Maternal Mortality: Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them
Released: 2020-04-07T00:00:00

Letter

Background

Death Registration Process

In the United States, deaths from all causes are recorded and tracked through a multi-step registration process, which may vary by state, according to CDC officials. According to CDC officials, when an individual dies, a death certificate is filed with the state. Funeral directors are responsible for providing demographic information about the deceased individual, while physicians, coroners, and medical examiners are responsible for providing information on cause of death. The local registrar of vital statistics is responsible for verifying the information, and then transferring copies of the death certificate to the city or county health department in some jurisdictions, and to the state registrar. The state vital registration office is responsible for verifying the information, maintaining official copies, and creating an electronic record. According to CDC officials we interviewed, state vital records offices submit their death certificate information to CDC electronically.

In 2003, CDC revised the standard death certificate to include a checkbox to indicate whether a woman was pregnant at the time of her death or up to 1 year after delivery or end of pregnancy. (See fig. 3)

The checkbox is part of the medical portion of the death certificate that is completed by a physician, coroner, or medical examiner. According to CDC officials, there has been staggered adoption of the revised death certificate by states, and not every state death certificate included the pregnancy checkbox until 2019.

CDC Has Two National Surveillance Systems Related to Maternal Mortality and Has Created a Resource to Facilitate State Efforts

CDC collects maternal mortality data using two national surveillance systems, NVSS and PMSS. In addition, CDC has developed a data application that state or local MMRCs can use to centrally collect information abstracted from various sources about each death.

Federal law directs CDC’s National Center for Health Statistics to collect statistics on maternal mortality. According to CDC officials, the National Center for Health Statistics receives copies of electronic records for deaths from all states and jurisdictions, such as the District of Columbia. It uses this death certificate information to assign ICD-10 codes based on the cause of death. According to CDC officials, the National Center for Health Statistics uses these coded records to compile national vital statistics files in NVSS, which is the source of official statistics on mortality in the United States, including maternal deaths. NVSS data are used to identify national trends and make international comparisons.

CDC published national maternal mortality rates for deaths that occurred in 2007 based on data collected in NVSS in its report on all deaths in the United States. CDC also made these data publicly available in microdata files that can be downloaded through website applications and, according to officials, in response to specific requests when additional details, such as geography, are sought. However due to staggered implementation of the 2003 revised death certificate by the states and reliability concerns about the use of the pregnancy checkbox, CDC officials said that as of September 2019, they have not published NVSS statistics on maternal mortality in the agency’s annual mortality reports since the report on deaths that occurred in 2007. For example, as specified in the technical notes of a June 2019 CDC report on national vital statistics for deaths in 2017, CDC noted evidence of an increase in false reporting of maternal deaths as a result of incorrect completion of the pregnancy checkbox on death certificates. According to CDC officials, the individual who completed the pregnancy checkbox may have incorrectly noted that a woman was pregnant or had been pregnant within 1 year of her death, and as a result, the death would have been recorded as a maternal death or late maternal death. However, prior to the addition of the pregnancy checkbox, there was a general concern that the United States was not identifying all of the maternal deaths and thus did not have a full picture of maternal mortality.

According to CDC officials, the agency has recently taken steps to improve NVSS data on maternal mortality. For example, in 2018, CDC developed training for individuals who complete the cause of death portion of a death certificate, and in 2019 was developing guidance on completing the pregnancy checkbox. The agency also participated in a quality assurance pilot from January 2016 through March 2017 with four states, Georgia, Louisiana, Michigan, and Ohio, to test processes that may improve state-level data on maternal mortality. The results of the pilot were made available in articles in 2019, and CDC officials said the agency is currently disseminating the findings from the pilot to other states. According to agency officials, one of the findings from the pilot was that a greater proportion of deaths where the pregnancy checkbox on the death certificate was marked incorrectly were for women aged 45 and older. As a result, CDC officials said they plan to use additional criteria when classifying deaths for these women. Specifically, they will only code the death as a maternal death or late maternal death if the cause of death is explicitly reported on the death certificate as due to pregnancy or an obstetric cause.

CDC officials stated that the changes they made improved the accuracy of data on maternal mortality, and they will implement the new reporting criteria for 2018 data. On January 30, 2020, CDC published maternal mortality statistics in a National Vital Statistics Report. For data on maternal mortality accessible through CDC’s website, CDC officials said they will direct users of these data to its limitations that are noted in the annual report. Officials said they will also publish guidance on the limitations of the maternal mortality statistics, and they will continue to monitor the accuracy of the data. Taking these steps to improve the NVSS data on maternal mortality and noting their limitations should help provide federal, state, and local organizations with accurate data. For example, CDC notes on its CDC WONDER website that state, local, and county health departments rely on this source of publicly accessible data to review their community’s population health trends, evaluate their program’s performance for planning purposes, and compare their community with other locations.

In 1986, CDC initiated a second national surveillance system for maternal mortality, PMSS. Unlike NVSS, PMSS is exclusively focused on pregnancy-related deaths. According to CDC, the system was developed because more clinical classification of the causes of these deaths was needed in order to fill data gaps and help clinicians and public health professionals to better understand circumstances surrounding pregnancy- related deaths, including the causes and appropriate actions to prevent them. This collection effort included expanding the scope of deaths under surveillance to those up to 1 year after the end of pregnancy, which is beyond the international standard of up to 42 days after the end of a pregnancy.

To collect the additional data, CDC officials annually send requests to vital records offices for all 50 states and other applicable jurisdictions to provide the following: death certificates, linked live birth or fetal death certificates, and any other supporting information for 1) deaths with an ICD-10 Chapter O code for the previous year, and 2) all deaths from any cause (including injury or trauma) among women who were pregnant or were within 1 year of pregnancy as identified by matching the death certificate to a birth or fetal death certificate or by a pregnancy checkbox on the death certificate. According to CDC officials and related literature, linking information on death certificates to information on infant birth or fetal death certificates can help confirm that the pregnancy checkbox on the death certificate was completed accurately. In addition to confirming validity of a pregnancy-related death as indicated by the checkbox, linking information on death certificates to infant birth or fetal death certificates can identify pregnancy-related deaths where the checkbox did not indicate a pregnancy but should have (false negatives). CDC officials said that PMSS data are considered the most reliable source of national data on pregnancy-related deaths because (1) PMSS links death certificates with birth or fetal death certificates and additional information when available (e.g., hospital records), and (2) these files are reviewed by medically trained epidemiologists to determine if the cause and time of death are related to the pregnancy.

CDC publishes national data from PMSS on the leading causes of pregnancy-related deaths and pregnancy-related mortality ratios using this system. However, the data are not published annually—such as is generally the case with NVSS data on deaths—and only national level data are made publicly available from PMSS in annual updates on the website and periodically in reports. According to agency officials, states and jurisdictions voluntarily provide the records in response to CDC’s request that specifies that PMSS analyses will only be published at the national and regional level, and those records are subject to confidentiality protections. Additionally, according to CDC officials, because of the time involved in collecting documentation from states, the most recent data available from PMSS as of September 2019 were for deaths in 2016.

To improve the timeliness of PMSS data, CDC is taking steps to gain access directly to the records that states have been submitting to the agency. Specifically, CDC entered into a contract, effective August 2019, for a pilot project with the National Association for Public Health Statistics and Information Systems to become an approved user of the State and Territorial Exchange of Vital Events system. According to the National Association for Public Health Statistics and Information Systems, this vital events system provides timely access to state vital records, including records on deaths, to federal and state data partners for use in authorized public health and administrative programs, like those at CDC. According to the contract, over the next 5 years, select CDC staff will receive training on the use of the system and will coordinate phased access to state and jurisdiction vital records. At the conclusion of the contract, authorized CDC staff are expected to have access to electronic vital records data from up to 51 states and jurisdictions. CDC officials said this should allow them to link birth and death certificate information and no longer rely on states and jurisdictions to conduct vital records linkages for PMSS. According to CDC officials, being able to access the vital events system will allow them to confirm and report pregnancy-related deaths with improved timeliness.

In 2017, CDC released MMRIA, in which MMRCs— multidisciplinary committees at the state and other jurisdictional level that review pregnancy-related deaths—can collect and review data from various sources (e.g., medical records, social service records, autopsy reports, and vital records) to determine preventability, and identify factors that contributed to these deaths as well as prevention strategies to address these factors. As of June 2019, CDC officials said that 25 states and one other jurisdiction were using this system.

While MMRCs provide the information collected in MMRIA, federally published reports only include aggregate information from select states collected through the application. For example, in May 2019, CDC published a study using information from 13 states. In the study, state MMRCs identified an average of three to four contributing factors per pregnancy-related death based on information collected through MMRIA, such as: community factors (e.g., unstable housing and limited access to transportation); health facility factors (e.g., limited experience with obstetric emergencies and lack of appropriate personnel or services); patient factors (e.g., lack of knowledge of warning signs and nonadherence to medical regimens); provider factors (e.g., missed or delayed diagnosis); and system-level factors (e.g., inadequate access to care and poor case coordination).

Similar to PMSS data, the most current aggregated data that CDC publishes from the MMRIA can be for deaths that occurred 2 or more years prior to the date of the report. As noted in the May 2019 article, the most recent information from states contributing to the article varied with some state data on these deaths being as recent as 2017 while the most recent data from other states was from 2014. According to CDC officials, in August 2019, CDC awarded 24 cooperative agreements covering 25 states, and under these agreements, the committees will use the system to record review results within 2 years of a death.

Data Show an Overall Increase in the Pregnancy-Related Mortality Ratio, with Specific Causes Varying by Race/Ethnicity, Age, and Other Factors

Our analysis of CDC’s PMSS data shows that from 2007 through 2016, over 6,700 women died of causes related to or aggravated by their pregnancy—either while pregnant or within 1 year of the end of pregnancy. Our analysis also shows that while there was an overall increase in the pregnancy-related mortality ratio during this time frame, the annual mortality ratio in the United States fluctuated. As previously noted, CDC data also show that racial and age disparities exist in the rates of pregnancy-related deaths. For example, from 2007 through 2016, non-Hispanic black women were more than three times as likely to die than non-Hispanic white women, while non-Hispanic American Indian/Alaska Native women were more than two times as likely to die than non-Hispanic white women. Similarly, rates of pregnancy-related deaths for women 35 years old and older are higher than the rates for women under 30 years old. During this time period, the specific causes of death varied by race/ethnicity and age. Further, CDC data show that most of the deaths occurred within 42 days of delivery or the end of pregnancy.

Cardiovascular Conditions, Infection, and Hemorrhage Were the Leading Causes of Pregnancy-Related Deaths, though Causes Differed Among Racial/Ethnic and Age Groups

CDC’s PMSS data show that among all pregnancy-related deaths, the cause of death varied. In general, what CDC classifies as “other cardiovascular conditions” was the most common cause of pregnancy- related deaths, followed by infection, hemorrhage, and cardiomyopathy. (See fig. 4.) These four leading causes comprised about 50 percent of all pregnancy-related deaths from 2007 through 2016. See appendix I for more information on leading causes of pregnancy-related deaths.

CDC data shows that the leading causes of pregnancy-related deaths differed by racial/ethnic groups. Specifically, for non-Hispanic white and black women, the leading cause was other cardiovascular conditions from 2007 through 2016; for non-Hispanic American Indian/Alaska Native and Asian/Pacific Islander women, it was hemorrhage; for Hispanic women, it was infection, as indicated by figure 5. CDC has reported that multiple factors contribute to pregnancy-related mortality and to racial/ethnic disparities, including community, health facility, patient/family, provider, and system factors.

Leading causes of pregnancy-related deaths also differed by the age of the woman, as indicated by figure 6. Specifically, the leading cause for women under 25 was infection, while for all other women the leading cause was other cardiovascular conditions. In a 2017 article, the authors noted that maternal morbidity and mortality rates increase with advanced maternal age, due in part to increased prevalence of chronic conditions (e.g., hypertension, diabetes, and chronic heart disease.). This may help explain the variation in the rate of pregnancy-related deaths among women of different ages.

Most Pregnancy-Related Deaths Occurred within 42 Days of the End of Pregnancy, while Specific Causes of Death Varied Depending on When the Death Occurred

Our analysis of CDC’s PMSS data shows that from 2011 through 2016, most pregnancy-related deaths occurred between 0 and 42 days postpartum—meaning that they occurred either on the day of delivery or end of pregnancy up to 42 days after pregnancy. (See fig. 7.) According to CDC officials, understanding the timing of pregnancy-related deaths is important for prioritizing intervention strategies. The officials noted that deaths resulting from cardiomyopathy can occur months after pregnancy but can also be prevented with appropriate interventions. In particular, the American College of Obstetricians and Gynecologists published guidance for managing pregnancy and heart disease that noted that complications are frequently encountered in the days, weeks, and months after delivery in women with known cardiovascular disease and in those with latent cardiovascular disease. Women with multiple risk factors for cardiovascular disease may be particularly at risk of manifesting symptoms for the first time during their postpartum course.

CDC’s data show that the leading causes of pregnancy-related death varied depending on when the death occurred. For example, over the period 2011-2016, hemorrhage and amniotic fluid embolism were leading causes of pregnancy-related deaths on the day of delivery or the end of pregnancy, while cardiomyopathy was the leading cause of pregnancy- related deaths between 43 and 365 days postpartum. (See fig. 8.) A recent article on pregnancy-related deaths stated that multiple factors contribute to pregnancy-related deaths during pregnancy, labor and delivery, and the postpartum period. Further, the article notes that no single intervention strategy is sufficient, and reducing these deaths requires reviewing and learning from each death, improving women’s health, and reducing social inequities across the life span, as well as ensuring quality care for pregnant and postpartum women, according to the article. See appendix II for supplemental data on pregnancy-related deaths.

HHS Funds Multiple Ongoing Efforts Focused on Reducing Pregnancy-Related Deaths

State Participation in the Alliance for Innovation on Maternal Health (AIM) Initiative According to the American College of Obstetrics and Gynecology, as of June 2019, 26 states were enrolled in the AIM initiative. The AIM initiative, funded by the Health Resources and Services Administration, engages provider organizations, state-based public health systems, consumer groups and others in a national partnership to assist state- based teams in implementing evidence-based maternal safety bundles. Ten of the 26 states joined in the last year and are beginning to implement maternal safety bundles and collect data. Five of these bundles are being implemented by one or more states. Bundle topics: Maternal Venous Thromboembolism, Postpartum Care Basics for Maternal Safety: From Birth to Comprehensive Postpartum Visit, Obstetric Care for Women with Opioid Use Disorder, Obstetric Hemorrhage, Reduction of Peripartum Racial/Ethnic Disparities, Safe Reduction of Primary Cesarean Birth, Severe Hypertension in Pregnancy, and Postpartum Care Basics for Maternal Safety: Transition from Maternity to Well Woman Care.

Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees Cooperative Agreements. Under these cooperative agreements, CDC is providing funding to state agencies and organizations that coordinate and manage MMRCs. As previously mentioned, MMRCs systematically and comprehensively review pregnancy-related deaths in order to identify prevention opportunities. Funding recipients will identify and review deaths within 1 year of death and enter clinical and non-clinical data and committee decisions in MMRIA—a standardized data system managed by CDC—within 2 years of death. As part of the agreement, recipients—in coordination with CDC—analyze data and share findings with stakeholders, such as clinicians, to inform policy and prevention strategies to reduce pregnancy-related deaths, such as screening procedures. According to CDC officials, in August 2019, CDC awarded these 5-year cooperative agreements to 24 recipients covering 25 states. Recipients received different amounts ranging from $150,000 to over $550,000 in the first year to support their MMRC. CDC anticipates awarding a similar level of funding for the 5- year period of performance.

Maternal and Child Health (MCH) Services Block Grant Program.

HRSA provides funding through this program to 59 states and jurisdictions to improve maternal and child health. According to agency officials, many recipients reported using their MCH Services Block Grant funding to help support or complement other federal initiatives, such as an MMRC, a Perinatal Quality Collaborative (PQC), and Alliance for Innovation on Maternal Health (AIM) maternal safety bundles. For example, according to HRSA officials, in fiscal year 2018, 38 recipients self-reported that the block grant partially or fully funded their MMRCs, and additional states and jurisdictions reported using block grant support for planning activities to begin development of their MMRC. Further, states and jurisdictions cited PQCs, networks of multidisciplinary teams that work to improve measurable outcomes for maternal and infant health, in their block grant narrative. Additionally, implementation of a HRSA-supported AIM maternal safety bundle, sets of actionable, evidence-based practices for improving maternal outcomes was cited. (Appendix III includes more information on funding for PQCs and AIM maternal safety bundles.) Our review of HRSA documentation shows that in fiscal year 2017, total federal expenditures for the block grant program were about $540 million for women and children covered by the program, and expenditures for services for pregnant women from all sources—federal funds, as well as state, local, program income, and other funds—was about $300 million.

Indian Health Service (IHS) Implementation of Alliance for Innovation on Maternal Health (AIM) Maternal Safety Bundles In 2017, IHS’s leadership released a request that IHS federal hospitals that provide inpatient obstetric care implement at least one maternal safety bundle—sets of evidence- based practices that when implemented collectively and reliably in the delivery setting may improve patient outcomes and reduce maternal mortality and severe maternal morbidity. According to IHS, since 2014, IHS has had phased implementation of the bundles in federal hospitals that provide inpatient obstetric care. Officials said that for many facilities, Obstetric Hemorrhage was the first bundle implemented. Others have also been implemented, such as the Severe Hypertension in Pregnancy bundle, and the Obstetric Care for Women with Opioid Use Disorder bundle.

According to officials we interviewed in five selected states, they use these two efforts—MMRC findings and MCH block grant funding—and other efforts collectively to address pregnancy-related deaths. For example, according to Georgia officials, Georgia’s PQC received funding from CDC and implemented the AIM obstetric hemorrhage maternal safety bundle in 2018 based on the state’s MMRC finding that hemorrhage was a leading cause of pregnancy-related deaths in Georgia. According to officials, Georgia’s MMRC was funded primarily through the MCH Services Block Grant. Similarly, according to Maryland officials, Maryland’s PQC oversees implementation of the state’s AIM initiative. Officials we interviewed from three of the five selected states said that the AIM initiative had an immediate or the largest effect on addressing maternal mortality in their state. Officials from the other two states said they could not identify which efforts had the largest or most immediate effect on addressing maternal mortality. Officials from one state noted the importance of their collaborative approach and the other noted that there is no one contributing factor for maternal mortality. See appendix V for more information about how the selected states we interviewed are using these funding efforts.

All five states also mentioned beginning or continuing to address racial/ethnic or other health disparities with block grant funding, through their MMRCs, or other efforts. For example, officials in one state said they use block grant funding to support its Black Infant Health Program, which helps address maternal morbidity and mortality of black mothers in the late maternal period. Additionally, two of the HHS funding efforts awarded in fiscal year 2019 have outcomes related to decreasing racial and ethnic disparities in maternal mortality: the Alliance for Innovation on Maternal Health Community Care Initiative and the State Maternal Health Innovation Program.

In addition to those efforts that are exclusive to maternal mortality or have a focus on maternal mortality, HHS agencies have other funding efforts that may reduce maternal mortality by improving maternal health. For example, agency officials also identified the following:

HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program supports voluntary, evidence-based home visiting services for at-risk pregnant women and parents with children up to kindergarten entry. Our review of agency documentation shows that in fiscal year 2019, HRSA awarded about $351 million in funding to 56 states, territories, and nonprofit organizations to support communities in providing voluntary evidence-based home visiting services through the Maternal, Infant, and Early Childhood Home Visiting Program.

The Substance Abuse and Mental Health Services Administration, which is responsible for leading public health efforts to advance the behavioral health of the nation and reducing the impact of substance abuse and mental illness on America’s communities. The agency funds two programs that provide grants to public and private nonprofit entities and state substance abuse agencies for substance use disorder treatment and recovery services for pregnant and postpartum women. Our review of agency documentation and interviews with agency officials shows that from fiscal year 2017 through 2019, the Substance Abuse and Mental Health Services Administration awarded 41 Services Grant Program for Residential Treatment for Pregnant and Postpartum Women and six State Pilot Grant Program for Treatment for Pregnant and Postpartum Women grants.

The Centers for Medicare & Medicaid Services, which administers the Medicare and Medicaid programs, developed the Maternal Opioid Misuse Model. Through this model, state Medicaid agencies will coordinate with care-delivery partners to test whether payments for evidence-based, coordinated care delivery improve outcomes and reduce costs for pregnant and postpartum Medicaid beneficiaries with opioid use disorder and their infants. According to agency officials, funding for cooperative agreements with 10 state Medicaid agencies began in January 2020.

Agency Comments

We provided a draft of this report to HHS. HHS provided technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of HHS, and appropriate congressional committees. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have questions about this report, please contact me at (202) 512-7114 or deniganmacauleym@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VI.

Appendix I: Pregnancy Mortality Surveillance System Cause of Death Categories

In 1986, the Centers for Disease Control and Prevention (CDC) initiated national surveillance of pregnancy-related deaths in the Pregnancy Mortality Surveillance System (PMSS) because more clinical information was needed to fill data gaps about causes of these deaths. A pregnancy- related death, as defined in statute, is the death of a woman while pregnant or within 1 year of the end of a pregnancy—regardless of the outcome, duration or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

As of September 2019, CDC used 11 categories when coding the cause of death for pregnancy-related deaths in PMSS, and 2016 data were the most recent data available. From 2007 through 2016, there were 6,765 pregnancy-related deaths, according to PMSS data. See table below for information on the 11 cause of pregnancy-related death categories, including PMSS data on leading causes, most common time frame, and most common age group affected.

Appendix II: Supplemental Data on Pregnancy-Related Deaths

The following tables include supplemental data on pregnancy-related deaths by racial/ethnic and age groups.

Appendix III: Ongoing Department of Health and Human Services Funding Efforts to Reduce Pregnancy-Related Deaths

As of September 2019, the Department of Health and Human Services was providing funding for 13 efforts with a stated outcome, goal, or focus on reducing pregnancy-related deaths. One of the these—Supporting Maternal Mortality Review Committees—is funded by CDC and has an exclusive focus on reducing deaths of the women during pregnancy or up to 1 year of pregnancy, while the other 12 have additional focus areas, such as improving infant health. Two of these efforts are not discrete funding opportunities, but rather a variety of research funding opportunities offered by the Health Resources and Services Administration and the National Institutes of Health. Table 5 lists the 13 efforts, their current awards, funding, purpose, and examples of goals or research.

Appendix IV: Health Resources and Services Administration and National Institutes of Health Research

Health Resources and Services Administration (HRSA) and National Institutes of Health (NIH) officials noted research the agencies support, including funding related to maternal health that also includes projects specific to maternal mortality or that can affect maternal mortality.

The Maternal and Child Health Bureau supports field-based, applied and translational research through an extramural research program that provides leadership and funding that support innovative research to inform practitioners, the scientific community, and the public. According to HRSA officials, this research program helps to advance the field of maternal and child health; improve the health and well-being of women, children, and families; and address the needs of economically or medically vulnerable maternal and child health populations.

According to HRSA officials, in fiscal year 2018, HRSA awarded a total of about $1.2 million in funding for six research projects related to maternal illness. The following HRSA website includes an option for searching for funded projects using key terms, https://mchb.hrsa.gov/research/.

Surveillance of Maternal Mortality

Baeva, S., D.L. Saxton, K. Ruggiero, et al. “Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012”, Obstetrics & Gynecology, vol. 131, no. 5 (2018): 762-769.

Maternal Health

Casey, M.M., P. Hung, C. Henning-Smith, et al. “Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures.” Joint Commission Journal on Quality and Patient Safety, vol. 42, no. 4 (2016): 179-187.

Hung, P., K.B. Kozhimannil, M.M. Casey, et al. “Why Are Obstetric Units in Rural Hospitals Closing Their Doors?” Health Services Research, vol. 51, no. 4 (2016): 1546-1560.

Kozhimannil, K.B., C. Henning-Smith, P. Hung, et al. “Ensuring Access to High-Quality Maternity Care in Rural America.” Women’s Health Issues, vol. 26, no. 3 (2016): 247-250.

Kozhimannil, K.B., P. Hung, M.M. Casey, et al. “Factors Associated with High-Risk Rural Women Giving Birth in Non-NICU Hospital Settings.” Journal of Perinatology, vol. 36, no. 7 (2016): 510-515.

Kozhimannil, K.B., M.M. Casey, P. Hung, et al. “Location of Childbirth for Rural Women: Implications for Maternal Levels of Care.” American Journal of Obstetrics and Gynecology, vol. 214, no. 5 (2016): 661e1- 10.

Kozhimannil, K.B., C. Henning-Smith, and P. Hung. “The Practice of Midwifery in Rural US Hospitals.” Journal of Midwifery & Women’s Health, vol. 61, no. 4 (2016): 411-418.

Kozhimannil, K.B., P. Hung, M.M. Casey, et al. “Relationship between Hospital Policies for Labor Induction and Cesarean Delivery and Perinatal Care Quality among Rural U.S. Hospitals.” Journal of Health Care for the Poor and Underserved, vol. 27, no. 4 (2016): 128-143.

Weigel, P.A., F. Ullrich, D.M. Shane, et al. “Variation in Primary Care Service Patterns by Rural-Urban Location.” Journal of Rural Health, vol. 32, no. 2 (2016): 196-203.

NIH support research, including funding maternal health research through a number of its institutes and centers, such as the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute of Alcohol Abuse and Alcoholism; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute of Mental Health; the National Institute of Nursing Research, and the Office of Research on Women’s Health. For example, NIH officials noted that The Eunice Kennedy Shriver National Institute of Child Health and Human Development supports essential research designed to overcome many of the complex challenges that women encounter in trying to achieve and maintain healthy pregnancies, and to prevent maternal mortality and severe maternal morbidity.

In fiscal year 2018, NIH funded 661 projects totaling almost $303 million that included a focus on maternal health. The following NIH website includes a link to funded research for fiscal years 2015 through 2018 and estimates for fiscal year 2019 and 2020 by category, including maternal health, https://report.nih.gov/categorical_spending.aspx.

Surveillance of Maternal Mortality

MacDorman, M.F., E. Declercq , and M.E. Thoma. “Making Vital Statistics Count: Preventing U.S. Maternal Deaths Requires Better Data.” Obstetrics & Gynecology, vol. 131, no. 5 (2018): 759-761.

MacDorman, M.F., E. Declercq, H. Cabral, et al. “Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends from Measurement Issues.” Obstetrics & Gynecology, vol. 128, no. 3 (2016): 447-455.

Thoma, M.E., D.A. De Silva, and M.F. MacDorman. “Examining Interpregnancy Intervals and Maternal and Perinatal Health Outcomes Using U.S. Vital Records: Important Considerations for Analysis and Interpretation.” Paediatric and Perinatal Epidemiology, vol. 33, no. 1 (2019): O60-O72.

Maternal Health

Brogly, S.B., K.E. Saia, M.M. Werler, et al. “Prenatal Treatment and Outcomes of Women with Opioid Use Disorder.” Obstetrics & Gynecology, vol. 132, no. 4 (2018): 916-922.

Dimidjian, S., S.H. Goodman, J.N. Felder, et al. “Staying Well During Pregnancy and the Postpartum: A Pilot Randomized Trial of Mindfulness-based Cognitive Therapy for the Prevention of Depressive Relapse/Recurrence.” Journal of Consulting and Clinical Psychology, vol. 84, no. 2 (2016): 134-145.

Hauspurg, A., S. Parry, B.M. Mercer, et al. “Blood Pressure Trajectory and Category and Risk of Hypertensive Disorders of Pregnancy in Nulliparous Women.” American Journal of Obstetrics and Gynecology, vol. 221, no. 3 (2019): 277.e1-277.e8.

Liu, T., M. Zhang, E. Guallar, et al. “Trace Minerals, Heavy Metals, and Preeclampsia: Findings from the Boston Birth Cohort.” Journal of the American Heart Association, vol. 8, no. 16 (2019): e012346.

Miller, E.C., M. Gallo, E.R. Kulick, et al. “Infections and Risk of Peripartum Stroke during Delivery Admissions.” Stroke, vol. 49, no. 5 (2018): 1129-1134.

Sheen, J.J., J. D. Wright, D. Goffman, et al. “Maternal Age and Risk for Adverse Outcomes.” American Journal of Obstetrics and Gynecology, vol. 219, no. 4 (2018): 390.e1-390.e15.

Appendix V: Maternal Mortality Efforts in Selected States

To describe how selected states use Department of Health and Human Services (HHS) funds to implement select efforts to reduce maternal mortality, we interviewed officials from five states—California, Georgia, Illinois, Maryland, and Texas—selected because of their geographic diversity and because these state have the following efforts shown in Table 6. Officials from three of the five states we interviewed said that the Alliance for Innovation on Maternal Health (AIM) Initiative had an immediate or the largest effect on addressing maternal mortality in their state. Officials from the other two states said they could not identify which efforts had the largest or most immediate effect on addressing maternal mortality. Officials from one state noted the importance of a collaborative approach and the other noted that there is no one contributing factor for maternal mortality. Some of the HHS-funded efforts previously described in appendix III had not been awarded at the time of our interviews, such as the State Maternal Health Innovation Program cooperative agreements. See table 6 below for information about these states’ efforts.

Appendix VI: GAO Contact and Staff Acknowledgments

GAO Contact:

Mary Denigan-Macauley, Director, (202) 512-7114 or deniganmacauleym@gao.gov.

Staff Acknowledgments:

In addition to the contact above, Raymond Sendejas (Assistant Director), Natalie Herzog (Analyst-in-Charge), Sam Amrhein, Margaret Cullinan, Kaitlin Dunn, Laura Ann Holland, Diona Martyn, Jennifer Rudisill, and Vikki Porter made key contributions to this report. Other contributors include Jieun Chang, Leia Dickerson, Sandra George, and Amy Leone.