Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States

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Abstract
The US has a high rate of maternal mortality, compared with other high-income countries, despite spending more per person on health care.1,2 Over the past 2 decades, maternal mortality in other high-income countries has decreased while in the US it has increased.2 The Global Burden of Disease (GBD) Study estimated that national maternal mortality ratios (MMRs) for high-income countries in 2019 ranged from 4 deaths/100 000 live births to 44 deaths/100 000 live births.3 At the national level, US MMRs (or maternal deaths per 100 000 live births) are 2 to 4 times higher in the non-Hispanic Black (hereafter referred to as Black) population than in the non-Hispanic White (hereafter referred to as White) population.2 These elevated risks hold true even when controlling for maternal comorbidities and education.2,4 A broad range of causes have been identified to explain inequities in US maternal mortality, including structural and interpersonal racism.5 While there has been substantial focus on disparities between Black and White populations, MMRs are also higher for non-Hispanic American Indian and Alaska Native (hereafter referred to as American Indian and Alaska Native) compared with White populations.6 Although it is known that maternal mortality differs by racial and ethnic groups nationally, there is little understanding of state-level trends. This is particularly true for smaller states with lower death counts, where the reporting of deaths by race and ethnicity can threaten anonymity and where drawing meaningful statistical comparisons can be challenging.7

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