PODCAST – Q & A on 2020 Maternal Mortality Data

February 23, 2022

https://www.cdc.gov/nchs/pressroom/podcasts/2022/20220223/20220223.htm

HOST: NCHS kicked off the month of February with the latest annual report on Births in the country, using final data from 2020.  Most of the data were already reported in the provisional 2020 report last May, but there are a few topics that did not appear in that report.

For example, cigarette smoking during pregnancy.  The new report shows nearly 6% of women smoked at some point during their pregnancy in 2020, which was an 8% decline from 2019.  Multiple births in the country have dropped as well.  The twin birth rate in 2020 was down 8% from its high in 2014, and the triplet and higher order multiple birth rate was down 9% from 2019.

NCHS also updated its state-by-state life tables, using data from 2019.  The report showed Hawaii and California had the highest life expectancy of any state.  Hawaiians and Californians are expected to live nearly 81 years, according to the 2019 data.  Mississippi had the lowest life expectancy of any state – 74.4 years at birth.

Two new reports using National Health Interview Survey data from 2020 looked at variations in Health Insurance coverage by geographic and demographic factors.  The studies focused on adults between ages 18 and 64.  The geographic study showed that four states – Georgia, Florida, Texas and North Carolina – had uninsured rates among adults that were higher than the national average.  This report also showed that another four states – New York, Pennsylvania, Michigan, and California – had uninsured rates among adults that were lower than the national average.

Meanwhile, in the demographic report, the data show that nearly 1 in 10 or 31.6 million people of all ages were uninsured at the time of the interview. This includes 31.2 million people under age 65. Five percent of children under 18 were uninsured, and 14% of working-age adults ages 18–64. Nearly 2/3 of people under age 65 were covered by private health insurance, and over half were covered from employment-based coverage.   Four percent were covered by exchange-based coverage, a type of directly purchased coverage. Among people under age 65, about 2 out of 5 children and 1 out of 5 adults were covered by public health coverage, mainly by Medicaid and the Children’s Health Insurance Program or “CHIP.”

In other NCHS news, the February release of provisional data on drug overdose deaths in America featured improvements in the timeliness of the data.  Since the monthly releases began in September of 2017, there has been a lag of six months in the data.  However, beginning with the February 2022 release, that lag has been tightened to only four months, so this new release features data from the one-year period ending in September 2021.  The trends, however, remain the same; drug overdose deaths in the U.S. continue to rise, driven by overdoses from fentanyl and other synthetic opioids.

NCHS also updated its marriage and divorce rate tables in February.  Though NCHS hasn’t collected comprehensive statistics on marriage and divorce since the 1990’s, the Center does post annual tables both nationally and by state on the number of marriages and divorces per 1,000 population.  As in years past, Nevada had the highest marriage rate in the nation, more than twice the rate of the next highest state, Montana.  Wyoming had the highest divorce rate per 1,000 in the country, edging out Alabama.

NCHS also has a new report coming out this week showing that 1 in 10 children under age 18 live in households that had food insecurity in the past month, using data from the 2019-2020 National Health Interview Survey.  Non-Hispanic Black children and Hispanic children were more than twice as likely as non-Hispanic white children to live in households experiencing food insecurity in the past month.

Finally, NCHS released new 2020 data on maternal mortality in the U.S.  The new data show that in 2020, 861 women in the United States died of maternal causes, compared with 754 deaths in 2019.  The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births, compared with a rate of 20.1 in 2019.  The rate for non-Hispanic black women was significantly higher than for Hispanic women and non-Hispanic white women.

For several years, NCHS had paused its collection of maternal mortality statistics due to data quality issues, but the Center resumed collection of these important data in 2018, and the first data in (11 years) were released in January 2020.  At that time we had a Statcast discussion with Robert Anderson, the chief of Mortality Statistics at NCHS about the data quality issues in the past, as well as the new collection efforts.  Here is a snippet of that conversation:

V/O: “STATCAST REPLAY… JANUARY 30, 2020”

HOST: Now, with maternal mortality there’s a whole back story – can you share that with us?

ROBERT ANDERSON: Yeah, it’s sort of a long and involved process that we’ve gone through over the last decade and a half or so.  So in the past, as we’ve collected data on maternal deaths – and here we’re talking about years prior to 2003 in particular – research had shown that we tended to underestimate maternal deaths.  And so in order to address that issue, we felt that adding a checkbox item to the death certificate asking whether the decedent was pregnant or recently pregnant was a good idea.  And so we revised our standard death certificate – this is the standard that the states use to base their own state death certificates on –  we revised that to include this checkbox item.  So that was implemented in 2003 but only in a few states. Unfortunately, not all states implemented at the same time and so over the next, well, decade and a half – a little bit more than that actually – we had states implementing gradually this checkbox item and as a result that we saw increases in maternal mortality.  And it got to the point that in 2007, we decided that we couldn’t adequately interpret what was going on and so we stopped reporting maternal mortality altogether, waiting for all of the states to get onto the standard certificate at which point we planned to resume.  So the final state implemented the checkbox item in mid-year 2017, so 2018 is the first data year for which we have data from all states that is based on that checkbox.  So we decided we needed to do an evaluation though, of the data because research post 2003 showed that there were some problems with the checkbox – some errors that were evident.  And so we did this evaluation and we found indeed there were some problems and so we had to come up with a new method to code maternal mortality that would mitigate those errors.  So with the 2018 data we’re now releasing a figure that we believe reasonably represents the risk of maternal mortality in the United States.

HOST: Can we say that the maternal mortality deaths and the maternal mortality rate increased over time?

ROBERT ANDERSON: Well, we can’t really say that with any sort of certainty.  We do know that the increases that we’ve seen compared to the older data that we released, the increases that we’ve seen are largely – mostly even – due to implementation of the checkbox.  They don’t appear to be real increases.

ROBERT ANDERSON: We did an analysis based on 2015 and 2016 data.  The purpose of that particular analysis was to look at the effect of the checkbox on maternal mortality and what we found was that there was a dramatic increase in the number of maternal deaths detected as a result of using the checkbox.  And we also found that that increased very dramatically by age, so at the older ages, the checkbox increased the number of maternal deaths detected by quite a lot.

HOST: So the checkbox you feel then is giving a clearer picture of what the scope of the problem is?

ROBERT ANDERSON: I wish I could say that was the case – we feel like it is definitely allowing us to detect maternal deaths that we weren’t able to detect before.  That said, we know that there are some errors in the checkbox and we’re not entirely sure why these errors are occurring.  This is something that we’re going to be exploring over the course of the next year.  We’re trying to sort that out so we can actually correct it.  But the effect of these errors on the checkbox is that we are finding deaths to women who were not pregnant but for whom that the checkbox was checked that they were pregnant.  And some of these women are quite old actually – beyond reproductive age.

HOST: So when did you start uncovering those problems along this process?

ROBERT ANDERSON: Well, we didn’t actually discover this.  There were some states that were doing their own research on this – the state of Texas, for example, did some important research and they found errors.  CDC’s Division of Reproductive Health did some work with four states recently, that they recently published, that showed that this was the case as well.  And so we were really taking the results of that research, along with our own evaluation, to determine what was going on.

HOST: What else have you found – are there any geographic patterns that suggest maternal deaths are more prevalent in certain parts of the country?

ROBERT ANDERSON: Well, we can’t really say much about maternal mortality by state or by region. Unfortunately, we really don’t understand very well the variation in data quality from state to state. The numbers get quite small and it’s difficult to make judgments based on small numbers – the death rates, mortality rates, get to be very unstable with small numbers.

HOST: So some have been saying or arguing that the problem has been getting worse over time, that even now we don’t have a complete picture.  What would you say to that?

ROBERT ANDERSON: Well, I would agree that we don’t have a complete picture. The evidence that we’re seeing suggests that the problem isn’t really getting worse, but it doesn’t appear to be getting better either.  And that’s, uh, that’s something to be concerned about.  We have data from maternal mortality back to 1915 and we saw substantial declines – they’re really dramatic declines, we’ve seen dramatic decline since then and in recent decades the rate has been rather flat in comparison.

HOST: So one of these new reports looks at a 20 year period prior to the 2018 data. Could you talk about that?

ROBERT ANDERSON: Sure.  As part of our evaluation we did this initial study based on the 2015 and 2016 data to get a sense of the impact of the checkbox and that was based on actual data that we had, we recoded not using the checkbox and then compared it to what we had with the checkbox.  This other study was a little more involved and involves some statistical modeling, and so what we wanted to do with that study was to get a sense for what things would have looked like had all of the states implemented in 2003.  So that was the goal and so we have this trend based on these statistical modeling procedures that shows a fairly stable trend .

HOST: The second report was more focused on the years 2015 and 2016 – can you talk about that work?

ROBERT ANDERSON: Sure.  Yeah, the report based on the data years 2015 and 2016 is really an evaluation of the effect of the checkbox.  And those years were chosen because those were years for which we had data coded without the checkbox.  So we took these data, assuming no checkbox existed, and then we compared that with the data that we had that included the checkbox to get a sense for, to evaluate the effect of the checkbox on the maternal mortality.

HOST: Looking forward, are there any more initiatives underway in terms of improving this whole process and the quality of the data?

ROBERT ANDERSON: Yeah, there’s a lot of, a lot more work to do, really.  I mean, we have to understand better why these errors are occurring in the checkbox.  It may have something to do with electronic registration systems in the way they’re configured.  We’re not really sure, but what we really need to understand if we’re going to correct these errors – we really need to understand why they are occurring and so that’s something that we’ll be working on over the course of the next year.   In addition, we need to work with states and our plan is to do this, to work with states to investigate deaths to women of reproductive age to determine if a pregnancy or recent pregnancy was a factor in their death and this is this can be done using some data linkage to look in birth records and fetal death records for evidence of a pregnancy. I think we can glean a lot of information if we just, you know, take the time and effort to go and look and see.  What we have to do is, we have to work with the states to do this because they are the keeper of those records. They’re the ones that will have to do it and if we can support them in those efforts then hopefully we can get information that will feed back into the vital statistics system and provide us with better data in the future.

HOST: Robert Anderson, thank you for joining us.


Monthly Provisional Drug Overdose Counts through September 2021

February 16, 2022

NCHS has released the next set of monthly provisional drug overdose death counts.  The monthly counts are released under the Vital Statistics Rapid Release program as an interactive data visualization.

Note that due to recent improvements in the timeliness of death certificate reporting, provisional estimates of drug overdose deaths will now be reported 4 months after the date of death, shortening the previous 6-month lag by 2 months (Please see the Technical Notes of the dashboard for more information). Thus, the new update today features data on the 12-month period ending in September 2021.


New NCHS Reports Released This Week

January 21, 2022

Monthly Provisional Drug Overdose Counts through June 2021

January 12, 2022

NCHS has released the next set of monthly provisional drug overdose death counts.  The monthly counts are released under the Vital Statistics Rapid Release program as an interactive data visualization.

Findings:

  • Provisional data show that the predicted number of drug overdose deaths showed an increase of 20.6% from the 12 months ending in June 2020 to the 12 months ending in June 2021, from 83,992 to 101,263. 
  • The predicted number of opioid-involved drug overdose deaths in the United States for the 12-month period ending in June 2021 (76,002) increased from 61,475 in the previous year.


NEW FEATURE: Provisional 2020 and Partial 2021 Mortality Data Available on CDC WONDER

December 7, 2021

CDC WONDER now includes provisional 2020 and partial 2021 mortality statistics by multiple cause of death at the national, state and county level. Data are based on death certificates for U.S. residents.

Multiple Cause of Death (Provisional)


Drug Overdose Deaths in the U.S. Top 100,000 Annually

November 17, 2021

Provisional data from NCHS indicate that there were an estimated 100,306 drug overdose deaths in the United States during 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before.

Read more here:

https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm

The interactive web dashboard is available at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm


PODCAST: The Record Increase in Homicide During 2020

October 8, 2021

https://www.cdc.gov/nchs/pressroom/podcasts/2021/20211008/20211008.htm

HOST: When analyzing trends among leading cause of death (as well as other health measures), it’s important to note that a statistically significant change from year-to-year, whether it be a percent increase or a percent decrease, usually ranges somewhere in the single digits.  So, for example in 2019, death rates from Septicemia dropped nearly 7 percent from 2018, making it the second biggest decline among all leading causes of death.

Occasionally, the one-year change will hit the low double digits.  Death rates from influenza and pneumonia fell 17 percent in 2019, the result of a mild flu season in comparison with a severe flu season the year before.  A double-digit change really stands out as significant when analyzing trends from year to year.

This is why the 30 percent increase in the U.S. homicide rate during 2020 is so remarkable.  The increase itself was not unexpected – after all, the FBI’s Uniform Crime Report had documented a similar increase just days before NCHS released its provisional quarterly estimates on October 6.  But the 30 percent jump in homicide in 2020 was the biggest one-year increase in over a century, with the lone bigger increase coming way back in 1905, essentially a statistical blip that was likely the result of changes to the national death registry at a time when the National Vital Statistics System was first being constructed.

Prior to 2020, the biggest increase in the national homicide rate came in 2001, the year of the September 11 attacks, when the rate increased 20 percent.

Joining us today to discuss this somewhat stunning increase, is Robert Anderson, Chief of the NCHS Mortality Statistics Branch.

Dr. Anderson, thanks for joining us.  When you first saw the number – the 30 percent increase in homicide – what was your reaction?

ROBERT ANDERSON: Well it was it was a pretty big surprise overall.  Now, not as big a surprise it might have been – as you know the FBI had recently released information that suggested nearly a 30% increase, so from that perspective we expected that the increase would be large but 30% is still sort of huge increase in terms of mortality.

HOST:  In terms of statistical history, how does this one-year change historically with other one-year changes, either major increases or major declines, in leading causes of death?

ROBERT ANDERSON:  Well for homicide we did see a pretty substantial increase in 2001 and of course that was directly due to 9/11, to the terrorist attacks that year.  Generally, we don’t see large increases like this for mortality.  You have to go back to when infectious diseases were really prevalent to see large increases for causes of death. I mean, in terms of homicide prior to 2001 you had to go all the way back to the early 1900s – 1904 to 1905 – to find a larger increase than what we saw from 2019 to 2020.  Although that’s likely, at least partly, artifactual due to increases in reporting in the number of states reporting and there’s some other things going on as well at that time that could explain the increase, but mainly it’s an artifact of reporting.

HOST:  So then that 1905 increase – is that even comparable to what we’ve seen here in 2020?

ROBERT ANDERSON:  Not really.  At the time there were maybe 20 states reporting and the number of states reporting was increasing at that time.  Not only the number of states but also the completeness of reporting was increasing in the states that were already reporting as well.  We didn’t have all states reporting in the United States with regard to vital statistics until 1933.  So anything prior to 1933 we would be missing some records and ideally the rate would be sort of reasonably representative for the United States but we know that some of the states coming on board at that time had higher homicide rates overall than the states that were already in the system.

HOST:  So while the increase in 2020 was probably the largest in history the actual rate itself – the number of homicides per 100,000 – is lower than at other points in history more recently.  Could you expand on this?  What period was the peak homicide rate in the country?

ROBERT ANDERSON:  Sure.  So the homicide rate that we’re seeing for 2020 is about 7.8 per 100,000 and it’s a big increase from 6 per 100,000 and 2019 but if you go back to the early 80s and actually in the 70s, you had rates of higher than 10 per 100,000, so at those times you had a higher homicide rate.  Not the big increases or big decreases at that time but the overall level was much higher.

HOST: Death certificate data don’t provide any details about societal issues that may have contributed to the increase, so there’s no way to look at the role the pandemic played in this, if any, correct?

ROBERT ANDERSON:  Yeah that’s essentially correct. With the death certificate data, you really would need to bring in more information.  And I know that there are folks currently looking at this issue to try to understand better the role of the pandemic in this increase, but with death certificate data solely then we really can’t make those determinations.  You really have to look at other patterns and there certainly seems to be a correlation between the two but as we know correlation is not causation.  It’s going to require some I think fairly intensive research to try to sort it all out.

HOST:  In the past, there have been some other studies that have drawn a link between economic downturns and increases in homicide.  What can you tell us about that?

ROBERT ANDERSON: Well there certainly has been some research and the argument is that when economic times get tough, people – crime rises and along with property crime rises, violent crime as well. The correlation though between economic downturns and increases homicide isn’t a perfect one – the correlation is actually fairly weak. It seems to be more correlated with activities that tend to foster violence.  So you saw fairly large increases during prohibition. In the mid 70’s and early 80’s you had big increases and in the drug trade so I think that the connection is more with illegal activity in general rather than economic downturns per se although that does seem to definitely have an impact.

HOST:  And to reiterate, nothing like that on the death certificate?

ROBERT ANDERSON:  No.  The research, they’re looking at patterns using multiple data sets so they can use the final statistics datasets to look at homicides, but they are also using economic data and other sort of social data to model increases and decreases.

HOST:  Could you talk a little bit about the differences between the data released by NCHS and the data in the Uniform Crime Report released by the FBI recently?

ROBERT ANDERSON:  Sure.  So the FBI data is a system where the FBI asks law enforcement agencies across the country to report certain types of information.  Homicides are part of that.  It’s a voluntary system, not all law enforcement agencies report.  The vital statistics data, of course, is coming from the death certificate.  Death certificates have to be filed for every death that occurs in the United States, so vital statistics data are more complete than the data that come out in the Uniform Crime Report.  That said, the trends match pretty closely between the UCR and the vital statistics data so you know when we see something come out in the UCR – like a big increase like we saw with homicide, – there’s a good bet that the vital statistics data will show that as well.  And that’s indeed what we’ve seen.

HOST: Do you expect these provisional numbers to hold up when the 2020 are finalized in the next couple months?

ROBERT ANDERSON:  Yeah the data are complete enough at this point that we’re confident that there won’t be any significant changes between now and when we release the final data.  So the numbers will be pretty close – they are pretty close to final now.

HOST: Is it too early to get a sense of whether this increase in homicide has continued into 2021?

ROBERT ANDERSON:  Yeah it really is because homicides typically require a death investigation.  Information on the cause of death comes to us later than is typical for deaths.  Generally, we get the fact of death and the cause of death in a reasonably timely fashion, within a few weeks at most of the date of death, but with homicides – and this is true for suicides as well and for drug overdoses generally, since an in-depth investigation has to be done and the cause of death may not come till months later and some jurisdictions may take six months for things like toxicology to be complete and the full investigation to be done.  So there’s necessarily a greater lag for causes such as homicides and suicides and drug overdoses, and things like that – deaths that require a lengthy death investigation. And so at this point we have data through the end of 2020 and those data are reasonably complete, but the data for 2021 are really not very complete at this point. We will be releasing some information for 2021 in the coming months but we just don’t have a sense yet for whether homicides are continuing to rise in 2021.

HOST:  Any other things you’d like to add?

ROBERT ANDERSON:  Well I think it is interesting that we’ve seen this large increase in homicides, large increase in drug overdose deaths, and that those seem to be correlated with this big increase in COVID-19 – of course, well COVID-19 was going from zero to 700,000 deaths.  I think for 2020 it’s you know about 350,000 or 370,000,000.  But this is sort of a strange time, I guess, from the standpoint of mortality statistics, I mean, this is just not the sort of thing that we typically see.  We’re usually talking about relatively small increases in mortality or small decreases in mortality.  We don’t normally see these big jumps.  As we go and as we calculate the official mortality statistics for 2020, we’re going to have a lot more work than we normally have to describe what’s going on.  We’re going to need to spend some significant time on these conditions, and these diseases that have increased so much during the pandemic.

HOST:  Strange days.

ROBERT ANDERSON:  Yeah.

HOST:  Thanks very much, Dr. Anderson.

ROBERT ANDERSON:  Alright – thank you.

HOST: The new data on homicide show there was a wide difference in the 2020 rates based on geography.  The states with the highest homicide rates were:  Mississippi, Louisiana, Alabama, Missouri, Arkansas, South Carolina, Tennessee, and Maryland.  The District of Columbia had a higher homicide rate  than any state.  The states with the biggest rate increase in 2020 were Montana, South Dakota, Delaware and Kentucky, while only two states, Alaska and Maine, had definitive declines in homicide rates.

Homicide is one of 21 leading causes of death that are included in the quarterly provisional data release that posted this week.  The new numbers are featured on a data visualization dashboard on the NCHS web site.  Some of the significant findings include:

  • A nearly 17% increase from 2019 to 2020 in death rates from accidents or unintentional injuries.
  • Death rates from Diabetes also increased nearly 17%, from the one year period ending in March 2020 to the same point in 2021.
  • Hypertension mortality increased nearly 16% in the one-year period ending in Quarter 1 2021.
  • And death rates from Influenza/Pneumonia dropped 17% during this period.

In other news, this week NCHS also released a report on mortality and marital status in the United States.  The report focused on adults age 25 and up, covering the period 2010 though 2019.  The study found that death rates for married adults during roughly the last decade  have declined by more than three times that of never-married or divorced adults.  Suicide was found to be among the ten leading causes of death for never-married and divorced people, but not among the leading killers for married or widowed people.  Cancer is the number one cause of death for married adults whereas heart disease is the leading killer for unmarried adults.

There are a number of other data releases in the queue for NCHS this month as well.  The National Health Interview Survey is releasing two new reports on October 20th, on mental health treatment among adults and social and emotional support among adults.  Both reports feature data from 2020.

In the area of vital statistics, the latest quarterly provisional estimates on infant mortality, featuring data through 2020, will be released on October 14.  The day before that, the NCHS vital statistics team will release the lastest monthly estimates on drug overdose deaths in the U.S., though March of 2021.  Later in the month, on October 26, there will be a study on 2019 data on fetal mortality  in the United States.  And the following day there will be the latest in the series of rural-urban health studies, this one focusing on rural-urban differences in death rates from unintentional injuries among children.

Also, two methodological studies from the National Health Care Survey will be released on October 18, one focusing on “enhancing identification of opioid-related health outcomes,” and another on “machine learning for medical coding.”

Finally, October is dedicated to several health observances, including Sudden Infant Death Syndrome Awareness.  SIDS is the 4th leading cause of infant death in the United States, according to the latest final data from NCHS.

October is also Breast Cancer Awareness Month.  Over 42,000 women died from breast cancer in the United States in 2019, according to the latest NCHS data.

Join us next month for another NCHS “Statcast,” which will include new studies on suicide by month and demographic characteristics for 2020, as well as a study on mortality among the American Indian/Alaskan Native population.


Fact or Fiction – Homicide Rates

October 6, 2021

Source: National Vital Statistics System

https://www.cdc.gov/nchs/nvss/vsrr/mortality-dashboard.htm


Monthly Provisional Drug Overdose Counts through February 2021

September 15, 2021

Monthy_Drugs_Feb21

NCHS has released the next set of monthly provisional drug overdose death counts.  The monthly counts are released under the Vital Statistics Rapid Release program as an interactive data visualization.

Findings: 

  • Provisional data show that the predicted number of drug overdose deaths showed an increase of 30.4% from the 12 months ending in February 2020 to the 12 months ending in February 2021, from 74,234 to 96,801.
  • The predicted number of opioid-involved drug overdose deaths in the United States for the 12-month period ending in February 2021 (72,689) increased from 52,712 in the previous year.

NCHS Releases Latest Quarterly Birth Data Through Q1 2021

September 1, 2021

The data is available at the interactive web dashboard below:

Quarterly Provisional Data for Selected Birth Estimates: Q1 2020 – Q1 2021 Vital Statistics Rapid Release Web Data Visualization

https://www.cdc.gov/nchs/nvss/vsrr/natality-dashboard.htm

Q1_2021_Births