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. Author manuscript; available in PMC: 2023 Apr 1.
Published in final edited form as: Am J Prev Med. 2022 Feb 5;62(4):548–557. doi: 10.1016/j.amepre.2021.10.009

Mortality Rates Among U.S. Women of Reproductive Age, 1999–2019

Alison Gemmill 1, Blair O Berger 1, Matthew A Crane 2,3,4, Claire E Margerison 5
PMCID: PMC8940663  NIHMSID: NIHMS1758729  PMID: 35135719

Abstract

Introduction:

High and increasing levels of pregnancy-related mortality and morbidity in the U.S. indicate that the underlying health status of reproductive-aged women may be far from optimal, yet few studies have examined mortality trends and disparities exclusively among this population.

Methods:

All-cause and cause-specific mortality data for 1999–2019 were obtained from the Centers for Disease Control and Prevention WONDER Underlying Cause of Death database. Levels and trends in mortality between 1999 and 2019 for women aged 15–44 years stratified by age, race/ethnicity, and state were examined. Given the urgent need to address pregnancy-related health disparities, the correlation between all-cause and pregnancy-related mortality rates across states for the years 2015–2019 was also examined.

Results:

Age-adjusted, all-cause mortality rates among women aged 15–44 years improved between 2003 and 2011, but worsened between 2011 and 2019. The recent increase in mortality among this age group was not driven solely by increases in external causes of death. Patterns differed by age, race/ethnicity, and geography, with non-Hispanic American Indian and Alaskan Native women having 2.3 and non-Hispanic Black women having 1.4 times the risk of all-cause mortality in 2019 compared with non-Hispanic White women. Age-adjusted all-cause mortality rates and pregnancy-related mortality rates were strongly correlated at the state level (r =0.75).

Conclusions:

Increasing mortality among reproductive-aged women has substantial implications for maternal, women’s, and children’s health. Given the high correlation between pregnancy-related mortality and all-cause mortality at the state level, addressing structural factors that shape mortality risks may have the greatest likelihood of improving women’s health outcomes across the life course.

INTRODUCTION

Recent efforts from researchers, journalists, and advocates have raised awareness about the current maternal health crisis in the U.S., whereby more women die during pregnancy and the first year postpartum (>18 per 100,000 live births) in the U.S. than in any other high-income nation.1–4 As others have argued,5,6 these alarming statistics likely represent a “canary in the coalmine” for women’s health more broadly, especially as recent reports find that death rates among women of reproductive age may be increasing.6–8

Few studies have examined mortality levels and trends exclusively among reproductive-aged women, even though worsening of mortality among this population has substantial implications for the health of women, children, and their families. The extent to which mortality of reproductive-aged women differs across demographic and geographic lines is also unclear. Geographic differences are particularly important, as a growing body of research shows that state-level contexts are a salient determinant of maternal and women’s health.9–11 Addressing these knowledge gaps can shed light on the underlying determinants and risk factors that shape women’s health during the reproductive years, pregnancy, and beyond.

This paper provides a critical, yet understudied, population health perspective on the health status of women by documenting trends and heterogeneity in mortality rates among women aged 15–44 years in the U.S. by age, race/ethnicity, and state of residence. Given the urgent need to address maternal health disparities and evaluate the influence of state-level contexts on women’s health,12 the correlation between all-cause and pregnancy-related mortality rates at the state level is also examined. Pregnancy-related deaths are defined as deaths to women during pregnancy or within 1 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.13

METHODS

Study Sample

Data were obtained from the Centers for Disease Control and Prevention (CDC) WONDER Underlying Cause of Death Database, which compiles information from death certificates for U.S. residents for the years 1999–2019.14 Data prior to 1999 were not included because these are not available on CDC WONDER, and data end in 2019 because of interest in studying trends prior to the coronavirus disease 2019 (COVID-19) pandemic. Cause of death was based on single underlying cause of death classified in accordance with ICD-10 4-digit codes, which have been used to classify deaths since 1999.15,16 Estimated population counts came from the U.S. Census Bureau, as described elsewhere.14

All analyses and reporting of results were conducted in accordance with STROBE reporting guidelines.17 IRB approval and informed consent were not required because data contain no identifiable information and are publicly available through a data use agreement with the National Center for Health Statistics.18 Analyses were conducted between April 20, 2020 and January 21, 2021.

Measures

Trends in mortality between 1999 and 2019 for women aged 15–44 years stratified by age, race/ethnicity, and state were examined. “Women” is defined here as people identified as female on the death certificate. Thus, this definition might include people who did not self-identify as women and excludes individuals that may have self-identified as women but who were not captured as female on the death certificate.

The analysis used 5-year age groups (15–19, 20–24, 25–29, 30–34, 35–39, 40–44 years) and 5 racial/ethnic groups based on U.S. Census Bureau classifications (non-Hispanic American Indian and Alaskan Native [AI/AN], non-Hispanic Asian and Pacific Islander [API], non-Hispanic Black, non-Hispanic White, and Hispanic). Because several studies have documented increasing death rates due to external causes (e.g., drug use, suicide, and homicide)7,19,20 and because of an interest in physiological health, including organ system diseases, trends and disparities in both all-cause mortality and mortality due to non-external causes (i.e., excluding ICD-10 codes V01–Y89) were analyzed separately. With the exception of age-specific analyses, analyses used age-adjusted rates provided by CDC WONDER.

Statistical Analysis

Trends in annual mortality rates were examined by using Joinpoint Regression Program, version 4.8.0.1, which detects if there are inflection points (joinpoints) in trends.21,22 The program iteratively searches for the optimal number of joinpoints by testing whether models with more joinpoints perform better than simpler models. Models with no joinpoints indicate a straight line. The program also calculates an annual percentage rate change (APC) for line segments that link joinpoints, as well as the weighted average of the APCs for the entire 21-year period (e.g., 1999–2019). All trends were modeled on the log scale and set the maximum number of joinpoints to 2.

The top 15 leading causes of death among women aged 15–44 years—overall and by race/ethnicity—between the years 1999 and 2019 were also documented to examine changes in the cause of death distribution over the past 2 decades. Rankable causes of death are a subset of the ICD-10 “113 Selected Causes of Death” groups for all ages, as defined by the National Center for Health Statistics.23 Rankings for each year are based on death counts.

Pregnancy-related deaths were identified by codes within the Pregnancy, Childbirth, and the Puerperium classification (ICD-10 codes O00–O99).24 Unlike the maternal death classification (i.e., deaths that occur during pregnancy or up to 42 days after end of pregnancy) the pregnancy-related death classification includes deaths in the late postpartum period (i.e., after 42 days but <1 year after end of pregnancy), which is a critical period for maternal health. To understand the population-level relationship between all-cause and pregnancy-related mortality among women of reproductive age, a Pearson correlation coefficient between state-level age-adjusted all-cause and pregnancy-related mortality rates for women aged 15–44 years was calculated. This analysis used mortality rates from the most recent 5 years of available data (i.e., 2015–2019) for the 39 states with adequate case counts that meet the National Center for Health Statistics threshold for statistical reporting, as well as those with large enough populations to calculate reliable pregnancy-related mortality rates. For this exercise, pregnancy-related deaths were removed from the calculation of all-cause mortality rates to ensure that correlations were not driven by their inclusion. Age-adjusted rates for both measures were used to ensure consistency and to limit the influence of compositional differences by age across states. Finally, to visually demonstrate this relationship, a scatter plot of values with a line estimated from locally weighted scatterplot smoothing (lowess) was produced.

RESULTS

Between 1999 and 2019, the all-cause age-adjusted mortality rate for women aged 15–44 years increased from 86.5/100,000 to 89.4/100,000, with an estimated average APC of 0.27 (95% CI= −0.18, 0.73). Although mortality for this population improved between 2003 and 2011, since 2011, the all-cause mortality rate increased (APC=1.83, 95% CI=1.23, 2.43) (Table 1 and Appendix Figure 1).

Table 1.

Joinpoint Analysis of Mortality Trends for All Causes of Death and for Non-External Causes of Death, by Age Group and Race/Ethnicity

1st segment 2nd segment 3rd segment AAPC 1999–2018 (95% CI)
Characteristic Period APC (95% CI) Period APC (95% CI) Period APC (95% CI)
All causes
 15–44 1999–2003 0.92 (−0.74, 2.58) 2003–2011 −1.56 (−2.28, −0.84) ** 2011–2019 1.83 (1.23, 2.43) ** 0.27 (−0.18, 0.73)
 15–19 1999–2004 −0.63 (−2.63, 1.42) 2004–2012 −4.46 (−5.77, −3.14) ** 2012–2019 1.36 (−0.11, 2.85) −1.50 (−2.31, −0.68) **
 20–24 1999–2014 −0.58 (−0.95, −0.21) * 2014–2017 4.91 (−3.39, 13.92) 2017–2019 −3.32 (−11.53, 5.66) −0.05 (−1.45, 1.36)
 25–29 1999–2014 0.46 (0.23, 0.70) ** 2014–2017 6.48 (1.32, 11.91) * 2017–2019 −3.02 (−7.83, 2.04) 0.99 (0.15, 1.83))*
 30–34 1999–2013 0.01 (−0.21, 0.24) 2013–2017 6.24 (3.99, 8.55) ** 2017–2019 −0.80 (−4.77, 3.33) 1.15 (0.59, 1.71) **
 35–39 1999–2012 −1.10 (−1.45, −0.76) ** 2012–2019 3.16 (2.24, 4.08) ** – – 0.37 (0.01, 0.73) *
 40–44 1999–2002 2.45 (0.34, 4.60) * 2002–2012 −1.62 (−2.01, −1.23) ** 2012–2019 0.82 (0.19, 1.46) * −0.17 (−0.56, 0.22)
 Non-Hispanic White 1999–2013 0.40 (0.09, 0.71) * 2013–2017 3.77 (0.48, 7.18) * 2017–2019 −2.34 (−8.24, 3.94) 0.79 (−0.06, 1.63)
 Non-Hispanic Black 1999–2003 −0.85 (−1.93, 0.25) 2003–2012 −3.31 (−3.70, −2.91) ** 2012–2019 1.88 (1.35, 2.40) ** −1.03 (−1.33, −0.72) **
 Hispanic 1999–2012 −2.01 (−2.38, −1.63) ** 2012–2019 2.93 (2.03, 3.84) ** – – −0.31 (−0.67, 0.06) *
 Non-Hispanic American Indian and Alaska Native 1999–2019 2.24 (1.92, 2.56) ** – – – – 2.24 (1.92, 2.56) **
 Non-Hispanic Asian and Pacific Islander 1999–2011 −1.89 (−2.50, −1.28) ** 2011–2019 0.71 (−0.33, 1.75) – – −0.86 (−1.37, −0.35) **
Non-external causes
 15–44 1999–2001 2.05 (−2.28, 6.58) 2001–2011 −1.96 (−2.37, −1.54) ** 2011–2019 0.37 (−0.18, 0.93) −0.63 (−1.11, −0.15) *
 15–19 1999–2012 −2.21 (−2.57, −1.84) ** 2012–2019 −0.56 (−1.54, 0.42) – – −1.63 (−2.02, −1.25) **
 20–24 1999–2019 −1.33 (−1.62, −1.04) ** – – – – −1.33 (−1.62, −1.04) **
 25–29 1999–2019 −0.56 (−0.83, −0.28) * – – – – −0.56 (−0.83, −0.28) *
 30–34 1999–2012 −1.16 (−1.50, −0.83) ** 2012–2019 2.08 (1.26, 2.91) ** – – −0.04 (−0.37, 0.29)
 35–39 1999–2001 0.89 (−4.48, 6.56) 2001–2010 −2.42 (−3.01, −1.82) ** 2010–2019 1.20 (0.68, 1.73) ** −0.47 (−1.06, 0.12)
 40–44 1999–002 1.21 (−0.89, 3.36) 2002–2011 −2.26 (−2.75, −1.77) ** 2011–2019 −0.03 (−0.58, 0.53) −0.86 (−1.26, −0.45) **
 Non-Hispanic White 1999–2001 3.28 (−0.94, 7.68) 2001–2010 −1.08 (−1.67, −0.48) ** 2010–2019 0.63 (0.11, 1.16) * 0.12 (−0.38, 0.62)
 Non-Hispanic Black 1999–2003 −0.98 (−1.92, −0.04) * 2003–2012 −3.42 (−3.76, −3.07) ** 2012–2019 −0.07 (−0.55, 0.40) −1.77 (−2.04, −1.50) **
 Hispanic 1999–2011 −2.42 (−2.97, −1.86) ** 2011–2019 1.33 (0.43, 2.23) * – – −0.94 (−1.39, −0.49) *
 Non-Hispanic American Indian and Alaska Native 1999–2019 2.17 (1.76, 2.58) ** – – – – 2.17 (1.76, 2.58) **
 Non-Hispanic Asian and Pacific Islander 1999–2019 −0.91 (−1.31, −0.52) ** – – – – −0.91 (−1.31, −0.52) **
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Note: Boldface indicates statistical significance

*

p<0.05;

**

p<0.01.

Source: CDC WONDER

AAPC, average annual percent change; APC, annual percent change.

Trends differed somewhat after removing external causes. Mortality due to non-external causes declined between 1999 and 2019 from 59.2/100,000 to 51.8/100,000, a trend that was largely driven by reductions between 2001 and 2011. Since 2011, however, mortality involving non-external causes remained flat (APC=0.37, 95% CI= −0.18, 0.93) (Table 1 and Appendix Figure 1).

Table 2 shows the top 15 leading causes of death among women of reproductive age for the year 2019, as well as the change in each cause-specific age-adjusted rate between 1999 and 2019. The leading cause of death was accidents (29.6% of deaths), followed by malignant neoplasms (15.5%), diseases of the heart (8.7%), intentional self-harm/suicide (7.9%), and assault/homicide (3.9%). Since 1999, rates of accidents and suicides have increased by 44% and 51%, respectively, whereas rates of malignant neoplasms, diseases of the heart, and assault decreased by 27%, 9%, and 19%, respectively. Other causes of death rates that increased since 1999 included chronic liver disease and cirrhosis (+53%); diabetes mellitus (+17%); pregnancy-related causes (+183%); septicemia (+11%); and nephritis, nephrotic syndrome, and nephrosis (+29%).

Table 2.

Top 15 Leading Causes of Mortality for U.S. Women Aged 15–44 Years, 2019, and Change in Rate Since 1999

Cause External or non-external Rank Deaths Percent of total deaths Age-adjusted rate Change in rate between 1999 and 2019
Accidents (unintentional injuries) (V01-X59,Y85-Y86)a External 1 16,418 29.6 25.7 +51.2%
Malignant neoplasms (C00-C97) Non-external 2 8,568 15.5 14.4 −26.5%
Diseases of heart (I00-I09,I11,I13,I20-I51) Non-external 3 4,822 8.7 8.1 −8.9%
Intentional self-harm (suicide) (*U03,X60-X84,Y87.0)a External 4 4,390 7.9 6.9 +43.8%
Assault (homicide) (*U01-*U02,X85-Y09,Y87.1) External 5 2,188 3.9 3.4 −19.0%
Chronic liver disease and cirrhosis (K70,K73-K74)a Non-external 6 1,688 3.0 2.9 +52.6%
Diabetes mellitus (E10-E14)a Non-external 7 1,265 2.3 2.1 +16.7%
Cerebrovascular diseases (I60-I69) Non-external 8 1,123 2.0 1.8 −33.3%
Pregnancy, childbirth and the puerperium (O00-O99)a Non-external 9 1,080 1.9 1.7 +183.3%
Influenza and pneumonia (J09-J18) Non-external 10 721 1.3 1.2 0
Septicemia (A40-A41)a Non-external 11 617 1.1 1.0 +11.1%
Chronic lower respiratory diseases (J40-J47) Non-external 12 590 1.1 1.0 −16.7%
Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Non-external 13 546 1.0 0.9 −10.0%
Nephritis, nephrotic syndrome and nephrosis (N00-N07,N17-N19,N25-N27)a Non-external 14 517 0.9 0.9 +28.6%
Human immunodeficiency virus (HIV) disease (B20-B24) Non-external 15 536 1.0 0.6 −84.6%
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a

Indicates cause-specific death rates that have increased between 1999 and 2019.

Mortality rates among reproductive-aged women showed a strong pattern by age, with women aged 40–44 years having >5 times the mortality risk compared with women aged 15–19 years (e.g., 161.3/100,000 vs 28.1/100,000 in 2019). Panels A and B in Figure 1 present trends in all-cause mortality and mortality due to non-external causes for each 5-year age group; Table 1 presents corresponding joinpoint regression results. Appendix Figures 3–15 show plots of each age group’s joinpoint results. Between 1999 and 2019, all-cause mortality declined for women aged 15–19 years, but increased for women aged 25–39 years. Notably, for all age groups, all-cause mortality has increased since 2012–2014, with the largest upward slopes occurring among women aged 25–34 years.

Figure 1.

Figure 1.

Figure 1.

Figure 1.

Figure 1.

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Among U.S. women aged 15–44 years, age-specific mortality rates for all causes of death (Panel A) and for non-external causes of death (Panel B); and age-adjusted mortality rates by race/ethnicity for all causes (Panel C) and non-external causes (Panel D), 1999–2019.

These patterns differed when analyses were limited to non-external causes. For women aged 15–29 years, there was a steady decline in mortality due to non-external causes between 1999 and 2019, with the youngest age group (i.e., 15–19 years) seeing the steepest declines (APC= −1.63, 95% CI= −2.02, −1.25). However, mortality rates due to non-external causes increased after 2010–2012 among women in their 30s and remained stagnant among women aged 40–44 years.

There were marked disparities in women’s reproductive-age mortality, with non-Hispanic AI/AN women having 2.3 and non-Hispanic Black women having 1.4 times the risk of all-cause mortality in 2019 compared with non-Hispanic White women (non-Hispanic AI/AN: 220.5/100,000, non-Hispanic Black: 133.3/100,000, non-Hispanic White: 94.9/100,000). By contrast, Hispanic women and non-Hispanic API women had lower mortality than non-Hispanic White women (Hispanic: 58.9/100,000, non-Hispanic API: 33.8/100,000). These patterns were largely similar when external causes were removed, with non-Hispanic AI/AN having 2.4 and non-Hispanic Black women having 1.8 times the risk of mortality of non-Hispanic White women.

Trends by race/ethnicity are presented in Panels C and D in Figure 1, with corresponding joinpoint results presented in Table 1. Appendix Figures 16–26 show plots of each group’s joinpoint results. Between 1999 and 2019, non-Hispanic AI/AN women witnessed a unique and sustained increase in mortality, with an annual rate of change of 2.24 (95% CI=1.92, 2.56). All-cause mortality trends for non-Hispanic White, non-Hispanic Black, and Hispanic women increased after 2012–2013 following either periods of decline or limited progress. The trend in mortality for non-Hispanic API women declined between 1999 and 2011 but remained relatively flat in recent years. Trends that excluded external causes shared similar patterns, with non-Hispanic AI/AN women showing an upward trajectory for the 21-year study period. Since 2010–2012, mortality excluding external causes also increased for non-Hispanic White and Hispanic women and remained relatively stable for non-Hispanic Black women; these recent trends for all 3 groups, however, show a reversal of downward trends that occurred in the first decade of the century.

Top causes of death and changes in cause-specific rates over the 21-year period differed by race/ethnicity as well (Appendix Tables 1–5). For example, homicide was ranked the fourth leading cause of death for Black women (versus sixth for White women), with non-Hispanic Black women having 4 times the homicide rate of White women (9.4 vs 2.3). Mortality rates for diabetes mellitus were also much higher for Black women (5.0) and non-Hispanic AI/AN women (7.2) than White women (1.9). The rate of accident-related mortality, which includes drug overdose, increased over time for all racial/ethnic groups except non-Hispanic API women. Last, non-Hispanic White and AI/AN women were the only racial/ethnic groups to see an increasing rate of diseases of the heart (+7% and +55%, respectively).

There were substantial differences in mortality rates among women of childbearing age across states (Appendix Figures 1 and 2). States with the highest rates of all-cause mortality (i.e., top quintile) were largely concentrated in the Southern census region (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Tennessee, West Virginia), but also included Alaska, New Mexico, and Ohio. All but 2 of these states (Alaska and Ohio) also were in the highest quintile for mortality rates that excluded external causes.

Among reproductive-aged women, the correlation between age-adjusted all-cause mortality rates that excluded pregnancy-related causes and age-adjusted pregnancy-related mortality rates across states was 0.64 (p<0.001). This correlation increased to 0.75 when external causes of death were further excluded from all-cause mortality rates (p<0.001) (Figure 2).

Figure 2.

Figure 2.

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Scatterplot of age-adjusted mortality for non-external causes (deaths per 100 000 women aged 15–44 years) excluding pregnancy-related deaths and age-adjusted pregnancy-related mortality (deaths per 100 000 women aged 15–44 years) for 39 U.S. states among women aged 15–44 years, 2015–2019.

Note: Line estimated using locally weighted scatterplot smoothing (lowess).

DISCUSSION

Because about 4 of 5 women will give birth during their lifetime,25 the health status of reproductive-aged women has important implications for maternal, perinatal, and child health. Findings show that all-cause mortality among women of reproductive age has increased over the last 10 years, with marked increases among women aged 25–39 years. Though much of these increases were driven by external causes of death, there is also evidence of worsening or stagnating trends in deaths due to non-external causes for some groups. This analysis further demonstrates a high correlation between overall mortality and pregnancy-related mortality at the state level—a novel finding with important implications for addressing the maternal health crisis.

The authors observed stark racial/ethnic and geographic disparities in levels and trends in mortality. Two striking patterns are highlighted here. First, there is clear indication that improvements in mortality levels among non-Hispanic AI/AN have lagged, as this was the only racial/ethnic group that showed sustained increases in both all-cause and non-external mortality rates over the last 2 decades. Second, mortality levels differed considerably across states; in 2019, the gap in mortality rates between the best and worst performing states differed by a factor of around 2.5.

These findings, moreover, underscore that the maternal health crisis is taking place against the backdrop of rising rates of suicides and drug-related deaths, particularly among younger age groups. Moreover, although deaths due to homicide have declined in the past 2 decades, racial/ethnic disparities have persisted, with non-Hispanic Black and non-Hispanic AI/AN women having 3–4 times the rate of homicide-specific mortality compared with non-Hispanic White women. As a result, these causes of death and associated disparities appear to mirror those among pregnant and postpartum women. For example, state-specific data estimate that up to 26%, 13%, and 13% of all deaths during pregnancy and postpartum may be accounted for by drug-related causes, suicide, and homicide, respectively.26–30

Although much of the burden of and increase in mortality among women of reproductive age is due to external causes of death, this study also finds worsening or stagnating mortality rates due to non-external causes, with pronounced worsening trends among women in their 30s. These findings comport with prior research indicating that chronic health conditions are increasingly prevalent among reproductive-aged women of all age groups in the U.S. and that more pregnant women are delivering with multiple comorbidities.31–34 Collectively, these results and those from other studies highlight the continued importance of access to preconception and interconception health care for early identification and continuous management of chronic conditions prior to pregnancy, as recent research suggests that many women, particularly those who are diabetic or hypertensive, are either unaware of their status or have an uncontrolled condition.33,34

This paper documents wide variation in state-level mortality rates among reproductive-aged women, which largely mirrors well-recognized geographic disparities in population health outcomes.35–37 Recent research shows that state differences in life expectancy have been growing since the 1980s, pointing to the critical role that states—as legal and administrative entities—have played in influencing this divergence.38 Given this growing body of research on state contexts, results showing a high correlation between all-cause mortality (excluding pregnancy-related deaths) and pregnancy-related mortality at the state level provide a new lens with which to view and address the U.S. maternal health crisis. These results strengthen the argument that interventions to improve maternal health need to look beyond individual risk factors and healthcare interventions to focus on the social and policy contexts that shape access to health-promoting resources and opportunities across the life course.39 Little empirical work, however, has examined which social or policy factors may impact maternal mortality or morbidity.40 State-level income inequality,10 Medicaid coverage of abortion services,41 and Medicaid expansion under the Affordable Care Act42 have been linked to pregnancy-related mortality, but additional research needs to identify the most promising policy levers to improve women’s health prior to, during, and after pregnancy.

Limitations

There are some limitations to note. First, this paper examined disparities by key sociodemographic characteristics that were readily available in the CDC WONDER database (e.g., age and race/ethnicity), but did not evaluate how other important dimensions of stratification, such as income, education, and occupation, may shape women’s mortality risks during the reproductive period. Moreover, this study provides only a preliminary exploration of geographic differences across states and regions and does not consider smaller spatial units. This analysis, therefore, sets the stage for future research in these areas. Second, mortality data are subject to reporting and misclassification errors, and the magnitude and direction of these errors may differ by subpopulation and cause of death attribution.43 This is especially the case for pregnancy-related deaths, which have well-documented challenges in measurement due to difficulties in case identification and inconsistent measurement across states.44,45 Moreover, this studied relied solely on ICD-10 codes to identify pregnancy-related deaths; this suggests that undercounting of these deaths is likely as information from the pregnancy checkbox was not used, which improves case ascertainment.44,45 Not all states in the analysis use the same standardized death certificate, which adds an additional source of error.44,45

CONCLUSIONS

The present findings highlight several important messages. First, despite declines in mortality in the first half of the 21st century (as well as declines in mortality across most of the world), overall mortality rates among women aged 25–39 years have increased in recent years. During this time (approximately 2010–2019), more women have gained health insurance (although, among low-income women, 20% remain uninsured),46,47 and medical advances over the past decades have enabled earlier detection of and treatment of chronic disease. Thus, although progress is still needed to provide high-quality, low-cost health care to all, these increases in mortality, especially mortality due to external causes such as drug overdose, suicide, and homicide, will likely not be reversed by interventions to health care alone, and greater attention to the structural causes of mortality among women of reproductive age is warranted. Moreover, particular efforts, including acknowledgement of how structural racism and systemic inequity shape population health,39,48 must be made to address the sustained rise in mortality among women identified as non-Hispanic AI/AN, as well as unacceptably high levels of mortality among both non-Hispanic Black and non-Hispanic AI/AN women, both of whom have experienced historical oppression and discrimination.

Supplementary Material

1

ACKNOWLEDGMENTS

AG and CEM were supported by National Institute of Child Health and Human Development (NICHD) award R01HD102319. AG was supported by a Hopkins Center for Health Disparities Solutions Pilot Project Award (U54MD000214). CEM was supported by NICHD awards R01HD095951 and K01HL128843.

No financial disclosures were reported by the authors of this paper.

Footnotes

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CRediT Author Statement

Alison Gemmill: Conceptualization, Formal anlaysis, Writing- Original draft preparation, Supervision; Blair O. Berger: Writing- Reviewing and Editing; Matthew A. Crane: Data Curation; Writing- Reviewing and Editing; Claire E. Margerison: Writing- Reviewing and Editing.

REFERENCES

  • 1.GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775–1812. 10.1016/S0140-6736(16)31470-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO; 2019. [Google Scholar]
  • 3.Martin N, Cillekens E, Freitas A. Lost Mothers. ProPublica. https://www.propublica.org/article/lost-mothers-maternal-health-died-childbirth-pregnancy. Published July 17, 2017. Accessed March 8, 2021. [Google Scholar]
  • 4.Chinn JJ, Eisenberg E, Dickerson SA, et al. Maternal mortality in the United States: research gaps, opportunities, and priorities. Am J Obstet Gynecol. 2020;223(4):486–492. 10.1016/j.ajog.2020.07.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Declercq E, Shah N. Maternal deaths represent the canary in the coal mine for women’s health. STAT News. https://www.statnews.com/2018/08/22/maternal-deaths-women-health/. Published August 22, 2018. Accessed March 8, 2021. [Google Scholar]
  • 6.Declercq E. Broadening the focus during pregnancy to total women’s health, not just healthy babies. Health Affairs Blog. August 7, 2020. 10.1377/hblog20200804.568913. [DOI] [Google Scholar]
  • 7.Woolf SH, Schoomaker H. Life expectancy and mortality rates in the United States, 1959–2017. JAMA. 2019;322(20):1996–2016. 10.1001/jama.2019.16932. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Astone NM, Martin S, Aron L. Death rates for US women ages 15 to 54: Some unexpected trends. Washington, DC: Urban Institute; 2015. [Google Scholar]
  • 9.Vilda D, Wallace M, Dyer L, et al. Income inequality and racial disparities in pregnancy-related mortality in the US. SMM Popul Health. 2019;9:100477. 10.1016/j.ssmph.2019.100477. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Vilda D, Wallace ME, Daniel C, et al. State abortion policies and maternal death in the United States, 2015–2018. Am J Public Health. 2021;111(9):1696–1704. 10.2105/ajph.2021.306396. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Montez JK, Zajacova A, Hayward MD. Explaining inequalities in women’s mortality between U.S. states. SSM Popul Health. 2016;2:561–571. 10.1016/j.ssmph.2016.07.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America. HHS; 2020. [Google Scholar]
  • 13.Petersen EE, Davis NL, Goodman D, et al. Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423–429. 10.15585/mmwr.mm6818e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Centers for Disease Control and Prevention. Underlying Cause of Death 1999–2018 on CDC WONDER Online Database. http://wonder.cdc.gov/ucd-icd10.html. Published 2020. Accessed July 3, 2020.
  • 15.The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO; 1992. [Google Scholar]
  • 16.Hoyert DL et al. Deaths: Final Data for 1999. Natl Vital Stat Rep. 2001;49(8):1–113. [PubMed] [Google Scholar]
  • 17.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–349. 10.1016/j.jclinepi.2007.11.008. [DOI] [PubMed] [Google Scholar]
  • 18.Centers for Disease Control and Prevention. CDC Wonder data use restrictions. https://wonder.cdc.gov/DataUse.html#. Published 2020. Accessed June 2, 2020.
  • 19.Alexander MJ, Kiang MV, Barbieri M. Trends in Black and White opioid mortality in the United States, 1979–2015. Epidemiology. 2018;29(5):707–715. 10.1097/ede.0000000000000858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Hedegaard H, Curtin SC, Warner M. Suicide rates in the United States continue to increase. NCHS Data Brief. 2018;(309):1–8. [PubMed] [Google Scholar]
  • 21.Joinpoint Regression Program, Version 4.8.0.1 - April 2020 Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute. [Google Scholar]
  • 22.Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2000;19(3):335–351: (correction: 2001;20:655). . [DOI] [PubMed] [Google Scholar]
  • 23.Heron M. Deaths: leading causes for 2017. Natl Vital Stat Rep. 2019;68(6):1–77. [PubMed] [Google Scholar]
  • 24.The WHO Application of ICD-10 to Deaths during Pregnancy, Childbirth and the Puerperium: ICD-MM. WHO; 2012. [Google Scholar]
  • 25.Livingston G. Childlessness Falls, Family Size Grows Among Highly Educated Women. Washington, DC: Pew Research Center; 2015. [Google Scholar]
  • 26.Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, Binswanger IA. Maternal deaths from suicide and overdose in Colorado, 2004–2012. Obstet Gynecol. 2016;128(6):1233–1240. 10.1097/aog.0000000000001695. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Bronson J, Reviere R. Pregnancy-associated deaths in Virginia due to homicides, suicides, and accidental overdoses compared with natural causes. Violence Against Women. 2017;23(13):1620–1637. 10.1177/1077801216663658. [DOI] [PubMed] [Google Scholar]
  • 28.Goldman-Mellor S, Margerison CE. Maternal drug-related death and suicide are leading causes of post-partum death in California. Am J Obstet Gynecol. 2019;221(5):489.e1–489.e9. 10.1016/j.ajog.2019.05.045. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Smid MC, Stone NM, Baksh L, et al. Pregnancy-associated death in Utah: contribution of drug induced deaths. Obstet Gynecol. 2019;133(6):1131–1140. 10.1097/aog.0000000000003279. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Wallace ME, Crear-Perry J, Mehta PK, Theall KP. Homicide during pregnancy and the postpartum period in Louisiana, 2016–2017. JAMA Pediatr. 2020;174(4):387–388. 10.1001/jamapediatrics.2019.5853. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Admon LK, Winkelman TNA, Moniz MH, Davis MM, Heisler M, Dalton VK. Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005–2014. Obstet Gynecol. 2017;130(6):1319–1326. 10.1097/aog.0000000000002357. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Lima FV, Yang J, Xu J, Stergiopoulos K. National trends and in-hospital outcomes in pregnant women with heart disease in the United States. Am J Cardiol. 2017;119(10):1694–1700. 10.1016/j.amjcard.2017.02.003. [DOI] [PubMed] [Google Scholar]
  • 33.Kim SY, Deputy NP, Robbins CL. Diabetes during pregnancy: surveillance, preconception care, and postpartum care. J Womens Health (Larchmt). 2018;27(5):536–541. 10.1089/jwh.2018.7052. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Azeez O, Kulkarni A, Kuklina EV, Kim SY, Cox S. Hypertension and diabetes in non-pregnant women of reproductive age in the United States. Prev Chronic Dis. 2019;16:E146. 10.5888/pcd16.190105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Fenelon A. Geographic divergence in mortality in the United States. Popul Dev Rev. 2013;39(4):611–634. 10.1111/j.1728-4457.2013.00630.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Dollar NT, Gutin I, Lawrence EM, et al. The persistent southern disadvantage in US early life mortality, 1965–2014. Demogr Res. 2020;42:343–382. 10.4054/demres.2020.42.11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Farina MP, Zajacova A, Montez JK, Hayward MD. US state disparities in life expectancy, disability-free life expectancy, and disabled life expectancy among adults aged 25 to 89 years. Am J Public Health. 2021;111(4):708–717. 10.2105/ajph.2020.306064. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Montez JK, Beckfield J, Cooney JK, et al. US state policies, politics, and life expectancy. Milbank Q. 2020;98(3):668–699. 10.1111/1468-0009.12469. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Crear-Perry J, Correa-de-Araujo R, Johnson TL, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health. 2021;30(2):230–235. 10.1089/jwh.2020.8882. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Wang E, Glazer KB, Howell EA, Janevic TM. Social determinants of pregnancy-related mortality and morbidity in the United States: a systematic review. Obstet Gynecol. 2020;135(4):896–915. 10.1097/aog.0000000000003762. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Jarlenski M, Hutcheon JA, Bodnar LM, Simhan HN. State Medicaid coverage of medically necessary abortions and severe maternal morbidity and maternal mortality. Obstet Gynecol. 2017;129(5):786–794. 10.1097/aog.0000000000001982. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Eliason EL. Adoption of Medicaid expansion is associated with lower maternal mortality. Womens Health Issues. 2020;30(3):147–152. 10.1016/j.whi.2020.01.005. [DOI] [PubMed] [Google Scholar]
  • 43.Anderson RN. Chapter 22: Coding and classifying causes of death: Trends and international differences. In: Rogers RG, Crimmins EM, eds. International Handbook of Adult Mortality. Dordrecht, Netherlands: Springer; 2011:467–489. 10.1007/978-90-481-9996-9_22. [DOI] [Google Scholar]
  • 44.Rossen LM, Womack LS, Hoyert DL, Anderson RN, Uddin SFG. 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]
  • 45.McDorman MF, Declercq E, Cabral H, Morton C. Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol. 2016;128(3):447–455. 10.1097/aog.0000000000001556. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Kaiser Family Foundation. Women’s Health Insurance Coverage. https://kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage/. Published January 12, 2021. Accessed June 29, 2021.
  • 47.Margerison CE, MacCallum CL, Chen J, Zamani-Hank Y, Kaestner R. Impacts of Medicaid expansion on health among women of reproductive age. Am J Prev Med. 2020;58(1):1–11. 10.1016/j.amepre.2019.08.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–1463. 10.1016/s0140-6736(17)30569-x. [DOI] [PubMed] [Google Scholar]

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