For the past several years, The Center for Community Solutions has insisted that tracking and releasing maternal morbidity data is key to improving health outcomes for both new mothers and infants. As we have previously reported, women and infants are facing a continued crisis in the United States, with mortality rates exceptionally high among women and infants of color during childbirth.
Data on morbidity or “near misses” allow us to identify, not only gaps in both clinical and social supports for women and their families, but also disparities in care given to families of color.
Data on morbidity or “near misses” allow us to identify, not only gaps in both clinical and social supports for women and their families, but also disparities in care given to families of color. Determining who is most affected by maternal morbidity and where it’s most likely to occur helps to identify patterns and contributes to developing and carrying out interventions that save lives. For every pregnancy-related death in the United States, 70 women experience a near miss.
After continued advocacy in this space, including during the previous two state budget cycles, and directly with the DeWine Administration, the Ohio Department of Health’s (ODH) Pregnancy Associated Mortality Review (PAMR) program released a report in early August detailing severe maternal morbidity and racial disparities in the state between 2016 and 2019.
The report affirmed what we already knew—Ohio is facing an unprecedented maternal health crisis.
Although the report affirmed what we already knew—Ohio is facing an unprecedented maternal health crisis—reports such as this provide data to help shape and target advocacy efforts moving forward. The report unveiled that Ohio had a severe maternal morbidity (SMM) rate of 71.1 for the four-year period, meaning the rate of SMM events for all four years combined was 71.1 per 10,000 deliveries. Nationally, the data on SMM are only available through 2014, as the International Classification of Disease (ICD) codes, used to identify and classify SMM during delivery, changed in 2015. Because of this, the national SMM data before the coding changes is not comparable to Ohio’s current rate. Until the Centers for Disease Control (CDC) develops a method to reconcile the changes so that data before the coding changes can be compared to data after the change, it will be unclear how our rate compares to the rest of the country.
We can, however, say with confidence that like national trends, rates of SMM among Black Ohio women were nearly two times higher (112.2 per 10,000 deliveries) compared to SMM rates for white women (60.5 per 10,000 deliveries). Black Ohio women also experienced SMM at significantly higher rates than any other race, with the closest being Non-Hispanic Asian women with a SMM rate of 84.6 per 10,000 deliveries over the four-year period. In fact, when controlling for county type (that is, the location of the delivery hospital) or insurance type, Black women still had the highest rates of SMM.
Birth outcomes for women should not be predicated on race or insurance status.
There are geographic disparities in SMM too. Overall, SMM rates for metropolitan counties were highest at 78.2 per 10,000 deliveries, with Appalachian counties following at 65.3 per 10,000 deliveries. When looking at county-type and race, non-Hispanic Asian women living in rural counties had a SMM rate 2.6 times greater than non-Hispanic Asian women in suburban counties. Non-Hispanic Black women in metropolitan counties experienced a SMM rate 1.4 times greater than non-Hispanic Black women living in Appalachian counties. It is imperative to explore these disparities to understand the driving forces behind them and to target resources and strategies to eliminate them.
Overall, disparities in SMM also exist across insurance status/payor type. Deliveries covered by Medicaid have disproportionately higher rates of SMM compared to private insurance or self-pay (self-pay includes self-pay, no charge, charity, and no expected payment). Women whose births are covered by Medicaid experience SMM rates of 85 per 10,000 deliveries, compared to 58.7 for private insurance and 56.8 for self-pay. Across payor type and race/ethnicity, disparities are even more stark. Non-Hispanic Black women have higher rates of SMM, nearly across the board, regardless of payor type. Rates for non-Hispanic Black women covered by Medicaid (109.7 per 10,000 deliveries) and private insurance (108.6 per 10,000 deliveries) and non-Hispanic Asian women covered by Medicaid (102.6 per 10,000 deliveries) are significantly higher than rates seen for any payor type among white and Hispanic women. Any strategies to address these differences must fully engage payors with targeted efforts to adequately understand and mitigate racial disparities.
Birth outcomes for women should not be predicated on race or insurance status.
The report concludes with a summary of efforts that are underway to address SMM and the racial and ethnic disparities that exist and persist. These efforts involve partnerships across ODH, the Ohio Hospital Association and national, state and local partners who are working together to address unacceptable and preventable negative maternal health outcomes. These are all good starts, but it’s not enough. Community Solutions will continue to look at the efforts underway in Ohio, including an initiative to better train emergency department staff in obstetric emergencies, as well as efforts across the nation that are working to reduce rates of poor maternal health outcomes.
SMM data should be reported on a regular basis so that trends, both positive and negative, can be acted upon. The United States has some of the highest rates of maternal death and morbidity in the developed world. This is an anomaly. Women should not be experiencing poor outcomes from pregnancy and delivery at these rates. The higher rates of poor outcomes for Black women are simply unacceptable. Incremental change is not enough. Ohio’s care providers and stakeholders across systems must utilize every tool we have to improve outcomes for moms—every mom—so they have every opportunity to be healthy.
