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Maternal mortality remains "unacceptably high" among all racial and ethnic groups in the U.S., but certain groups are at even more of an increased risk, an observational study revealed.

From 1999 to 2019, the median state maternal mortality ratio (MMR) -- defined as maternal deaths per 100,000 live births -- increased from 14.0 to 49.2 among the American Indian and Alaska Native population, and from 26.7 to 55.4 among the Black population, reported Gregory A. Roth, MD, MPH, of the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, and colleagues.

The median state MMR for the Black population remains the highest in the U.S., they noted in .

"Maternal mortality persists as a source of worsening disparities in many U.S. states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis," Roth and team wrote.

Roth told MedPage Today that the rapid rise in maternal mortality for American Indian and Alaska Native women was "especially concerning, and much higher than we expected."

"During this time period, maternal mortality did not improve for any racial and ethnic group," he added.

The increase in median state MMRs for other racial and ethnic groups were as follows:

• Asian, Native Hawaiian, or other Pacific Islander: 9.6 to 20.9
• Hispanic: 9.6 to 19.1
• White: 9.4 to 26.3

For each racial and ethnic group, MMRs differed across geographic regions. The team found that Oregon, Hawaii, Colorado, Illinois, Wisconsin, Delaware, Vermont, and Rhode Island had lower MMRs for all racial and ethnic groups, and the researchers posited that these states either have lower risk factors for maternal deaths or have had success with maternal death prevention efforts.

Other states had stark racial disparities, such as Arizona and Tennessee, which both had lower MMRs for white women but higher MMRs for all other racial and ethnic groups, relative to other states. In Wyoming, Montana, and Nevada, Asian, Native Hawaiian, or other Pacific Islanders had higher MMRs than other states, which is notable because Filipinos are the largest subset of that group in those states. has shown that Filipinos have poorer perinatal outcomes compared to East Asians.

In the West, American Indian and Alaska Native women had higher MMRs than in other regions. Black women had higher MMRs in the South, as well as states including New York, New Jersey, Arizona, and Montana.

Maternal mortality in the U.S. is much higher than other high-income countries, and that burden is not felt equally across regions or racial and ethnic groups. Roth said that he's "interested in creating the evidence that policymakers need to inform their decisions" and that this research "can be used by local policymakers to guide decisions and target resources where they are needed."

He pointed to possible strategies, including enhancing prenatal and postnatal care, addressing barriers to care and social determinants of health, and treating mental health and chronic diseases.

Roth and team noted that previous research has looked at a handful of states or at the U.S. as a whole, while this study looked at data from every state.

"More recent data is only just now being released that will help us examine trends during the pandemic," Roth said, adding that he and his team are also working on future research to "test interventions that will move the needle to quickly improve maternal health for the most high-risk groups."

For this study, the researchers used data from the National Vital Statistics System and census data from 1999 to 2019 on pregnant and recently pregnant people ages 10 to 54.

Live births were modeled using birth data and deaths were modeled using death certificates from pregnant or recently pregnant people up through 1 year post-birth. Non-pregnancy-related deaths, such as unintentional injuries, suicides, and homicides, were excluded, as they do not meet maternal death criteria.

Overall, 1,210 maternal deaths were counted in 2019, up from 505 in 1999.

Roth and team noted that racial and ethnic data could have been misclassified for some people -- though nationally the misclassification rates are low. Additionally, states added a pregnancy checkbox on death certificates from 2003 to 2017, which could have contributed to increased reporting. Because homicides, suicides, overdoses, and death from other unintentional injuries were excluded, the authors said they believe their study actually undercounted maternal deaths.

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