Mortality Rates Among U.S. Women of Reproductive Age, 1999-2019

Memorable Messages about Pregnancy and Abortion from the Perspective of College-Enrolled Emerging Adults

Emerging adults are the age group in the U.S. most likely to become pregnant, have a child, receive abortions, and be most supportive of legal abortion. To gain insight into these seemingly contradictory facts and attitudes, this study examines emerging adults' memorable messages about abortion and pregnancy to understand the beliefs, norms, values, and expectations circulating for younger adults. Ninety-two emerging adult college students provided memorable messages about both abortion and pregnancy. Utilizing thematic co-occurrence analysis, messages about pregnancy and abortion were characterized by three themes: political ideologies of sex, healthcare experience, and life-changing. Emerging adults described the messages as making them feel knowledgeable, empowered, and scared. Two theoretical relationships were identified: (1) pregnancy is connected to the political ideologies of sex with reactions of feeling empowered and scared and (2) abortion is connected to the politics of sex and the reactions of feeling knowledgeable and scared. Theoretical implications for the theory of memorable messages and practical applications for emerging adults are discussed.

Changes in Racial and Ethnic Inequities in Pregnancy-Associated Death in the United States During the COVID-19 Pandemic

Objectives. To examine changes in cause-specific pregnancy-associated deaths during the COVID-19 pandemic by race and ethnicity and assess changes in racial and ethnic inequities in pregnancy-associated deaths. Methods. We used US vital statistics mortality data from 2018 to 2021 to identify pregnancy-associated deaths among females aged 15 to 44 years. We calculated crude pregnancy-associated death rates (deaths per 100 000 live births) by year, cause, and race/ethnicity, percent change in death rate, and the inequity (difference) in rate for each racial or ethnic group compared with non-Hispanic White people. Results. The pregnancy-associated death rate for obstetric, drug-related, homicide, and other causes of death increased during 2020, and obstetric deaths continued to increase in 2021. Overall estimates mask 2021 increases in drug-related deaths among Hispanic, non-Hispanic American Indian and Alaska Native (AI/AN), and non-Hispanic Asian people; increases in homicide among most racial and ethnic groups; and increases in suicide among Hispanic, non-Hispanic AI/AN, and non-Hispanic Asian people. Conclusions. We found disproportionate increases in pregnancy-associated deaths from nonobstetric causes among minoritized racial and ethnic groups during the COVID-19 pandemic. (Am J Public Health. 2024;114(7):733-742. https://doi.org/10.2105/AJPH.2024.307651).

Evolution of mortality rates among women of reproductive age in Brazilian municipalities: an ecological analysis using Global Burden of Disease estimates

OBJECTIVES

Women's mortality at a reproductive age has been a global concern, and its decrease has been incorporated as a target of the UN Sustainable Development Goals. The aim of this study was to describe the spatial-temporal evolution of mortality rates among women of reproductive age in Brazilian municipalities by groups of causes and socioeconomic indicators from 2000 to 2018.

STUDY DESIGN

Ecological analysis.

METHODS

This work was an ecological, descriptive study that analyzed estimates of mortality rates among women of reproductive age (15-49 years) by main groups of causes of death from the Global Burden of Disease (GBD) study in three consecutive trienniums, T1 (2000-2002), T2 (2009-2011), and T3 (2016-2018). To quantify the temporal evolution in mortality rates, the present study calculated the percentage change for each triennium. The spatial analysis of mortality rates was carried out using Moran's index. The Pearson coefficient was used to analyze the correlation between the data.

RESULTS

A significant decline in mortality rates was found for all groups of causes in all regions of the country. Despite the downward trend, the percentage change from 2009 to 2011 to 2016 to 2018 showed a decrease in the group of Noncommunicable Diseases (NCDs) and external causes. The decline in mortality rates of women due to external causes showed only a minimal change in the North and Northeast regions from T2 to T3, whereas a cluster of neighboring municipalities with high mortality rates persisted in the municipalities of the South region and in the state of Roraima. The ranking of the main causes of death in Brazilian municipalities showed an increase in neoplasms in detriment to cardiovascular diseases (CVDs).

CONCLUSIONS

The main causes of death in women of reproductive age at a more local level could be used to recognize inequalities and to develop interventions aimed at tackling premature and preventable deaths.

The impact of early death on birth counts in the United States, 1950 to 2019

In a previous issue of PNAS Nexus, Bor et al. quantified the number of "missing Americans"-the deaths that would have been averted if the United States had experienced the mortality conditions of other wealthy nations. In 2019 alone, their estimates indicate that more than 100,000 individuals in reproductive ages (15-49 years) would have survived. The concept of the "missing Americans" is a valuable one, but here we argue that it is incomplete because it does not include children that would have been born to those who died an early death. We examine 3 indicators to assess the strength of the mortality-fertility nexus at the population level, showing that mortality more negatively affects birth counts in the United States than in other wealthy nations. Using the mortality conditions in other wealthy nations as a reference, we estimate that between 2010 and 2019 alone, approximately 200,000 children were not born in the United States due to the premature death of their potential mothers. Our findings highlight that improving morbidity and mortality among people of reproductive age-without compromising their reproductive autonomy-is critical in the United States.

Adverse Pregnancy Outcomes and Predicted 30-Year Risk of Maternal Cardiovascular Disease 2-7 Years After Delivery

OBJECTIVE

To determine whether adverse pregnancy outcomes are associated with a higher predicted 30-year risk of atherosclerotic cardiovascular disease (CVD; ie, coronary artery disease or stroke).

METHODS

This was a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. The exposures were adverse pregnancy outcomes during the first pregnancy (ie, gestational diabetes mellitus [GDM], hypertensive disorder of pregnancy, preterm birth, and small- and large-for-gestational-age [SGA, LGA] birth weight) modeled individually and secondarily as the cumulative number of adverse pregnancy outcomes (ie, none, one, two or more). The outcome was the 30-year risk of atherosclerotic CVD predicted with the Framingham Risk Score assessed at 2-7 years after delivery. Risk was measured both continuously in increments of 1% and categorically, with high predicted risk defined as a predicted risk of atherosclerotic CVD of 10% or more. Linear regression and modified Poisson models were adjusted for baseline covariates.

RESULTS

Among 4,273 individuals who were assessed at a median of 3.1 years after delivery (interquartile range 2.5-3.7), the median predicted 30-year atherosclerotic CVD risk was 2.2% (interquartile range 1.4-3.4), and 1.8% had high predicted risk. Individuals with GDM (least mean square 5.93 vs 4.19, adjusted β=1.45, 95% CI, 1.14-1.75), hypertensive disorder of pregnancy (4.95 vs 4.22, adjusted β=0.49, 95% CI, 0.31-0.68), and preterm birth (4.81 vs 4.27, adjusted β=0.47, 95% CI, 0.24-0.70) were more likely to have a higher absolute risk of atherosclerotic CVD. Similarly, individuals with GDM (8.7% vs 1.4%, adjusted risk ratio [RR] 2.02, 95% CI, 1.14-3.59), hypertensive disorder of pregnancy (4.4% vs 1.4%, adjusted RR 1.91, 95% CI, 1.17-3.13), and preterm birth (5.0% vs 1.5%, adjusted RR 2.26, 95% CI, 1.30-3.93) were more likely to have a high predicted risk of atherosclerotic CVD. A greater number of adverse pregnancy outcomes within the first birth was associated with progressively greater risks, including per 1% atherosclerotic CVD risk (one adverse pregnancy outcome: 4.86 vs 4.09, adjusted β=0.59, 95% CI, 0.43-0.75; two or more adverse pregnancy outcomes: 5.51 vs 4.09, adjusted β=1.16, 95% CI, 0.82-1.50), and a high predicted risk of atherosclerotic CVD (one adverse pregnancy outcome: 3.8% vs 1.0%, adjusted RR 2.33, 95% CI, 1.40-3.88; two or more adverse pregnancy outcomes: 8.7 vs 1.0%, RR 3.43, 95% CI, 1.74-6.74). Small and large for gestational age were not consistently associated with a higher atherosclerotic CVD risk.

CONCLUSION

Individuals who experienced adverse pregnancy outcomes in their first birth were more likely to have a higher predicted 30-year risk of CVD measured at 2-7 years after delivery. The magnitude of risk was higher with a greater number of adverse pregnancy outcomes experienced.

Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease

BACKGROUND

Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. However, the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated.

OBJECTIVE

To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score.

STUDY DESIGN

An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic cardiovascular disease (ASCVD, composite of fatal and nonfatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2 to 7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD ≥10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty.

RESULTS

Among 4309 nulliparous individuals at baseline, the median age was 27 years (interquartile range [IQR]: 23-31) and the median ADI was 43 (IQR: 22-74). At 2 to 7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk ≥10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adjusted ß: 0.41; 95% confidence interval [CI]: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top 2 ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted risk ratio [aRR]: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69).

CONCLUSION

Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

Sex and Sleep Disruption as Contributing Factors in Alzheimer's Disease

Alzheimer's disease (AD) affects more women than men, with women throughout the menopausal transition potentially being the most under researched and at-risk group. Sleep disruptions, which are an established risk factor for AD, increase in prevalence with normal aging and are exacerbated in women during menopause. Sex differences showing more disrupted sleep patterns and increased AD pathology in women and female animal models have been established in literature, with much emphasis placed on loss of circulating gonadal hormones with age. Interestingly, increases in gonadotropins such as follicle stimulating hormone are emerging to be a major contributor to AD pathogenesis and may also play a role in sleep disruption, perhaps in combination with other lesser studied hormones. Several sleep influencing regions of the brain appear to be affected early in AD progression and some may exhibit sexual dimorphisms that may contribute to increased sleep disruptions in women with age. Additionally, some of the most common sleep disorders, as well as multiple health conditions that impair sleep quality, are more prevalent and more severe in women. These conditions are often comorbid with AD and have bi-directional relationships that contribute synergistically to cognitive decline and neuropathology. The association during aging of increased sleep disruption and sleep disorders, dramatic hormonal changes during and after menopause, and increased AD pathology may be interacting and contributing factors that lead to the increased number of women living with AD.

Role of Maternal Age in Increasing Severe Maternal Morbidity Rates in the United States

OBJECTIVE

To evaluate a commonly proposed explanation for increasing rates of severe maternal morbidity (SMM) in the United States: shifts in the birthing population to older maternal ages, a known risk factor for SMM.

METHODS

We conducted a cross-sectional analysis comparing delivery hospitalizations from two time points (2008-2009 to 2017-2018) using hospital discharge data from the National Inpatient Sample. We used demographic decomposition techniques to evaluate whether increasing rates of SMM and nontransfusion SMM were explained by population-level increases in maternal age or changes in age-specific rates. Analyses were stratified by race and ethnicity.

RESULTS

Rates of SMM and nontransfusion SMM significantly increased in the United States between 2008 and 2018 from 135.6 to 170.5 and 58.8 to 67.9 per 10,000 delivery hospitalizations, respectively, with increases observed for nearly all racial and ethnic groups. Over this same period, the proportion of births to people younger than age 25 years decreased and births to people of advanced maternal age (35 years and older) increased, with the largest increases occurring among people identified as non-Hispanic American Indian/Alaskan Native (9.8-13.0%), non-Hispanic Black (10.7-14.4%), and Hispanic (12.1-17.1%). Decomposition analyses indicated that the changing maternal age distribution had little effect on SMM trends. Rather, increases in SMM and nontransfusion SMM were primarily driven by increases in age-specific SMM rates, including rising rates among younger people. Contributions of maternal age shifts were minimal for all racial and ethnic groups except among non-Hispanic Black people, for which 17-34% of the rise in SMM was due to increasing maternal age.

CONCLUSION

Except among certain racial groups, increases in U.S. population-level SMM rates over the past decade were due to increases in age-specific rates rather than shifts to older maternal age among the birthing population. Increasing SMM rates across the maternal age spectrum could indicate worsening prepregnancy health status of the birthing population.

Trends and Factors Associated With the Mortality Rate of Depressive Episodes: An Analysis of the CDC Wide-Ranging Online Data for Epidemiological Research (WONDER) Database

Background Depressive episodes are associated with increased mortality rates across the United States. Recognizing the relationship between depression and physical health, understanding the contributing factors, and addressing disparities are critical in reducing mortality rates and improving the overall well-being of individuals experiencing depressive episodes. Continued research, public health efforts, and collaborative approaches are essential to tackle this complex public health concern effectively. Studying the mortality rate trends of depressive episodes along with other related factors will help enhance the understanding of the condition, which, in turn, will assist in reducing mortality rates in the vulnerable population. Methodology Data from the CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) database on the Underlying Cause of Death were examined to identify individuals who experienced fatal outcomes related to depressive episodes from 1999 to 2020. The WONDER database refers to the online system used by the CDC to make its various resources accessible to the public and public health experts. CDC WONDER offers access to a broader range of information on public health. Results A total of 13,290 individuals who died from depressive episodes between 1999 and 2020 were identified. Data analysis revealed an overall mortality rate of 0.20 per 100,000 individuals during the specified period. The highest mortality rates were observed in the years 2003 (0.28), 2001 (0.27), and 1999 (0.27). The analysis revealed significant disparities in mortality rates among different demographic groups. Older adults, females, specific racial groups, including Whites and African Americans, and specific geographic areas, including the Midwest, Northeast, South, and West, exhibited higher mortality rates associated with depressive episodes. Conclusions The study identified that older individuals, females, Whites, and African Americans, as well as certain geographic regions, exhibited an increased likelihood of mortality related to depressive episodes. These findings highlight the importance of understanding the complex interplay between mental health and mortality. The findings emphasize the importance of addressing disparities in mental health outcomes among different demographic groups. Identifying vulnerable populations can inform targeted interventions and resources to address the elevated mortality risk.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance

OBJECTIVE

There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity.

STUDY DESIGN

This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used.

RESULTS

Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation.

CONCLUSION

Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Legalisation of abortion in a poor-resource setting: nigerian undergraduates' perspectives

Background

Abortion is one of the leading causes of morbidity and mortality amongst Nigerian women in a country with restrictive abortion laws. Despite being illegal, abortions are still performed, and about 50% of abortions are performed by untrained persons in unhygienic conditions. This study assessed the determinants of attitude of undergraduates to legalisation of safe abortion in Nigeria.

Methods

It is a descriptive cross-sectional study. We used a three-stage sampling technique to select 423 undergraduates using a pre-tested questionnaire. The predictors of attitude towards abortion and its legalisation were identified during multivariate analysis.

Results

Good knowledge of abortion and its sequelae was found in about two-thirds (62.2%) of the participants, while over half (56.3%) had a negative perspective to abortion legalisation in Nigeria. Older participants were more likely to have positive perspectives to legalisation of abortion compared to their younger counterparts (odds ratio [OR] = 4.72, confidence interval [CI]: 2.61-8.55). Furthermore, respondents from upper social class and those with good knowledge were more likely to have positive perspectives to legalisation of abortion compared to their counterparts (OR = 5.63, CI: 3.12-10.16 and OR = 4.50, CI: 2.89-7.01).

Conclusion

The study showed that respondents' knowledge of abortion was relatively low amongst the study population, and more than half of the respondents did not want abortion to be legalised. Increasing awareness on the importance of abortion and its complications in Nigeria will curb the menace of death due to abortion now and in the future.

Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians

In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50 years of precedent and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive health care, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

Abortion Criminalization: A Public Health Crisis Rooted in White Supremacy

The Supreme Court decision to overturn Roe v. Wade and the growing onslaught of state laws that criminalize abortion are part of a long history of maintaining White supremacy through reproductive control of Black and socially marginalized lives. As public health continues to recognize structural racism as a public health crisis and advances its measurement, it is imperative to explicate the connection between abortion criminalization and White supremacy. In this essay, we highlight how antiabortion policies uphold White supremacy and offer concrete strategies for addressing abortion criminalization in structural racism measures and public health research and practice. (Am J Public Health. 2022;112(11):1662-1667. https://doi.org/10.2105/AJPH.2022.307014).