Perceptions of Maternal Mortality in the Pregnant Missouri Birthing Population
Authors: Ellis Lindsey , Ahluwalia Amit , Gosch Kensey , Schmidt Laura , Florio Karen 
Published: July 2024

Introduction: The US has the highest maternal mortality (MM) rate among developed countries with significant disparities between Black, Hispanic, and Native American birthing people and their White counterparts. Missouri ranks among the 10 states with the highest MM. It has been presumed that the general population’s lack of knowledge surrounding the issue and distrust of the medical system both contribute significantly to MM. Thus, suggestions for improving maternal mortality have been centered primarily around education. To date, there has been a paucity of research surrounding the knowledge and perceptions of MM in the general population. This study sought to understand the perceptions of MM among a representative sample of pregnant people in Missouri. Methods: This is an anonymous, cross-sectional survey conducted from May 2022-August 2022 across the state of Missouri. The Missouri Perinatal Quality Collaborative/ Maternal-Child Learning and Action Network (LAN/PQC) iteratively developed a 46-question survey, distributed in both English and Spanish, to elicit opinions of birthing people in Missouri, assessing their knowledge about state-specific maternal mortality issues. The target population included individuals 18 years and older with a Missouri zip code who identified as someone of birthing potential. Those without a Missouri zip code, who identified as male, and not pregnant were excluded. All survey questions were uploaded into a secure database (REDcap) and accessible to participants through a survey link. The survey was pilot tested by placing a QR code and survey link on social media platforms by the authors. Once feasibility was confirmed, an additional survey link was distributed through an email listserv purchased from a data distribution platform (Dynata). Demographic data, including age, race, pregnancy status, number of lifetime pregnancies, number of living children, and preferred language, were recorded. All survey responses were documented without patient identifiers following signed, informed consent. The survey was aimed to sample 1500 respondents online racially representative of the Missouri birthing population. The study was approved by Saint Luke’s Hospital of Kansas City IRB and was designed to follow STROBE guidelines for the reporting of cross-sectional studies. Participants were asked general knowledge about maternal mortality including whether or not they knew it was a public health issue in Missouri, if they knew someone who died as a result of pregnancy, and if they themselves had ever been concerned about dying as a result of pregnancy. These results were reported as “yes” or “no” responses. Qualifying questions to positive responses included whether the perceived rate of maternal mortality in Missouri was high or low, suspected underlying medical and social causes and timeframe, and personal relationship to the decedent in the case of known death. For those who answered positively about concern for dying in pregnancy, qualifying responses were recorded on a Likert scale (1 for not at all concerned, 2 for a little concerned, 3 for somewhat concerned, 4 for very concerned and 5 for extremely concerned). Respondents were also asked to identify certain groups of people according to race, income status, insurance status, urban versus rural place of residence, educational status, and marital status that may suffer disproportionately from maternal deaths. Statistical analysis was performed in SAS 9.4. Descriptive statistics are reported in percentages and counts for categorical outcomes and means ± SD for continuous outcomes. Knowledge questions were analyzed as yes or no responses and reported in frequencies. Perceived etiologies for maternal mortality are reported as nominal data in percentages. Logistic regression was performed utilizing employment status, insurance status, marital status, education attainment, and difficulty with finances as predictors variables. Questions were stratified by age, race, and self-reported zip code. Results: Eighty-five people met inclusion criteria with an average age of 30.4 ± 7.6 and parity of 3.1 ± 2.0. Of those, 65.9% identified as White, 25.9% as Black, 8.2% as Hispanic, 3.5% as Native American, 4.7% as Asian, and 2.4% as Hawaiian Native or Pacific Islander. Over 85% reported awareness that MM was an issue in Missouri, and 59.2% reported they believed those numbers to be high. Thirty percent of people reported knowing someone who had died from a pregnancy-related cause; of those, 73.9% reported that the person who died was a family member or personal friend. Only 21.2% of pregnant people reported not being concerned about dying during their pregnancy. Seventy-five percent of the pregnant cohort reported trusting their medical providers’ recommendations. Discussion: Our study found that over 85% of pregnant people in Missouri are aware of MM, and a majority are aware that the MM rate is high. This contradicts commonly held beliefs that our patients’ lack of knowledge may be an opportunity for our efforts. Our survey also revealed that 75% of patients trust their medical providers despite much blame being placed on distrust of the health care system. Further surveys of health care providers may be helpful to reveal how exactly MM can be improved.