Deaths of white women with no higher education largely driving rising maternal mortality 

The racial gap in maternal mortality is narrowing, driven largely by climbing death rates of white women with no more than a high school education and declining rates for college-educated Black women, new research shows.

For Black women with less education and for both Black and white women giving birth at later ages, maternal mortality rates increased, according to researchers from the University of Michigan, Harvard University and National Association to Advance Black Birth.

One of the more alarming findings showed mortality rates doubling for white women with no higher education and a 9% increase for Black women with the same education level.

"Older maternal ages at birth explained some of the increase for white, less-educated mothers, and older maternal age was substantially more risky for Black mothers at any education level," said Arline Geronimus, Sc.D., lead author of the study and a professor of health behavior and health equity at U-M's School of Public Health.

The study, published in the American Journal of Epidemiology, analyzed the highest quality national statistics by race, age, education and cause of death between 2000-2019, going beyond earlier studies to understand more about who dies and why during pregnancy up to one year postpartum.

Overall, maternal death rates in the U.S. jumped from 7.2 deaths per 100,000 women in 1987 to 17.6 deaths per 100,000 women in 2019. Rates in other high-income countries declined over the same period.

The number of mothers younger than 30 has steadily decreased since the early 2000s, while the number of mothers in their 30s and early 40s has increased. By 2016 and for the first time, the birth rate for U.S. women ages 30-34 was greater than the birth rate for those ages 25-29.

"Even as death rates for Black women with a college education decline, they still have a far greater chance of dying from pregnancy-related causes," said Geronimus, a member of the National Academy of Medicine. "By ages 35-39 years, the Black maternal mortality rate is more than three times the rate for Black 20-to-24-year-olds, blunting the positive effects of higher education.

"If not for the shift in American women having babies at older ages, the racial gap likely would have seen a greater decline." 

The researchers applied the concept of weathering, coined by Geronimus, to their analysis. It describes the accumulated exposure to stress and high effort coping with chronic material hardship, biopsychosocial stressors, environmental toxicity and medical underservice, to understand why some women are more likely to die.

"Such exposure activates an accelerated aging, or 'weathering' process in women's bodies, increasing the risk of maternal mortality over their reproductive ages," said Geronimus, author of "Weathering: The Extraordinary Stress of Ordinary Life in an 
Unjust Society."

The mortality rate in the U.S. now surpasses rates of all high-income countries in Europe and Asia, the researchers said, spurring high personal, community and economic costs and losses. It is important to note that 80% of deaths, which occur during pregnancy through the first year after delivery, are deemed preventable. 

"Increasing maternal mortality rates for less-educated white and Black mothers coincided with the growing affordability crisis of the last decades and the national maternal health crisis, including Medicaid funding cuts, hospital closures in rural and low‑income communities, obstetric unit consolidation, long travel distances to care, limited broadband and specialty coverage, and economic precarity," Geronimus said.

Regarding high maternal death rates in the first year post-partum, the authors wrote: "All U.S. mothers—including the most educated—may be jeopardized by the lack of institutionalized wraparound postnatal support, parental leave or child care and family policies to keep pace with the growing and holistic needs of working families.

"The institutionalization of widespread and deep family policies might also open the door for people who want children to consider earlier ages at childbirth than their 30s or for those who wish to postpone childbearing to later ages to expect societal support and responsive maternity care, including in the postpartum period and beyond."  

The study also points out solutions and approaches that may lower deaths.

"The declining maternal mortality rates for more educated Black women came as Black‑led midwifery and community‑rooted programs designed to address cultural dissonance, racism and fragmented perinatal care emerged," Geronimus said. 

"In partnership with Black community-based organizations, the American College of Obstetrics and Gynecology co-designed state perinatal quality collaboratives that were found to be associated with reductions in mortality risk due to improved client trust, navigation of systems and continuity of care, along with lower health care costs."

However, systemic harm persists, Geronimus said.

"The decline in maternal mortality among Black mothers at higher levels of education implies that progress can be made through best clinical practice," she said. "Yet, racialized bias in the health care system is not the only structural driver affecting reproductive outcomes."

Study co-authors also include John Bound, U-M Department of Economics and Institute for Social Research; Landon Hughes, Harvard Medical School and Harvard Pilgrim Health Care Institute; and Kanika Harris, National Association to Advance Black Birth.

Study: Increasing and Inequitable U.S. Pregnancy-related Mortality Ratios among NonHispanic Black and White women, 2000-2019 (DOI: 10.1093/aje/kwaf287)