Increasing and inequitable US pregnancy-related mortality ratios among non-Hispanic Black and White women, 2000-2019

Reported increases in US maternal mortality rates and entrenched Black/White rate inequity are alarming. We analyze rigorously collected US Pregnancy Mortality Surveillance System data to describe pregnancy-related mortality ratios (PRMR) levels and trends, 2000-2019. Conceptually guided by the weathering framework, we hypothesize that the increasing maternal age distribution of births contributed to PRMR increases. Stratifying on maternal age, race, educational level, and cause of death, we find US PRMR inequities persist, yet actual PRMR increases do not apply uniformly. White women with no more than a high school education averaged a 3.61% increase per year, implying a 92% increase over the period, with little growth observed among the more educated. Less-educated Black women exhibited a small proportional increase (9% over the study period). PRMRs for Black women at higher educational levels declined by over 1% per year, still remaining in excess of White rates. Simulations suggest that the shift in the maternal age distribution contributed a small amount to White PRMR increases. It would have increased PRMRs overall for Black mothers by just over 1% per year, suggesting that if the maternal age distribution had not shifted upward, the overall Black/White PRMR inequity would have decreased.