Author ORCID Identifier

Date of Award

Spring 5-13-2022

Degree Type

Capstone Project

Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Colin K. Smith

Second Advisor

Sarah A. McCool


Objective: To show evidence of the relationship between insurance status, type, and duration of coverage on severe maternal morbidity and mortality outcomes in the United States.

Methods: A review of multi-state and national studies was done to show the relationship between insurance type on the incidence, timing, and outcome of severe maternal morbidities (SMM). A retrospective cohort study from 2010-2014 used data from the IBM MarketScan Multi-State Medicaid and Commercial Claims and Encounters databases to evaluate timing of SMM during delivery hospitalization of 2,667,325 women aged 15-44 years. Women with SMM were identified using the ICD-9-CM codes for 21 factors associated with SMM. Results from the national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 was reviewed for pregnancy-related deaths by sociodemographic characteristics, timing relative to end of pregnancy, and the leading causes of death. Results from 13 state maternal mortality review committees (MMRCs) from 2013-2017 on pregnancy-related deaths was reviewed for predisposing factors and preventability.

Results: For the retrospective cohort study, a total of 2,399 women (73.5%) in the Medicaid cohort and 3,993 women (75.7%) in the commercial insurance cohort with SMM after discharge were diagnosed in the first 2 weeks after delivery hospitalization discharge. In the Medicaid cohort, Black women had a higher likelihood (aOR, 1.69; 95% CI, 1.57-1.81) of SMM in the postdelivery discharge period compared with White women. In the commercial insurance cohort in the post-delivery discharge period, women residing in the southern region of the US compared with women residing in the northeastern region had a higher likelihood of SMM (aOR, 1.29; 95% CI, 1.18-1.39).

From the PMSS results (2011–2015), the national pregnancy-related mortality ratio (PRMR) was 17.2 per 100,000 live births. Black women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic White women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1–6 days postpartum, 21.4% 7–42 days postpartum, and 11.7% 43–365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and these causes of maternal deaths varied by timing; in pregnancy, during childbirth and postpartum. About 60% of pregnancy-related deaths from state MMRCs were determined to be preventable. The MMRC results indicated that multiple factors contributed to pregnancy-related deaths, and prevention strategies should include improving access to, and coordination and delivery of, quality care to birthing parents.

Conclusion: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. 15.7% and 14.1% of SMM cases in the Medicaid and commercial insurance cohorts, respectively, first occurred after the delivery hospitalization, with disparities in factors and maternal characteristics associated with SMM. Approximately 60% of pregnancy-related deaths were preventable.


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