Myra J. Tucker

Pregnancy-Related Mortality in the United States, 1991-1997

OBJECTIVE To describe trends in pregnancy-related mortality and risk factors for pregnancy-related deaths in the United States for the years 1991 through 1997. METHODS In collaboration with the American College of Obstetricians and Gynecologists and state health departments, the Pregnancy Mortality Surveillance System, part of the Division of Reproductive Health at the Centers for Disease Control and Prevention, has collected information on all reported pregnancy-related deaths occurring since 1979. Data include those present on death certificates and, when available, matching birth or fetal death certificates. Data are reviewed and coded by clinically experienced epidemiologists. The pregnancy-related mortality ratio was defined as pregnancy-related deaths per 100,000 live births. RESULTS The reported pregnancy-related mortality ratio increased from 10.3 in 1991 to 12.9 in 1997. An increased risk of pregnancy-related death was found for black women, older women, and women with no prenatal care. The leading causes of death were embolism, hemorrhage, and other medical conditions, although the percent of all pregnancy-related deaths caused by hemorrhage declined from 28% in the early 1980s to 18% in the current study period. CONCLUSION The reported pregnancy-related mortality ratio has increased, probably because of improved identification of pregnancy-related deaths. Black women continue to have an almost four-fold increased risk of pregnancy-related death, the greatest disparity among the maternal and child health indicators. Although review of pregnancy-related deaths by states remains an important public health function, such work must be expanded to identify factors that influence the survival of women with serious pregnancy complications.

The Black–White Disparity in Pregnancy-Related Mortality From 5 Conditions: Differences in Prevalence and Case-Fatality Rates

Objectives. We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States.Methods. We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999.Results. Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women.Conclusions. Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more preci...

Maternal smokeless tobacco use in Alaska Native women and singleton infant birth size

Objective. To examine the effects of maternal prenatal smokeless tobacco use on infant birth size. Design. A retrospective medical record review of 502 randomly selected deliveries. Population and Setting. Singleton deliveries to Alaska Native women residing in a defined geographical region in western Alaska, 1997–2005. Methods. A regional medical centers electronic records were used to identify singleton deliveries. Data on maternal tobacco exposure and pregnancy outcomes were abstracted from medical records. Logistic models were used to estimate adjusted mean birthweight, length and head circumference for deliveries to women who used no tobacco (n=121), used smokeless tobacco (n=237) or smoked cigarettes (n=59). Differences in mean birthweight, length and head circumference, 95% confidence intervals and p‐values were calculated using non‐users as the reference group. Main Outcome Measures. Infant birthweight, crown–heel length and head circumference. Results. After adjustment for gestational age and other potential confounders, the mean birthweight of infants of smokeless tobacco users was reduced by 78g compared with that of infants of non‐users (p=0.18) and by 331g in infants of smokers (p<0.01). No association was found between maternal smokeless tobacco use and infant length or infant head circumference. Conclusions. We found a modest but non‐significant reduction in the birthweight of infants of smokeless tobacco users compared with infants of tobacco non‐users. Because smokeless tobacco contains many toxic compounds that could affect other pregnancy outcomes, results of this study should not be construed to mean that smokeless tobacco use is safe during pregnancy.

Adoption of preventive behaviors in response to the 2009 H1N1 influenza pandemic: a multiethnic perspective

As public health leaders prepare for possible future influenza pandemics, the rapid spread of 2009 H1N1 influenza highlights the need to focus on measures the public can adopt to help slow disease transmission. Such measures may relate to hygiene (e.g., hand washing), social distancing (e.g., avoiding places where many people gather), and pharmaceutical interventions (e.g., vaccination). Given the disproportionate impact of public health emergencies on minority communities in the United States, it is important to understand whether there are differences in acceptance across racial/ethnic groups that could lead to targeted and more effective policies and communications.

Effects of maternal smokeless tobacco use on selected pregnancy outcomes in Alaska Native women: a case–control study

To examine the potential effects of prenatal smokeless tobacco use on selected birth outcomes.

TUCKER ET AL. RESPOND

We appreciate Holtzman’s interest in our efforts to gain insight into the reasons for racial disparities in maternal mortality. The persistent 3- to 4-times greater risk of pregnancy-related mortality for Black women is the largest gap among the traditional indicators of maternal and infant health in the United States. We, too, are concerned that racial disparities also exist for infant outcomes and that they, like those for pregnancy-related mortality, remain largely unexplained. The role of stress, neuroendocrine pathways, and immune system functions are all areas of biomedical research that we hope will help us to better understand why some groups have increased risks for adverse health outcomes. In addition, as implied by Holtzman, we must make efforts to understand how biology is affected by the larger context of women’s lives. Further, while we work to identify and change factors that convey susceptibility to pregnancy complications, preterm birth, and infant mortality, it is critical to improve access and quality of care for all women and infants.