Last data update: Jun 17, 2024. (Total: 47034 publications since 2009)
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Query Trace: Hoyert D [original query] |
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US trends in maternal mortality by racial and ethnic group
Rossen LM , Hoyert D , Branum AM . JAMA 2023 330 (18) 1799-1800 ![]() A recent article1 described increases in MMRs from 1999 to 2019, racial and ethnic disparities, and differences by US state. The use of bayesian models to provide more precise estimates of MMRs for small racial and ethnic subgroups is a strength, but not a panacea for the problem of small numbers. The utility of state-level estimates by subgroup is questionable when driven mainly by the priors and associated with wide uncertainty intervals, a concern for subgroups with fewer than 20 events each year. Additionally, failure to account for differential adoption of the pregnancy checkbox by US states over time biased the trend estimates and resulting conclusions of this study.1 | | The study authors acknowledged in the Discussion section that “it is possible that some of the increases in maternal mortality over time are due to an increasing number of states incorporating the pregnancy checkbox….”1 However, it is insufficient to simply note the effect of the pregnancy checkbox as a limitation, given numerous prior studies describing trends in maternal mortality in the context of changes in ascertainment. These studies have quantified the effect of the incremental adoption of the pregnancy checkbox on the standard certificate of death (which occurred from 2003 to 2017), showing that observed increases in MMRs from the early 2000s to 2017 are entirely or nearly entirely an artifact of changes in measurement over time, with no significant trends in MMRs once the checkbox was accounted for.2-4 It is highly likely that the increases reported in this study1 were an artifact of changes in ascertainment. | | Estimated racial and ethnic disparities in MMR trends are also subject to bias due to the incremental adoption of the checkbox by states over time, given the geographic concentration of specific subpopulations such as non-Hispanic American Indian or Alaska Native persons. The effect of checkbox implementation varies by age, race and ethnicity, state, and cause of death, with larger effects seen among people aged 35 years or older, among non-Hispanic Black individuals, and for nonspecific maternal causes of death.2-4 Consequently, it is important to explicitly account for the effect of the pregnancy checkbox and other changes in measurement5 over time when estimating trends and racial and ethnic disparities in MMRs as well as state-level patterns. Without accurate and comparable measurement of MMR trends and disparities, conclusions cannot be drawn about the effect of prevention efforts. |
Racial and ethnic disparities in fetal deaths - United States, 2015-2017
Pruitt SM , Hoyert DL , Anderson KN , Martin J , Waddell L , Duke C , Honein MA , Reefhuis J . MMWR Morb Mortal Wkly Rep 2020 69 (37) 1277-1282 The spontaneous death or loss of a fetus during pregnancy is termed a fetal death. In the United States, national data on fetal deaths are available for losses at ≥20 weeks' gestation.* Deaths occurring during this period of pregnancy are commonly known as stillbirths. In 2017, approximately 23,000 fetal deaths were reported in the United States (1). Racial/ethnic disparities exist in the fetal mortality rate; however, much of the known disparity in fetal deaths is unexplained (2). CDC analyzed 2015-2017 U.S. fetal death report data and found that non-Hispanic Black (Black) women had more than twice the fetal mortality rate compared with non-Hispanic White (White) women and Hispanic women. Fetal mortality rates also varied by maternal state of residence. Cause of death analyses were conducted for jurisdictions where >50% of reports had a cause of death specified. Still, even in these jurisdictions, approximately 31% of fetal deaths had no cause of death reported on a fetal death report. There were differences by race and Hispanic origin in causes of death, with Black women having three times the rate of fetal deaths because of maternal complications compared with White women. The disparities suggest opportunities for prevention to reduce the U.S. fetal mortality rate. Improved documentation of cause of death on fetal death reports might help identify preventable causes and guide prevention efforts. |
Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978-2012
Davis NL , Hoyert DL , Goodman DA , Hirai AH , Callaghan WM . Am J Obstet Gynecol 2017 217 (3) 352 e1-352 e7 BACKGROUND: Maternal mortality ratios (MMR) appear to have increased in the United States over the last decade. Three potential contributing factors are: 1) a shifting maternal age distribution, 2) changes in age-specific MMR, and 3) the addition of a checkbox indicating recent pregnancy on the death certificate. OBJECTIVE: Determine the contribution of rising maternal age on changes in MMR from 1978-2012, and estimate the contribution of the pregnancy checkbox on increases in MMR over the last decade. STUDY DESIGN: Kitagawa decomposition analyses were conducted to partition the maternal age contribution to the MMR increase into two components: changes due to a shifting maternal age distribution, and changes due to higher age-specific mortality ratios. We used National Vital Statistics System (NVSS) natality and mortality data. The following five-year groupings were used: 1978-1982, 1988-1992, 1998-2002, and 2008-2012. Changes in age-specific MMRs among states that adopted the standard pregnancy checkbox onto their death certificate before 2008 (n=23) were compared with states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (n=11) to estimate the percentage increase in the MMR due to the pregnancy checkbox. RESULTS: Overall U.S. MMRs for 1978-1982, 1988-1992, and 1998-2002 were 9.0, 8.1, and 9.1 deaths per 100,000 live births, respectively. There was a modest increase in the MMR between 1998-2002 and 2008-2012 in the 11 states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (8.6 and 9.9 deaths per 100,000 respectively). However, the MMR more than doubled between 1998-2002 and 2008-2012 in the 23 states that adopted the standard pregnancy checkbox (9.0 to 22.4); this dramatic rise was almost entirely attributable to increases in age-specific MMRs (94.9%) as opposed to increases in maternal age (5.1%), with an estimated 90% of the observed change reflecting the change in maternal death identification rather than a real change in age-specific rates alone. Of all age categories, women ages 40 and older in states that adopted the standard pregnancy checkbox had the largest increase in MMR-from 31.9 to 200.5-a relative increase of 528%, which accounted for nearly one-third of the overall increase. An estimated 28.8% of the observed change was potentially due to maternal death misclassification among women ≥40. CONCLUSION: Increasing age-specific maternal mortality seems to be contributing more heavily than a changing maternal age distribution to recent increases in MMR. In states with the standard pregnancy checkbox, the vast majority of the observed change in MMR over the last decade was estimated to be due to the pregnancy checkbox, with the greatest change in MMR occurring in women ages ≥40 years. The addition of a pregnancy checkbox on state death certificates appears to be increasing case identification, but may also be leading to maternal death misclassification, particularly for women ages ≥40 years. |
Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance
Wallace ME , Hoyert D , Williams C , Mendola P . Am J Obstet Gynecol 2016 215 (3) 364.e1-364.e10 BACKGROUND: Pregnant and postpartum women may be at increased risk of violent death including homicide and suicide relative to nonpregnant women, but US national data have not been reported since the implementation of enhanced mortality surveillance. OBJECTIVE: The objective of the study was to estimate homicide and suicide ratios among women who are pregnant or postpartum and to compare their risk of violent death with nonpregnant/nonpostpartum women. STUDY DESIGN: Death certificates (n = 465,097) from US states with enhanced pregnancy mortality surveillance from 2005 through 2010 were used to compare mortality among 4 groups of women aged 10-54 years: pregnant, early postpartum (pregnant within 42 days of death), late postpartum (pregnant within 43 days to 1 year of death), and nonpregnant/nonpostpartum. We estimated pregnancy-associated mortality ratios and compared with nonpregnant/nonpostpartum mortality ratios to identify differences in risk after adjusting for potential levels of pregnancy misclassification as reported in the literature. RESULTS: Pregnancy-associated homicide victims were most frequently young, black, and undereducated, whereas pregnancy-associated suicide occurred most frequently among older white women. After adjustments, pregnancy-associated homicide risk ranged from 2.2 to 6.2 per 100,000 live births, depending on the degree of misclassification estimated, compared with 2.5-2.6 per 100,000 nonpregnant/nonpostpartum women aged 10-54 years. Pregnancy-associated suicide risk ranged from 1.6-4.5 per 100,000 live births after adjustments compared with 5.3-5.5 per 100,000 women aged 10-54 years among nonpregnant/nonpostpartum women. Assuming the most conservative published estimate of misclassification, the risk of homicide among pregnant/postpartum women was 1.84 times that of nonpregnant/nonpostpartum women (95% confidence interval, 1.71-1.98), whereas risk of suicide was decreased (relative risk, 0.62, 95% confidence interval, 0.57-0.68). CONCLUSION: Pregnancy and postpartum appear to be times of increased risk for homicide and decreased risk for suicide among women in the United States. |
Annual summary of vital statistics: 2010-2011
Hamilton BE , Hoyert DL , Martin JA , Strobino DM , Guyer B . Pediatrics 2013 131 (3) 548-58 The number of births in the United States declined by 1% between 2010 and 2011, to a total of 3,953,593. The general fertility rate also declined by 1% to 63.2 births per 1000 women, the lowest rate ever reported. The total fertility rate was down by 2% in 2011 (to 1894.5 births per 1000 women). The teenage birth rate fell to another historic low in 2011, 31.3 births per 1000 women. Birth rates also declined for women aged 20 to 29 years, but the rates increased for women aged 35 to 39 and 40 to 44 years. The percentage of all births to unmarried women declined slightly to 40.7% in 2011, from 40.8% in 2010. In 2011, the cesarean delivery rate was unchanged from 2010 at 32.8%. The preterm birth rate declined for the fifth straight year in 2011 to 11.72%; the low birth weight rate declined slightly to 8.10%. The infant mortality rate was 6.05 infant deaths per 1000 live births in 2011, which was not significantly lower than the rate of 6.15 deaths in 2010. Life expectancy at birth was 78.7 years in 2011, which was unchanged from 2010. Crude death rates for children aged 1 to 19 years did not change significantly between 2010 and 2011. Unintentional injuries and homicide were the first and second leading causes of death, respectively, in this age group. These 2 causes of death jointly accounted for 47.0% of all deaths of children and adolescents in 2011. |
Evaluation of pregnancy mortality in Louisiana using enhanced linkage and different indicators defined by WHO and CDC/ACOG: challenging and practical issues
Tran T , Roberson E , Borstell J , Hoyert DL . Matern Child Health J 2011 15 (7) 955-63 Differences in definitions and methods of data collection on deaths occurring during or shortly after pregnancy have created confusion and challenges in evaluating research findings. The study aimed to determine if the use of enhanced linkage procedures improve data collection of deaths occurring during or shortly after pregnancy, and how different definitions of those deaths changed the results of data analysis. The study used 2000-2005 Louisiana Pregnancy Mortality Surveillance System (LPMSS) and 2000-2005 death certificates linked with 1999-2005 live birth and fetal death certificates. Five indicators of deaths occurring during or shortly after pregnancy using WHO and CDC/ACOG definitions were estimated. One-sided Spearman rank test was used to analyze maternal mortality trends from 2000 to 2005. Of 345 women who died within 1 year of pregnancy, 187 were identified through linkage; 38 of those were missed by the LPMSS. Total mortality ratios of deaths occurring within 1 year of pregnancy ranged from 13.4 to 88.9 per 100,000 live births depending on the indicator used. CDC/ACOG pregnancy-related death and pregnancy-associated death statistically increased, whereas WHO pregnancy-related death decreased between 2000 and 2005. The most common causes of death differed by indicator. Universal adoption of linkage procedures could improve data on deaths occurring during or shortly after pregnancy. Estimates, trends, and most common causes of death were markedly different depending on which indicator was used. Additionally, the use of different mortality indicators during analysis provides a more detailed picture of potential target areas for future research and interventions. |
Changes in pregnancy mortality ascertainment: United States, 1999-2005
MacKay AP , Berg CJ , Liu X , Duran C , Hoyert DL . Obstet Gynecol 2011 118 (1) 104-10 OBJECTIVE: To estimate mortality ratios for all reported pregnancy deaths in the United States, 1999-2005, and to estimate the effect of the 1999 implementation of International Classification of Diseases, Tenth Revision (ICD-10) and adoption of the U.S. Standard Certificate of Death, 2003 Revision, on the ascertainment of deaths resulting from pregnancy. METHODS: We combined information on pregnancy deaths from the National Vital Statistics System and the Pregnancy Mortality Surveillance System to estimate maternal (during or within 42 days of pregnancy) and pregnancy-related (during or within 1 year of pregnancy) mortality ratios (deaths per 100,000 live births). Data for 1995-1997, 1999-2002, and 2003-2005 were compared in order to estimate the effects of the change to ICD-10 and the inclusion of a pregnancy checkbox on the death certificate. RESULTS: The maternal mortality ratio increased significantly from 11.6 in 1995-1997 to 13.1 for 1999-2002 and 15.3 in 2003-2005; the pregnancy-related mortality ratio increased significantly from 12.6 to 14.7 and 18.1 during the same periods. Vital statistics identified significantly more indirect maternal deaths in 2002-2005 than in 1999-2002. Between 2002 and 2005, mortality ratios increased significantly among 19 states using the revised death certificate with a pregnancy checkbox; ratios did not increase in states without a checkbox. CONCLUSION: Changes in ICD-10 and the 2003 revision of the death certificate increased ascertainment of pregnancy deaths. The changes may also have contributed to misclassification of some deaths as maternal in the vital statistics system. Combining data from both systems estimates higher pregnancy mortality ratios than from either system individually. LEVEL OF EVIDENCE: II. |
Introduction to the special issue on promoting cognitive health in diverse populations of older adults
Anderson L , Logsdon RG , Hochhalter AK , Sharkey JR . Gerontologist 2009 49 S1-2 This special issue of The Gerontologist, “Promoting Cognitive Health in Diverse Populations of Older Adults,” is devoted to cognitive health, a major factor in ensuring quality of life and preserving independence. Cognitive health has been identified as a priority area for aging and public health through national efforts such as the National Institutes of Health's Cognitive and Emotional Health Project (Hendrie et al., 2006) and the Centers for Disease Control and Prevention's (CDC) Healthy Brain Initiative (Anderson & McConnell, 2007). This increased recognition also aligns with growing awareness of the significant health, social, and economic burden associated with cognitive impairments; rising concerns and fears about potential loss of cognitive functions with age; and increasing demands of family and professional caregivers. As the readers of The Gerontologist are well aware, the U.S. population as a whole is aging at an unprecedented rate, and with that change comes an increasing incidence of cognitive impairments, such as Alzheimer's disease and other dementias (Administration on Aging, 2005). Alzheimer's disease is now the sixth leading cause of death among U.S. adults aged 18 years or older and the fifth leading cause of death among those aged 65 years or older (Heron, Hoyert, Xu, Scott, & Tejada-Vera, 2008). |
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