Vital Signs: Maternity Care Experiences - United States, April 2023

Introduction

Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths.

Methods

CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care.

Results

Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider.

Conclusions and implications for public health practice

Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Trends in Postpartum Contraceptive Use in 20 U.S. States and Jurisdictions: The Pregnancy Risk Assessment Monitoring System, 2015-2018

INTRODUCTION

In the last decade, state and national programs and policies aimed to increase access to postpartum contraception; however, recent data on population-based estimates of postpartum contraception is limited.

METHODS

Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted multivariable-adjusted weighted multinomial regression to assess variation in method use by insurance status and geographic setting (urban/rural) among people with a recent live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018 overall and within subgroups using weighted multinomial logistic regression.

RESULTS

In 2018, those without insurance had lower odds of using permanent methods (adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53-0.98), long-acting reversible contraception (LARC) (AOR, 0.67; 95% CI, 0.51-0.89), and short-acting reversible contraception (SARC) (AOR, 0.61; 95% CI, 0.47-0.81) than those with private insurance. There were no significant differences in these method categories between public and private insurance. Rural respondents had greater odds than urban respondents of using all method categories: permanent (AOR, 2.15; 95% CI, 1.67-2.77), LARC (AOR, 1.31; 95% CI, 1.04-1.65), SARC (AOR, 1.42; 95% CI, 1.15-1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11-1.72). From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI, 1.01-1.05) and use of no method (OR, 1.05; 95% CI, 1.02-1.07) and a decrease in SARC use (OR, 0.97; 95% CI, 0.95-0.99). LARC use increased among those with private insurance (OR, 1.05; 95% CI, 1.02-1.08) and in urban settings (OR, 1.04; 95% CI, 1.02-1.07), but not in other subgroups.

CONCLUSIONS

We found that those without insurance had lower odds of using effective contraception and that LARC use increased among those who had private insurance and lived in urban areas. Strategies to increase access to contraception, including increasing insurance coverage and investigating whether effectiveness of existing initiatives varies by geographic setting, may increase postpartum contraceptive use and address these differences.

Maltreatment Related Hospitalizations Among Children Ages 17 Years and Younger: New York State, 2011-2013

BACKGROUND

Child maltreatment is an important societal and public health problem. However, there are limited data on the epidemiology of maltreatment related hospitalizations.

OBJECTIVE

The objective of this study was to describe maltreatment related hospitalizations among children ages 17 and younger in New York State (NYS).

METHODS

Using 2011-2013 statewide planning and research cooperative system (SPARCS) inpatient hospital discharge data, maltreatment related hospitalizations among children ages 17 years and younger were identified using international classification of diseases, ninth revision, clinical modification codes for diagnoses and external cause of injury. Distributions of demographic and inpatient care characteristics were compared between hospitalizations for maltreatment and those for other causes, and between different types of maltreatment, using chi-square tests (for categorical variables) and t-tests (for continuous variables).

RESULTS

During 2011-2013, a total of 853 maltreatment related hospitalizations among 836 children ages 17 years and younger were documented in NYS SPARCS. Infants (children < 1) had the highest rates of hospitalization. Overall, physical abuse was the most prevalent maltreatment type reported.

CONCLUSIONS

This is the first study in NYS to describe the epidemiology of child maltreatment hospitalizations; it establishes a statewide baseline for this public health and societal issue.

Estimating the Burden of Prematurity on Infant Mortality: A Comparison of Death Certificates and Child Fatality Review in Ohio, 2009-2013

Introduction Infant mortality is a key population health indicator, and accurate cause of death reporting is necessary to design infant mortality prevention strategies. Death certificates and child fatality review (CFR) both track leading infant causes of death in Ohio but produce different results. Our aim was to determine the frequency and characteristics of differences between the two systems to understand both cause of death ranking systems for Ohio. Methods We linked and analyzed data from death certificates and CFR records for all infant deaths (aged < 1 year) in Ohio during 2009-2013. Death certificate and CFR cause of death assignments were compared. Kappa statistic was used to measure concordance. Death certificate-CFR cause of death pairs were plotted to identify common concordant and discordant pairs. Results A total of 5030 infant deaths with death certificate and CFR records were analyzed. The most common discordant cause of death pair was other perinatal condition on the death certificate and prematurity by CFR (1119). Specific injury categories had higher concordance (kappa 0.71-1.00) than medical categories (kappa 0.00-0.78). Among 456 deaths categorized as sudden infant death syndrome on death certificates, approximately 50% (230) were categorized as missing, unknown, or undetermined by CFR. Discussion Linking death certificate and CFR causes of death provided a more robust understanding of infant causes of death in Ohio. Separately, each system serves distinct and valuable purposes that should be reviewed before selecting one system for ranking leading causes of infant mortality.

Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care

Saving Mothers, Giving Life used 6 strategies to address the third delay—receiving adequate health care after reaching a facility—in maternal and newborn health care. The intervention approaches can be adapted in low-resource settings to improve facility-based care and reduce maternal and perinatal mortality.

Background:

Saving Mothers, Giving Life (SMGL) is a 5-year initiative implemented in participating districts in Uganda and Zambia that aimed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care: seeking, reaching, and receiving. Approaches to addressing the third delay included adequate health facility infrastructure, specifically sufficient equipment and medications; trained providers to provide quality evidence-based care; support for referrals to higher-level care; and effective maternal and perinatal death surveillance and response.

Methods:

SMGL used a mixed-methods approach to describe intervention strategies, outcomes, and health impacts. Programmatic and monitoring and evaluation data—health facility assessments, facility and community surveillance, and population-based mortality studies—were used to document the effectiveness of intervention components.

Results:

During the SMGL initiative, the proportion of facilities providing emergency obstetric and newborn care (EmONC) increased from 10% to 25% in Uganda and from 6% to 12% in Zambia. Correspondingly, the delivery rate occurring in EmONC facilities increased from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia. Nearly all facilities had at least one trained provider on staff by the endline evaluation. Staffing increases allowed a higher proportion of health centers to provide care 24 hours a day/7 days a week by endline—from 74.6% to 82.9% in Uganda and from 64.8% to 95.5% in Zambia. During this period, referral communication improved from 93.3% to 99.0% in Uganda and from 44.6% to 100% in Zambia, and data systems to identify and analyze causes of maternal and perinatal deaths were established and strengthened.

Conclusion:

SMGL's approach was associated with improvements in facility infrastructure, equipment, medication, access to skilled staff, and referral mechanisms and led to declines in facility maternal and perinatal mortality rates. Further work is needed to sustain these gains and to eliminate preventable maternal and perinatal deaths.

Preconception Health Indicators for Public Health Surveillance

OBJECTIVES

In response to an expressed need for more focused measurement of preconception health (PCH), we identify a condensed set of PCH indicators for state and national surveillance.

METHODS

We used a systematic process to evaluate, prioritize, and select 10 PCH indicators that maternal and child health programs can use for surveillance. For each indicator, we assessed prevalence, whether it was addressed by professional recommendations, Healthy People 2020 objectives, or Centers for Disease Control and Prevention winnable battles, measurement simplicity, data completeness, and stakeholders' input.

RESULTS

Fifty PCH indicators were evaluated and prioritized. The condensed set includes indicators that rely on data from the Pregnancy Risk Assessment Monitoring System (n = 4) and the Behavioral Risk Factor Surveillance System (n = 6). The content encompasses heavy alcohol consumption, depression, diabetes, folic acid intake, hypertension, normal weight, recommended physical activity, current smoking, unwanted pregnancy, and use of contraception.

CONCLUSIONS

Having a condensed set of PCH indicators can facilitate surveillance of reproductive-aged women's health status that supports monitoring, comparisons, and benchmarking at the state and national levels.

Implementing CDC's Level of Care Assessment Tool (LOCATe): A National Collaboration to Improve Maternal and Child Health

Perinatal regionalization, or risk-appropriate care, is an approach that classifies facilities based on capabilities to ensure women and infants receive care at a facility that aligns with their risk. The CDC designed the Levels of Care Assessment Tool (LOCATe) to assist jurisdictions working in risk-appropriate care in assessing a facility's level of maternal and neonatal care aligned with the most current American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) and American Academy of Pediatrics (AAP) guidelines. LOCATe produces standardized assessments for each hospital that participates and facilitates conversations among stakeholders in risk-appropriate care. This article describes how public health departments implement and use LOCATe in their jurisdictions.

Reduced Disparities in Birth Rates Among Teens Aged 15-19 Years - United States, 2006-2007 and 2013-2014

Teen childbearing can have negative health, economic, and social consequences for mothers and their children (1) and costs the United States approximately $9.4 billion annually (2). During 1991-2014, the birth rate among teens aged 15-19 years in the United States declined 61%, from 61.8 to 24.2 births per 1,000, the lowest rate ever recorded (3). Nonetheless, in 2014, the teen birth rate remained approximately twice as high for Hispanic and non-Hispanic black (black) teens compared with non-Hispanic white (white) teens (3), and geographic and socioeconomic disparities remain (3,4), irrespective of race/ethnicity. Social determinants associated with teen childbearing (e.g., low parental educational attainment and limited opportunities for education and employment) are more common in communities with higher proportions of racial and ethnic minorities (4), contributing to the challenge of further reducing disparities in teen births. To examine trends in births for teens aged 15-19 years by race/ethnicity and geography, CDC analyzed National Vital Statistics System (NVSS) data at the national (2006-2014), state (2006-2007 and 2013-2014), and county (2013-2014) levels. To describe socioeconomic indicators previously associated with teen births, CDC analyzed data from the American Community Survey (ACS) (2010-2014). Nationally, from 2006 to 2014, the teen birth rate declined 41% overall with the largest decline occurring among Hispanics (51%), followed by blacks (44%), and whites (35%). The birth rate ratio for Hispanic teens and black teens compared with white teens declined from 2.9 to 2.2 and from 2.3 to 2.0, respectively. From 2006-2007 to 2013-2014, significant declines in teen birth rates and birth rate ratios were noted nationally and in many states. At the county level, teen birth rates for 2013-2014 ranged from 3.1 to 119.0 per 1,000 females aged 15-19 years; ACS data indicated unemployment was higher, and education attainment and family income were lower in counties with higher teen birth rates. State and county data can be used to understand disparities in teen births and implement community-level interventions that address the social and structural conditions associated with high teen birth rates.

Increased cesarean section rate over time (1994-2006) in Delaware is not associated with improved outcomes in very low birth weight infants

Cesarean deliveries (C-section) have been increasing over time. The objectives of this study were to analyze cesarean section delivery rates over time, and determine whether there is an association between C-section, mortality, and severe intraventricular hemorrhage (IVH) in VLBW infants. We performed a retrospective cohort study of babies with birth weight < 1,500 grams, between 1994 and 2006, at Christiana Hospital (n = 2,040). Severe IVH was considered grade 3 to 4. Data were analyzed by three-year cohorts. Statistics included unadjusted and multivariable analyses. Cesarean delivery increased 22 percent from 1994 to 2006. When controlling for potential confounding variables including gestational age and presentation at birth, odds of C-section delivery remained elevated in Cohort 4 (2003-2006) compared with Cohort 1 (1994-1997; OR = 1.12, 95% CI 1.01-1.24). The rate of infant death and severe IVH did not change over time. After multivariable analysis, C-section was not associated with a decrease in death, severe IVH, or death and/or IVH. In our population of VLBW infants, the rate of C-section delivery increased over time. This increased rate was not associated with any change in the odds of death and/or severe IVH.

Increased preeclampsia in mothers delivering very low-birth-weight infants between 1994 and 2006

We sought to determine if there has been any change in the proportion of mothers with preeclampsia in a sample of very low-birth-weight (VLBW) infants over time. We performed a retrospective cohort study. Study sample included infants with birth weights 1500 g or less cared for from July 1994 to July 2006 ( n = 2045) from a single level 3 neonatal intensive care unit in Delaware. The main outcome examined was the occurrence of maternal preeclampsia over the study time. The proportion of mothers with preeclampsia delivering VLBW infants increased over time. After controlling for potential confounding variables, the odds of maternal preeclampsia were increased (1.3, 95% confidence interval 1.2 to 1.5) in infants born between 2003 and 2006 compared with those born between 1994 and 1997. In our population of VLBW infants, the proportion of mothers with the diagnosis of preeclampsia increased over time. From our investigation, we cannot determine if the increase in the proportion of mothers with preeclampsia is related to a true increase in the disease, changes in diagnostic surveillance, or other factors.

Translating policy to practice and back again: implementing a preconception program in Delaware

The state of Delaware is in the unique position of implementing legislatively supported policy on preconception health. The state has allocated funding to translate preconception care policy to practice through a statewide program. The Delaware Division of Public Health has been given the responsibility of defining and implementing the preconception care program targeting a high-risk population. The state partnered with Medicaid, private practitioners, local hospitals, state service centers, and Federally Qualified Health Centers to develop a scope of program services that supplement the current clinical care provided at annual visits for women of childbearing age. Because the program has been in operation for 9 months, the Division of Public Health utilized feedback from the providing agencies to begin efforts for program sustainability and to modify the existing policy. Current efforts include developing outcome measures for the program, measuring program effectiveness through evaluation, and working with Medicaid and Managed Care Organizations to develop a reimbursement system for services.

A population study of the contribution of medical comorbidity to the risk of prematurity in blacks

OBJECTIVE

The purpose of this study was to test the hypothesis that the higher prevalence of medical comorbidities among black women accounts for their increased risk of prematurity.

STUDY DESIGN

A population-based regional cohort of women receiving obstetric care for singleton pregnancies at a large community hospital between 2003 and 2006 were analyzed using univariate and multivariable logistic regression.

RESULTS

Data for 18,624 consecutive births found increased odds of adverse outcomes for black compared to white women: prematurity OR = 1.6 (1.4-1.8), extreme prematurity OR = 2.5 (2.0-3.2). Logistic regression modeling identified black race, age < 20, preconception diabetes and hypertension, smoking, underweight, and gestational hypertension as the greatest risks for adverse outcomes. Controlling for these risks did not attenuate the higher risk for prematurity among blacks.

CONCLUSION

Though there is a greater burden of health risk among black women, this did not account for the higher rates of low birthweight and prematurity.

Rising infant mortality in Delaware: an examination of racial differences in secular trends

OBJECTIVES

Recent increases in the Delaware Infant Mortality Rate (IMR) have been attributed to a rise in the mortality of very low birth weight (VLBW, <1500 g) infants born to mothers of higher socioeconomic status. This study examines whether the determinants of infant mortality trends in Delaware vary by race.

METHODS

Linked birth/infant death cohort files for the two periods 1993-1997 and 1998-2002 were used to evaluate the determinants of infant mortality trends separately for White and Black racial groups. Kitagawa analyses determined the components of race-specific infant mortality trends attributable to changes in both the birthweight distribution and birthweight-specific mortality rates. Maternal characteristics were examined to identify factors associated with IMR changes.

RESULTS

Between the two time periods, infant mortality increased 23% among White infants and 17% among Black infants. For both races, the infant mortality increase was explained by increases in the incidence and mortality of VLBW infants, specifically below <500 grams for Blacks and <1,000 grams for Whites. The increased incidence of VLBW deliveries was statistically significant only among Whites, almost 40% of which was explained by an increase in multiple births. For both Whites and Blacks, the increase in VLBW mortality occurred mainly among births to more traditionally advantaged women who were twenty or older, at least high school educated, married, privately insured, had received first trimester prenatal care, and those who delivered multiple births.

CONCLUSIONS

These findings suggest that conventional strategies of increasing access to prenatal care among disadvantaged women may be insufficient to reverse recent IMR increases in Delaware, irrespective of race. Future efforts should focus on understanding the causes of the increased infant mortality associated with higher socioeconomic status, including changes in assisted reproductive technology utilization, maternal health status, and obstetric practice.