing—review & editing.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the publication of this article was provided by a Mercer University Provost Office Seed Grant awarded to Dr. Anthony J Kondracki.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Availability of data and materials: The original dataset used in this study can be obtained by researchers upon request from the Georgia Department of Public Health.
References
- 1. World Population Review. Maternal mortality rate by country, https://worldpopulationreview.com/country-rankings/maternal-mortality-rate-by-country (2023, accessed 18 December 2023).
- 2. Centers for Disease Control and Prevention (CDC). Pregnancy mortality surveillance system maternal mortality prevention, https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm (2023, accessed 15 December 2023).
- 3. Rossen LM, Womack LS, Hoyert DL, et al. The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. Vital Health Stat 3 2020(44): 1–61. [PubMed] [Google Scholar]
- 4. Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep 2019; 68(35): 762–765. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. World Population Review. Maternal mortality rate by state, https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state (2023, accessed 18 December 2023).
- 6. Nelson GD. The two Georgia’s: disparities in rural health and healthcare. J Georgia Public Health Assoc 2016; 5(4): 294–296. [Google Scholar]
- 7. Bastain RG, Garner M, Barron JS, et al. Georgia’s rural hospital closures: the common-good approach to ethical decision-making. J Georgia Public Health Assoc 2016; 5(4): 297–303. [Google Scholar]
- 8. Ibrahim BB, Vedam S, Illuzzi J, et al. Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean. PLoS ONE 2022; 17(9): e0274790. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Georgia Department of Public Health. Reducing maternal mortality in Georgia, https://dph.georgia.gov/document/publication/maternal-mortality-2013-case-review/download (2023, accessed 10 December 2023).
- 10. Georgia Department of Public Health. Georgia: Maternal mortality, https://dph.georgia.gov/document/document/maternal-mortality-factsheet-2015-2017-data/download (2023, accessed 10 December 2023).
- 11. Georgia Department of Public Health. Regional perinatal centers, https://dph.georgia.gov/RPC (2023, accessed 18 December 2023).
- 12. Georgia Department of Public Health. Vital records, https://dph.georgia.gov/VitalRecords (2023, accessed 18 December 2023).
- 13. Hoyert DL, Miniño AM. Maternal mortality in the United States: changes in coding, publication, and data release, 2018. Natl Vital Stat Rep 2020; 69(2): 1–18. [PubMed] [Google Scholar]
- 14. World Health Organization (WHO). International statistical classification of diseases and related health problems, ICD-10. Genève: World Health Organization, 2015. [Google Scholar]
- 15. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014; 12(12): 1495–1499. [DOI] [PubMed] [Google Scholar]
- 16. Kondracki AJ, Reddick B, Smith BE, et al. Sociodemographic disparities in preterm birth and low birthweight in the State of Georgia: results from the 2017–2018 Pregnancy risk assessment monitoring system. J Rural Health 2023; 39(1): 91–104. [DOI] [PubMed] [Google Scholar]
- 17. Health Resources Services Administration (HRSA). Defining rural population, https://www.hrsa.gov/rural-health/about-us/what-is-rural (2023, accessed 15 December 2023).
- 18. Merkt PT, Kramer MR, Goodman DA, et al. Urban-rural differences in pregnancy-related deaths, United States, 2011–2016. Am J Obstet Gynecol 2021; 225(2): 183.e1–183.e16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Davis NL, Smoots AN, Goodman MSDA. Pregnancy-related deaths: data from 14 U.S. maternal mortality review committees, 2008-2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, https://reviewtoaction.org/sites/default/files/2022-08/MMR-Data-Brief_2019-h.pdf (2019, accessed 15 December 2023). [Google Scholar]
- 20. Centers for Disease Control and Prevention. Pregnancy-related deaths: data from maternal mortality review committees in 36 US states, 2017–2019 maternal mortality prevention, https://www.cdc.gov/maternal-mortality/php/data-research/mmrc-2017-2019.html?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html (2023, accessed 14 December 2023).
- 21. Georgia Department of Public Health. Maternal mortality fact sheet 2018–2020, https://dph.georgia.gov/document/document/maternal-mortality-factsheet-2018-2020-data/download (2023, accessed 15 December 2023).
- 22. Pan American Health Organization (PAHO). Health in the Americas. Potentially avoidable premature mortality: what is it and why is it relevant? https://hia.paho.org/en/potentially-avoidable-premature-mortality-what-it-and-why-it-relevant (2021, accessed 12 December 2023).
- 23. Moran PS, Wuytack F, Turner M, et al. Economic burden of maternal morbidity–a systematic review of cost-of-illness studies. PLoS ONE 2020; 15(1); e0227377. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Centers for Disease Control and Prevention. Maternal infant health. Severe maternal morbidity, https://www.cdc.gov/maternal-infant-health/php/severe-maternal-morbidity/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html (2023, accessed 15 December 2023).
- 25. March of Dimes. Nowhere to go: maternity care deserts across the United States, https://www.marchofdimes.org/research/maternity-care-deserts-report.aspx (2023, accessed 12 December 2023).
- 26. Fabiyi CA, Reid LD, Mistry KB. Postpartum health care use after gestational diabetes and hypertensive disorders of pregnancy. J Womens Health 2019; 28(8): 1116–1123. [DOI] [PubMed] [Google Scholar]
- 27. Tipre M, Bolaji B, Blanchard C, et al. Relationship between neighborhood socioeconomic disadvantage and severe maternal morbidity and maternal mortality. Ethn Dis 2022; 32(4): 293–304. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Kilpatrick SJ, Abreo A, Gould J, et al. Confirmed severe maternal morbidity is associated with high rate of preterm delivery. Am J Obstet Gynecol 2016; 215(2): 233e1–233.e2337. [DOI] [PubMed] [Google Scholar]
- 29. Barry MJ, Nicholson WK, Silverstein M, et al. Screening for hypertensive disorders of pregnancy: US Preventive Services Task Force final recommendation statement. JAMA 2023; 330(11): 1074–1082. [DOI] [PubMed] [Google Scholar]
- 30. McDonald SD, Malinowski A, Zhou Q, et al. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J 2008; 156(5): 918–930. [DOI] [PubMed] [Google Scholar]
- 31. Havers-Borgersen E, Butt JH, Johansen M, et al. Preeclampsia and long-term risk of venous thromboembolism. JAMA Netw Open 2023; 6(11): e2343804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. von Schmidt auf, Altenstadt JF, Hukkelhoven CW, van Roosmalen J, et al. Pre-eclampsia increases the risk of postpartum haemorrhage: a nationwide cohort study in the Netherlands. PLoS ONE 2013; 8(12): e81959. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Savitz DA, Danilack VA, Elston B, et al. Pregnancy-induced hypertension and diabetes and the risk of cardiovascular disease, stroke, and diabetes hospitalization in the year following delivery. Am J Epidemiol 2014; 180: 41–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Tanz LJ, Stuart JJ, Williams PL, et al. Preterm delivery and maternal cardiovascular disease in young and middle-aged adult women. Circulation 2017; 135(6): 578–589. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Brown CC, Adams CE, George KE, et al. Mental health conditions increase severe maternal morbidity by 50 percent and cost $102 million yearly in the United States. Health Aff 2021; 40(10): 1575–1584. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. U.S. Department of Health and Human Services. Health resources and services administration. designated health professional shortage areas statistics, https://data.hrsa.gov (2023, accessed 12 December 2023).
- 37. Johnson M. Georgia extends Medicaid postpartum coverage for pregnant women. National Academy for State Health Policy, https://nashp.org/georgia-extends-medicaid-postpartum-coverage-for-pregnant-women/ (2023, accessed 14 December 2023). [Google Scholar]
- 38. Office of Disease Prevention and Health Promotion. Reduce maternal deaths—MICH-04. Healthy People 2030 Objectives and Data, https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-maternal-deaths-mich-04 (2023, accessed 15 December 2023).
- 39. Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG: Int J Obstet Gynaecol 2015; 122(2): 202–210. [DOI] [PubMed] [Google Scholar]
- 40. American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin No. 212: Pregnancy and heart disease. Obstet Gynecol 2019; 133(5): e320–e355. [DOI] [PubMed] [Google Scholar]
- 41. Williams KE, Koleva H. Identification and treatment of peripartum anxiety disorders. Obstet Gynecol Clin North Am 2018; 45(3): 469–481. [DOI] [PubMed] [Google Scholar]
- 42. Glazer KB, Howell EA. A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health. Arch Womens Ment Health 2021; 24(5): 823–830. [DOI] [PubMed] [Google Scholar]
- 43. Maughan BC, Marin M, Han J, et al. Venous thromboembolism during pregnancy and the postpartum period: risk factors, diagnostic testing, and treatment. Obstet Gynecol Surv 2022; 77(7): 433–444. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Varrias D, Spanos M, Kokkinidis DG, et al. Venous thromboembolism in pregnancy: challenges and solutions. Vasc Health Risk Manag 2023; 19: 469–484. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Roberts JM, King TL, Barton JR, et al. Care plan for individuals at risk for preeclampsia: shared approach to education, strategies for prevention, surveillance, and follow-up. Am J Obstet Gynecol 2023; 229(3): 193–213. [DOI] [PubMed] [Google Scholar]
- 46. Thenuwara K, Dunbar A. Using simulation to improve and maintain obstetrical skills in rural hospitals. Clin Obstet Gynecol 2022; 65(4): 817–828. [DOI] [PubMed] [Google Scholar]
- 47. Kozhimannil KB, Interrante JD, Tuttle MS, et al. Local capacity for emergency births in rural hospitals without obstetrics services. J Rural Health 2021; 37(2): 385–393. [DOI] [PubMed] [Google Scholar]
- 48. National Academies of Sciences Engineering and Medicine. Integrating social care into the delivery of health care: moving upstream to improve the nation’s health. Washington, DC: The National Academies Press, 2019. [PubMed] [Google Scholar]
- 49. Centers of Disease Control and Prevention (CDC) Foundation. Report from maternal mortality review committees: a view into their critical role, https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf (2017, accessed 17 December 2023).
- 50. Simas TAM, Whelan A, Byatt N. Postpartum depression—new screening recommendations and treatments. JAMA 2023; 330(23): 2295–2296. [DOI] [PubMed] [Google Scholar]
- 51. American College of Obstetricians and Gynecologists (ACOG). ACOG Committee Opinion No. 762: Prepregnancy counseling. Obstet Gynecol 2019; 133(1): e78–e89. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material, sj-docx-1-whe-10.1177_17455057241267103 for Pregnancy-related maternal mortality in the state of Georgia: Timing and causes of death by Anthony J Kondracki, Wei Li, Manouchehr Mokhtari, Bhuvaneshwari Muchandi, John A Ashby and Jennifer L Barkin in Women’s Health