Severe Maternal Morbidity and Mortality among Indigenous Women in the United States

Katy B. Kozhimannil, Julia D. Interrante, Alena N. Tofte, Lindsay K. Admon

Research output: Contribution to journalArticlepeer-review

79 Scopus citations


OBJECTIVE: To describe delivery-related severe maternal morbidity and mortality among indigenous women compared with non-Hispanic white (white) women, distinguishing rural and urban residents. METHODS: We used 2012–2015 maternal hospital discharge data from the National Inpatient Sample to conduct a pooled, cross-sectional analysis of indigenous and white patients who gave birth. We used weighted multivariable logistic regression and predictive population margins to measure health conditions and severe maternal morbidity and mortality (identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes) among indigenous and white patients, to test for differences across both groups, and to test for differences between rural and urban residents within each racial category. RESULTS: We identified an estimated 7,561,729 (unweighted n51,417,500) childbirth hospitalizations that were included in the analyses. Of those, an estimated 101,493 (unweighted n519,080) were among indigenous women, and an estimated 7,460,236 (unweighted n51,398,420) were among white women. The incidence of severe maternal morbidity and mortality was greater among indigenous women compared with white women (2.0% vs 1.1%, respectively; relative risk [RR] 1.8, 95% CI 1.6–2.0). Within each group, incidence was higher among rural compared with urban residents (2.3% for rural indigenous women vs 1.8% for urban indigenous women [RR 1.3, 95% CI 1.0–1.6]; 1.3% for rural white women vs 1.2% for urban white women [RR 1.1, 95% CI 1.1–1.2]). CONCLUSION: Severe maternal morbidity and mortality is elevated among indigenous women compared with white women. Incidence is highest among rural indigenous residents. Efforts to improve maternal health should focus on populations at greatest risk, including rural indigenous populations.

Original languageEnglish (US)
Pages (from-to)294-300
Number of pages7
JournalObstetrics and gynecology
Issue number2
StatePublished - Feb 1 2020

Bibliographical note

Funding Information:
This research was supported in part with funding from the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS) Cooperative Agreement U1CRH03717. The information, conclusions and opinions expressed are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

Publisher Copyright:
© 2020 The Author(s). Published by Wolters Kluwer Health, Inc.


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