Maternal Mortality Among American Indian/Alaska Native Women: A Scoping Review

Foundational features of indigenous pregnancy care: Lessons learned from indigenous pregnancy care providers

PROBLEM

Indigenous populations experience higher odds of poor maternal and infant health outcomes than non-Hispanic White mothers yet have lower odds of receiving adequate prenatal care.

BACKGROUND

Many Indigenous communities rely on modern Western medical institutions to provide pregnancy related health care. These systems were not developed with or for Indigenous communities and often fail to meet the needs of Indigenous pregnant patients. Offering culturally congruent models of care may increase prenatal care utilization.

QUESTION, HYPOTHESIS OR AIM

This paper used qualitative inquiry to identify Indigenous approaches to caring for pregnancy.

METHODS

Our team conducted 16 semi-structured individual interviews and one group interview with a total of 19 respondents. To arrive at thematic categories, the research team engaged in a modified pile sorting technique. The final set of categories, along with sub-themes, descriptions and example quotes, were sent to interviewees for approval.

FINDINGS

Ten Foundational Features of Indigenous Pregnancy Care were identified. These covered themes related to Indigenous cultural practices, relationships, Indigenous sovereignty, local Indigenous community, full spectrum care, wholistic care, birthing person's wisdom, power and autonomy, flexibility, historical trauma, and cultural awareness.

DISCUSSION

Modern midwifery care delivered by Indigenous practitioners may partially bridge the cultural gap; however, intentional effort is needed to integrate Indigenous ways into medical doctor practice models and facilities.

CONCLUSION

This paper identifies ten foundational features of Indigenous pregnancy care and demonstrates the importance of recognizing the effects of trauma and providing opportunities for healing, upholding sovereignty, and centering relationships when caring for Indigenous pregnancies.

Disparities in postpartum readmission by patient- and hospital-level social risk factors in the United States: a retrospective multistate analysis, 2015-2020

BACKGROUND

Postpartum readmission is an area of focus for improving obstetric care and reducing costs. We examined disparities in all-cause 30-day postpartum readmission by patient- and hospital-level factors in the United States.

METHODS

We conducted a retrospective cohort study using 2015-2020 records from the State Inpatient Databases from four states. Generalized linear mixed models were constructed to estimate the effects of individual patient- and hospital-level factors on adjusted odds of 30-day readmission after controlling for confounders. Stratified analyses by delivery and anesthesia type (New York only) and interaction models were performed.

RESULTS

Black mothers were more likely than White mothers to be readmitted within 30-days postpartum (aOR 1.57, 95% CI 1.52 to 1.61). Mothers with public insurance had increased odds of readmission compared with those with private insurance (Medicare: aOR 2.13, 95% CI 1.95 to 2.32; Medicaid: aOR 1.14, 95% CI 1.11 to 1.17). Compared with mothers in the lowest income quartile, those in the highest quartile experienced a 14% lower odds of readmission (aOR 0.86, 95% CI 0.83 to 0.89). There were no significant associations between hospital-level characteristics and readmission. Black mothers were more likely to be readmitted regardless of delivery type and most combinations of delivery and anesthesia type. Black mothers from the highest income quartile were more likely to be readmitted than White mothers from the lowest income quartile.

CONCLUSION

Substantial disparities in 30-day postpartum readmissions by patient-level social factors were observed, particularly amongst Black mothers. Action is needed to address and mitigate disparities in postpartum readmission.

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).

Medicolegal death investigations on tribal lands-underrepresented or underserved?

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands.

Factors associated with timely initiation of antenatal care among reproductive age women in The Gambia: a multilevel fixed effects analysis

BACKGROUND

A significant factor impacting the incidence of maternal and neonatal fatalities is the timely initiation of antenatal care (ANC) services in healthcare facilities. Despite the recommendations by the World Health Organization and the numerous benefits of timely initiation of ANC, studies have revealed that the overall prevalence of timely ANC initiation in 36 sub-Saharan African countries remains low and women in The Gambia also initiate ANC late. However, no known study in The Gambia has focused on assessing the factors associated with timely initiation of ANC at the time of writing this paper. Thus, this study aimed to assess the prevalence and factors associated with the timely initiation of ANC among reproductive-age women in The Gambia.

METHODS

A cross-sectional survey design was used in this study and conducted among 5,734 reproductive-age women using data from the 2019-2020 Gambia Demographic and Health Survey (GDHS). Using STATA version 14.0, we conducted the analysis using descriptive and inferential statistics. Multilevel logistic regression models were fitted to determine the factors associated with timely ANC utilization and adjusted odds ratios were used to present the results with statistical significance set at p < 0.05.

RESULTS

The overall prevalence of timely initiation of ANC services among reproductive-age women in The Gambia was 43.0%. We found that women aged 30-34 [aOR = 1.79, 95% CI = 1.30-2.47], those who were married [aOR = 2.69, 95% CI = 1.85-3.90] as well as women from the richest households [aOR = 1.63, 95% CI = 1.20, 2.20] had higher odds of seeking timely ANC services as compared to their counterparts. Also, those who had given birth to two children [aOR = 0.74, 95% CI = 0.6 -0.91] had lower odds of initiating timely ANC as compared to those who had given birth only once. Women who reside in rural areas [aOR = 1.72, 95%CI = 1.34, 2.20] also had higher odds of seeking timely ANC services than those residing in urban areas.

CONCLUSION

Individual-level factors such as maternal age, marital status, parity, wealth status, place of residence, and religion were associated with the timely initiation of ANC services among reproductive-age women. These factors ought to be considered in efforts to increase the timely initiation of ANC among reproductive-age women in The Gambia.

Non-Obstetric Maternal Mortality Trends by Race in the United States

OBJECTIVES

Public health interventions to reduce maternal mortality have largely focused on obstetric causes of death. However, previous studies have noted that non-obstetrics factors, such as motor vehicle accidents, substance overdoses, homicides, and suicides, may account for a large proportion of maternal deaths. The study objective was to examine trends in maternal deaths from non-obstetric causes across races in the United States (US).

METHODS

A population-based cross-sectional study was conducted on 80,710,348 live births using data from the "Birth Data" and "Mortality Multiple Cause" files compiled by the Centers for Disease Control and Prevention from 2000 to 2019. The annual incidence of maternal deaths attributed to non-obstetric causes (/100,000 live-births) during pregnancy and up to 42 days postpartum were calculated across racial groups. Then the effects of race on the risk of non-obstetric maternal mortality and temporal changes over the study period were examined using logistic regression models.

RESULTS

From 2000 to 2019, a total 7,334 women died during pregnancy, childbirth, and within 42 days postpartum from non-obstetric causes, representing 34.5% (7,334/21,241) of all maternal mortality. Of non-obstetric deaths, 31.3% were caused by transport accidents and 27.3% by accidental poisoning. American Indian women were found to have the highest risk of non-obstetric maternal mortality (OR 2.20,95% CI 1.90-2.56), and 46.1% (176/382) of all deaths among pregnant American Indian women were caused by non-obstetric complications. Risk of non-obstetric maternal mortality increased overall during the 20-year study period, with a greater increase among Black (1.15, 1.13-1.17) and American Indian women (1.17, 1.13-1.21).

CONCLUSION

Non-obstetric causes of death have become increasingly prevalent in the US, especially in American Indian women. Novel interventions to address these non-obstetric factors should especially target American Indian women to improve maternal outcomes.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

A Strategy To Support Perinatal Mental Health By Collaborating With Tribal Communities In Montana

Among Indigenous women and birthing people, reported rates of perinatal mental health complications are consistently higher than in the general US population. However, perinatal mental health programs and interventions tend to focus on the general population and do not account for the unique experiences and worldviews of Indigenous Peoples. We highlight a collaborative strategy employed by a Montana nonprofit to engage Tribal communities in completing a statewide online resource guide designed to help pregnant and parenting families find resources, including mental health and substance use treatment options, within and beyond their local communities. Based on this strategy, cultural resources relevant to Tribal communities were added to the resource guide. Agencies committed to addressing perinatal mental health disparities among Indigenous populations should consider similar strategies to share power with Tribal communities and collaboratively create culturally congruent programs and interventions.

Racial disparities in national maternal mortality trends in the United States from 2000 to 2019: a population-based study on 80 million live births

PURPOSE

In the United States (US), deaths during pregnancy and childbirth have increased over the past 2 decades compared to other high-income countries, and there have been reports that racial disparities in maternal mortality have widened. The study objective was to examine recent trends in maternal mortality in the US by race.

METHODS

Our population-based cross-sectional study used data from the Centers for Disease Control and Prevention's 2000-2019 "Birth Data" and "Mortality Multiple Cause" data files from the US to calculate maternal mortality during pregnancy, childbirth, and puerperium across race. Logistic regression models estimated the effects of race on the risk of maternal mortality and examined temporal changes in risk across race.

RESULTS

A total of 21,241 women died during pregnancy and childbirth, with 65.5% caused by obstetrical complications and 34.5% by non-obstetrical causes. Black women, compared with White women, had greater risk of maternal mortality (OR 2.13, 95% CI 2.06-2.20), as did American Indian women (2.02, 1.83-2.24). Overall maternal mortality risk increased during the 20-year study period, with an annual increase of 2.4 and 4.7/100,000 among Black and American Indian women, respectively.

CONCLUSIONS

Between 2000 and 2019, maternal mortality in the US increased, overall and especially in American Indian and Black women. Targeted public health interventions to improve maternal health outcomes should become a priority.

Cervical Cancer: Preventable Deaths Among American Indian/Alaska Native Communities

American Indian/Alaska Native (AI/AN) individuals have twice the mortality rate of cervical cancer than the general US population. Participation in prevention programs such as cervical cancer screening and human papillomavirus (HPV) vaccination are under-utilized in this population. There are high rates of established cervical cancer risk factors among this community, with AI/AN people having a higher likelihood of infection with high-risk HPV strains not included in the 9-valent vaccine. There is a need for more robust and urgent prevention and treatment efforts in regard to cervical cancer in the AI/AN community.

Disparities in Breast Cancer Care-How Factors Related to Prevention, Diagnosis, and Treatment Drive Inequity

Breast cancer survival has increased significantly over the last few decades due to more effective strategies for prevention and risk modification, advancements in imaging detection, screening, and multimodal treatment algorithms. However, many have observed disparities in benefits derived from such improvements across populations and demographic groups. This review summarizes published works that contextualize modern disparities in breast cancer prevention, diagnosis, and treatment and presents potential strategies for reducing disparities. We conducted searches for studies that directly investigated and/or reported disparities in breast cancer prevention, detection, or treatment. Demographic factors, social determinants of health, and inequitable healthcare delivery may impede the ability of individuals and communities to employ risk-mitigating behaviors and prevention strategies. The disparate access to quality screening and timely diagnosis experienced by various groups poses significant hurdles to optimal care and survival. Finally, barriers to access and inequitable healthcare delivery patterns reinforce inequitable application of standards of care. Cumulatively, these disparities underlie notable differences in the incidence, severity, and survival of breast cancers. Efforts toward mitigation will require collaborative approaches and partnerships between communities, governments, and healthcare organizations, which must be considered equal stakeholders in the fight for equity in breast cancer care and outcomes.

Individual and community-level risk factors for maternal morbidity and mortality among Native American women in the USA: protocol for systematic review

INTRODUCTION

Incidents of maternal morbidity and mortality (MMM) continue to rise in the USA. Significant racial and ethnic health inequities exist, with Native American (NA) women being three to four times more likely to die than white, non-Hispanic women, and three to five times more likely to experience an incident of severe maternal morbidity. Few studies have identified individual and community-level risk factors of MMM experienced by NA women. Therefore, this systematic review will identify said risk factors of MMM experienced by NA women in the USA.

METHODS AND ANALYSIS

This systematic review will be conducted according to the Cochrane Handbook for Systematic Reviews, and the findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The search strategy will include searches from electronic databases: PUBMED, EMBASE, CINAHL and SCOPUS, from 1 January 2012 to 10 October 2022. The search strategy will include terms related to the search concepts: 'maternal', 'Native American' and 'MMM'. Bibliographies of selected articles, previously published reviews and high-yield journals will also be searched. All included papers will be evaluated for quality and bias using NIH Quality Assessment Tools for Observational Studies. A description of the study findings will be presented in a tabular format organised by outcome of interest along with study characteristics.

ETHICS AND DISSEMINATION

There are no formal ethics approvals needed for this protocol. The findings of this systematic review will be shared with academic, governmental, community-based, institutes and NA (tribal) entities via a published peer-reviewed article, informational brief, poster and oral presentations.

PROSPERO REGISTRATION NUMBER

CRD42022363405.

Rural hospital and obstetric unit closures as social determinants of racial and ethnic maternal health disparities: A scoping review

AIMS

To synthesize literature examining (1) rural hospital or obstetric unit closures as a social determinant of maternal/infant health outcomes and (2) closures as a social determinant of racial/ethnic disparities in maternal/infant health outcomes.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, OVID/Embase and CINAHL were searched systematically to identify sources from 31 July 2003 to 31 July 2023. The Arksey and O'Malley methodology for scoping reviews was used.

RESULTS

Four studies from the United States and Australia documented the impact of rural hospital or obstetric unit closures on maternal/infant health outcomes, such as increased births in hospitals without obstetric units, out-of-hospital births or babies born before arrival, preterm birth, infant mortality and sociocultural risks that contribute to clinical risk. No eligible studies investigated hospital or obstetric unit closure as a social determinant of racial disparities in rural maternal/infant health outcomes.

CONCLUSION

Despite significant racial and ethnic rural maternal health disparities, associations between rural closures and maternal health outcomes for racial and ethnic minorities are understudied. More research is needed to understand the extent to which rural closures, a social determinant of health, could disproportionately, negatively affect the health of racially and ethnically minoritized women.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Rural women have a greater risk of maternal and infant mortality and morbidity compared with urban women, and the impact of rural closures on racial and ethnic maternal health disparities is not well documented. Research about the impact of rural closures on maternal health disparities could inform policy to assure essential obstetric care is available for rural populations globally.

IMPACT

Findings provide a call to action for research to understand relationships between rural closures and racial and ethnic maternal health disparities, which is especially important for serving rural Non-Hispanic Black and American Indian/Alaska Native women.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Pathways and processes to the embodiment of historical trauma secondary to settler colonialism

AIM(S)

This discursive article aims to examine how systemic factors of settler colonialism influence health outcomes among Indigenous peoples in the United States through pathways and processes that may lead to the embodiment of historical trauma.

DESIGN

Discursive paper.

METHODS

We completed a comprehensive search of empirical and grey literature between September 2022 and January 2023 in PubMed, CINAHL and Google Scholar. Using these articles as a foundation, we explored factors related to the pathways and processes leading to the embodiment of historical trauma rooted in settler colonialism.

RESULTS

A conceptual framework of the pathways and processes of the embodiment of historical trauma secondary to settler colonialism was developed, and is presented.

CONCLUSION

The societal and historical context for Indigenous peoples includes harmful settler colonial structures and ideologies, resulting in stressors and historical trauma that impact health outcomes and disparities through the phenomenon of the process of embodiment.

IMPLICATIONS FOR NURSING

To provide holistic nursing care, nurses must be aware of settler colonialism as a determinant of health. They must be attuned to the pathways and processes through which settler colonial exposures may impact health among Indigenous peoples. Nurses must challenge existing structural inequities to advance health equity and social justice.

Visioning an Effective Health Encounter: Indigenous Healthcare Experiences and Recommendations for Health Professionals

PURPOSE

Indigenous patients experience challenges while accessing and utilizing healthcare services that relate to worsened health experiences. Bias towards Indigenous patients is prevalent in healthcare settings and leads to poor health outcomes. The purpose of this study was to learn about the healthcare experiences, both positive and negative, of Indigenous patients and solicit subsequent recommendations to improve care delivered to this population.

METHODS

This study sampled Indigenous patients (n = 20) from an Indigenous-serving health clinic to discuss participants' health experiences and elicit recommendations for improved care. Four focus groups were conducted, and template analysis was employed to analyze the data.

RESULTS

A total of 15 themes were developed under the category of an effective health encounter. Highlighted themes include healthcare that is free of stigma, quality care, respecting trauma experiences, expanded integrated care and the patient-provider relationship. Based on participant recommendations, a checklist was created for healthcare professionals to improve care delivery to Indigenous patients. Results indicated that bias in healthcare settings may masquerade as poor clinical care but is really founded in biased beliefs and healthcare delivery. Alternatively, when patients received good quality care, their healthcare outcomes improved. Further, effective healthcare incorporates culture, family, tribe, and community and addresses these aspects of health in both clinical and systemic settings.

CONCLUSIONS

With some of the largest proportions of health disparities and bias experiences in the US, it is critical that healthcare delivered to Indigenous patients incorporate culturally safe care to regain dignity and improve health outcomes for this population.

Screening for Hypertensive Disorders of Pregnancy: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Hypertensive disorders of pregnancy are a leading cause of pregnancy-related morbidity and mortality in the US.

Objective

To conduct a targeted systematic review to update the evidence on the effectiveness of screening for hypertensive disorders of pregnancy to inform the US Preventive Services Task Force.

Data Sources

MEDLINE and the Cochrane Central Register of Controlled Trials for relevant studies published between January 1, 2014, and January 4, 2022; surveillance through February 21, 2023.

Study Selection

English-language comparative effectiveness studies comparing screening strategies in pregnant or postpartum individuals.

Data Extraction and Synthesis

Two reviewers independently appraised articles and extracted relevant data from fair-or good-quality studies; no quantitative synthesis was conducted.

Main outcomes and measures

Morbidity or mortality, measures of health-related quality of life.

Results

The review included 6 fair-quality studies (5 trials and 1 nonrandomized study; N = 10 165) comparing changes in prenatal screening practices with usual care, which was routine screening at in-person office visits. No studies addressed screening for new-onset hypertensive disorders of pregnancy in the postpartum period. One trial (n = 2521) evaluated home blood pressure measurement as a supplement to usual care; 3 trials (total n = 5203) evaluated reduced prenatal visit schedules. One study (n = 2441) evaluated proteinuria screening conducted only for specific clinical indications, compared with a historical control group that received routine proteinuria screening. One additional trial (n = 80) only addressed the comparative harms of home blood pressure measurement. The studies did not report statistically significant differences in maternal and infant complications with alternate strategies compared with usual care; however, estimates were imprecise for serious, rare health outcomes. Home blood pressure measurement added to prenatal care visits was not associated with earlier diagnosis of a hypertensive disorder of pregnancy (104.3 vs 106.2 days), and incidence was not different between groups in 3 trials of reduced prenatal visit schedules. No harms of the different screening strategies were identified.

Conclusions and Relevance

This review did not identify evidence that any alternative screening strategies for hypertensive disorders of pregnancy were more effective than routine blood pressure measurement at in-person prenatal visits. Morbidity and mortality from hypertensive disorders of pregnancy can be prevented, yet American Indian/Alaska Native persons and Black persons experience inequitable rates of adverse outcomes. Further research is needed to identify screening approaches that may lead to improved disease detection and health outcomes.

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

Importance

Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated.

Objective

To quantify trends in MMRs (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups using a bayesian extension of the generalized linear model network.

Design, Setting, and Participants

Observational study using vital registration and census data from 1999 to 2019 in the US. Pregnant or recently pregnant individuals aged 10 to 54 years were included.

Main Outcomes and Measures

MMRs.

Results

In 2019, MMRs in most states were higher among American Indian and Alaska Native and Black populations than among Asian, Native Hawaiian, or Other Pacific Islander; Hispanic; and White populations. Between 1999 and 2019, observed median state MMRs increased from 14.0 (IQR, 5.7-23.9) to 49.2 (IQR, 14.4-88.0) among the American Indian and Alaska Native population, 26.7 (IQR, 18.3-32.9) to 55.4 (IQR, 31.6-74.5) among the Black population, 9.6 (IQR, 5.7-12.6) to 20.9 (IQR, 12.1-32.8) among the Asian, Native Hawaiian, or Other Pacific Islander population, 9.6 (IQR, 6.9-11.6) to 19.1 (IQR, 11.6-24.9) among the Hispanic population, and 9.4 (IQR, 7.4-11.4) to 26.3 (IQR, 20.3-33.3) among the White population. In each year between 1999 and 2019, the Black population had the highest median state MMR. The American Indian and Alaska Native population had the largest increases in median state MMRs between 1999 and 2019. Since 1999, the median of state MMRs has increased for all racial and ethnic groups in the US and the American Indian and Alaska Native; Asian, Native Hawaiian, or Other Pacific Islander; and Black populations each observed their highest median state MMRs in 2019.

Conclusion and Relevance

While maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.

Establishment of a Community Advisory Board to Address Postpartum Depression Among Indigenous Women

In this article, we describe the process of establishing an academically and tribally supported community advisory board (CAB) to guide and inform community-engaged research about postpartum depression (PPD) among Indigenous women. Using a community-based participatory research framework, we created a CAB with stakeholders from the Chickasaw Nation because they are well situated to inform a research agenda about PPD in Indigenous women. We developed CAB roles, goals, and responsibilities; established processes for compensation and recognition; identified and recruited potential members; and conducted meetings to build rapport, brainstorm, receive feedback, and invite discussion of topics related to PPD that have been deemed important by the tribe (October 2021 through June 2022). The CAB defined specific roles, goals, and responsibilities for the academic-community partnership, including assumptions, expectations, and confidentiality. We used a standing agenda item to recognize member achievements. Members of the CAB represented many tribal departments and professional disciplines. We use a CAB framework to evaluate our process and to provide recommendations for future research and policymaking.

Improving Racial and Ethnic Equity in Clinical Trials Enrolling Pregnant and Lactating Individuals

Racial and ethnic marginalized populations have historically been poorly represented, underrecruited, and underprioritized across clinical trials enrolling pregnant and lactating individuals. The objectives of this review are to describe the current state of racial and ethnic representation in clinical trials enrolling pregnant and lactating individuals and to propose evidence-based tangible solutions to achieving equity in these clinical trials. Despite efforts from federal and local organizations, only marginal progress has been made toward achieving equity in clinical research. This continued limited inclusion and transparency in pregnancy trials exacerbates health disparities, limits the generalizability of research findings, and may heighten the maternal child health crisis in the United States. Racial and ethnic underrepresented communities are willing to participate in research; however, they face unique barriers to access and participation. Multifaceted approaches are required to facilitate the participation of marginalized individuals in clinical trials including partnering with the local community to understand their priorities, needs, and assets; establishing accessible recruitment strategies; creating flexible protocols; supporting participants for their time; and increasing culturally congruent and/or culturally sensitive research staff. This article also highlights exemplars in pregnancy research.

A Systems Approach to Identify Factors Influencing Participation in Two Tribally-Administered WIC Programs

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.

Long-term Quality of Life in Patients With Breast Cancer After Breast Conservation vs Mastectomy and Reconstruction

Importance

Treatment options for early breast cancer include breast-conserving surgery with radiation therapy (RT) or mastectomy and breast reconstruction without RT. Despite marked differences in these treatment strategies, little is known with regard to their association with long-term quality of life (QOL).

Objective

To evaluate the association of treatment with breast-conserving surgery with RT vs mastectomy and reconstruction without RT with long-term QOL.

Design, Setting, and Participants

This comparative effectiveness research study used data from the Texas Cancer Registry for women diagnosed with stage 0-II breast cancer and treated with breast-conserving surgery or mastectomy and reconstruction between 2006 and 2008. The study sample was mailed a survey between March 2017 and April 2018. Data were analyzed from August 1, 2018 to October 15, 2021.

Exposures

Breast-conserving surgery with RT or mastectomy and reconstruction without RT.

Main Outcomes and Measures

The primary outcome was satisfaction with breasts, measured with the BREAST-Q patient-reported outcome measure. Secondary outcomes included BREAST-Q physical well-being, psychosocial well-being, and sexual well-being; health utility, measured using the EuroQol Health-Related Quality of Life 5-Dimension, 3-Level questionnaire; and local therapy decisional regret. Multivariable linear regression models with weights for treatment, age, and race and ethnicity tested associations of the exposure with outcomes.

Results

Of 647 patients who responded to the survey (40.0%; 356 had undergone breast-conserving surgery, and 291 had undergone mastectomy and reconstruction), 551 (85.2%) confirmed treatment with breast-conserving surgery with RT (n = 315) or mastectomy and reconstruction without RT (n = 236). Among the 647 respondents, the median age was 53 years (range, 23-85 years) and the median time from diagnosis to survey was 10.3 years (range, 8.4-12.5 years). Multivariable analysis showed no significant difference between breast-conserving surgery with RT (referent) and mastectomy and reconstruction without RT in satisfaction with breasts (effect size, 2.71; 95% CI, -2.45 to 7.88; P = .30) or physical well-being (effect size, -1.80; 95% CI, -5.65 to 2.05; P = .36). In contrast, psychosocial well-being (effect size, -8.61; 95% CI, -13.26 to -3.95; P < .001) and sexual well-being (effect size, -10.68; 95% CI, -16.60 to -4.76; P < .001) were significantly worse with mastectomy and reconstruction without RT. Health utility (effect size, -0.003; 95% CI, -0.03 to 0.03; P = .83) and decisional regret (effect size, 1.32; 95% CI, -3.77 to 6.40; P = .61) did not differ by treatment group.

Conclusions and Relevance

The findings support equivalence of breast-conserving surgery with RT and mastectomy and reconstruction without RT with regard to breast satisfaction and physical well-being. However, breast-conserving surgery with RT was associated with clinically meaningful improvements in psychosocial and sexual well-being. These findings may help inform preference-sensitive decision-making for women with early-stage breast cancer.

An imbalance-aware deep neural network for early prediction of preeclampsia

Preeclampsia (PE) is a hypertensive complication affecting 8-10% of US pregnancies annually. While there is no cure for PE, aspirin may reduce complications for those at high risk for PE. Furthermore, PE disproportionately affects racial minorities, with a higher burden of morbidity and mortality. Previous studies have shown early prediction of PE would allow for prevention. We approached the prediction of PE using a new method based on a cost-sensitive deep neural network (CSDNN) by considering the severe imbalance and sparse nature of the data, as well as racial disparities. We validated our model using large extant rich data sources that represent a diverse cohort of minority populations in the US. These include Texas Public Use Data Files (PUDF), Oklahoma PUDF, and the Magee Obstetric Medical and Infant (MOMI) databases. We identified the most influential clinical and demographic features (predictor variables) relevant to PE for both general populations and smaller racial groups. We also investigated the effectiveness of multiple network architectures using three hyperparameter optimization algorithms: Bayesian optimization, Hyperband, and random search. Our proposed models equipped with focal loss function yield superior and reliable prediction performance compared with the state-of-the-art techniques with an average area under the curve (AUC) of 66.3% and 63.5% for the Texas and Oklahoma PUDF respectively, while the CSDNN model with weighted cross-entropy loss function outperforms with an AUC of 76.5% for the MOMI data. Furthermore, our CSDNN model equipped with focal loss function leads to an AUC of 66.7% for Texas African American and 57.1% for Native American. The best results are obtained with 62.3% AUC with CSDNN with weighted cross-entropy loss function for Oklahoma African American, 58% AUC with DNN and balanced batch for Oklahoma Native American, and 72.4% AUC using either CSDNN with weighted cross-entropy loss function or CSDNN with focal loss with balanced batch method for MOMI African American dataset. Our results provide the first evidence of the predictive power of clinical databases for PE prediction among minority populations.

Suicide and Maternal Mortality

PURPOSE OF REVIEW

Suicide is a leading cause of death in the perinatal period (pregnancy and 1 year postpartum). We review recent findings on prevalence, risk factors, outcomes, and prevention and intervention for suicide during pregnancy and the first year postpartum.

RECENT FINDINGS

Standardization of definitions and ascertainment of maternal deaths have improved identification of perinatal deaths by suicide and risk factors for perinatal suicide. Reports of a protective effect of pregnancy and postpartum on suicide risk may be inflated. Clinicians must be vigilant for risk of suicide among their perinatal patients, especially those with mental health diagnoses or prior suicide attempts. Pregnancy and the year postpartum are a time of increased access to healthcare for many, offering many opportunities to identify and intervene for suicide risk. Universal screening for suicide as part of assessment of depression and anxiety along with improved access to mental health treatments can reduce risk of perinatal suicide.

Assessing Social Determinants of Health in a Prenatal and Perinatal Cultural Intervention for American Indians and Alaska Natives

American Indians and Alaska Natives (AIANs) refer to cultural traditions and values to guide resilient and strength-based practices to address maternal and infant health disparities.

METHODS

A case study of a culturally-based educational intervention on AIAN maternal and child health.

RESULTS

Cultural teachings have successfully been applied in AIAN behavioral interventions using talking circles and cradleboards, but maternal and child health interventions are not well-represented in peer-reviewed literature. Zero publications included interventions centered around cradleboards and safe sleep.

DISCUSSION

There is a need for rigorous published research on culturally based interventions and effectiveness on health outcomes for mothers and babies.

CONCLUSIONS

This paper discusses how a cradleboard educational intervention incorporates national guidelines to address maternal and infant health while mediating social determinants of health.

Correlates of Early Prenatal Care Access among U.S. Women: Data from the Pregnancy Risk Assessment Monitoring System (PRAMS)

OBJECTIVES

Early first trimester prenatal counseling could reduce adverse maternal and child health outcomes. Existing literature does not identify the length of time between suspecting pregnancy and attending their first prenatal visit. Identifying this potential window for change is critical for clinical practice, intervention programming and policy change.

METHODS

The study sample was composed of women in the United States who responded to the Pregnancy Risk Assessment Monitoring Systems survey in 2016, for the following questions-when they first suspected pregnancy, when they attended their first prenatal visit, were they able to receive prenatal care as early as they wished, and perceived barriers to receiving prenatal care.

RESULTS

On average, participants became certain they were pregnant at 6.0 (SE = 0.1) weeks gestation, while participants reported having their first prenatal care visit at 9.3 (SE = 0.1) weeks, with clear health disparities by race, age, WIC participation, education level, and marital status. About 15% of women reported not receiving prenatal care as early as they wished. Structural or financial barriers in the health care system were common: 38.1% reported that no appointments available, 28.2% reported not having money or insurance to pay for the visit, 27.3% reported that the doctor or health plan would not start care, and 22.5% reported not having a Medicaid card.

CONCLUSIONS FOR PRACTICE

This study illustrates a window for opportunity to provide earlier prenatal care, which would facilitate earlier implementation of prenatal counseling. Strategies to address barriers to care on the patient, provider and systemic levels, particularly among vulnerable population groups, are warranted. WHAT IS ALREADY KNOWN ON THIS SUBJECT?: Seeking prenatal care early is associated with better health outcomes for women and infants. A window of opportunity exists between suspecting pregnancy and attending a first prenatal visit. WHAT THIS STUDY ADDS?: Clear health disparities were apparent in both recognizing their pregnancies, and receiving early prenatal care by race, age, WIC participation, education level, and marital status. About 15% of women reported not receiving prenatal care as early as they wished, and many attributed this later care to structural or financial barriers in the health care system.

Summary and Conclusion: Framing a New Research Agenda on Maternal Morbidities and Mortality in the United States

Maternal mortality in the United States is at an alarming rate. Research can have an important role in addressing maternal mortality, but our current understanding of its causes and prevention remains woefully incomplete. The collection of articles in this volume begin to frame a new research agenda by asking four critical questions. First, what truly makes vulnerable populations vulnerable? Second, how do we prevent pregnancy complications and their long-term sequelae? Third, how can we make maternity care safer for all women? Finally, what can we do about the social, structural, and environmental determinants of maternal health? Answers to these questions can help inform practice, systems, and policy change to reduce and ultimately eradicate maternal deaths in the United States.