The Correlation Between Education Level and Maternal Death Rates in North Dakota

The Correlation Between Education Level and Maternal Death Rates in North Dakota | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Correlation Between Education Level and Maternal Death Rates in North Dakota Madelyn V Jablonski, Jonah W Muller, Thomas F Arnold, Steffen P Christensen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7401115/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study examines the relationship between maternal mortality rates and socioeconomic factors, particularly education level and race, in North Dakota. Lower educational attainment is often linked to reduced socioeconomic status and limited access to healthcare, potentially contributing to the rising maternal mortality rates observed in this rural state. North Dakota’s unique demographic makeup, with significant Native American and Caucasian populations, provides a lens through which to explore persistent health disparities. Maternal mortality data from 2008 to 2022 were obtained from the North Dakota Department of Health and Human Services. The dataset included 119 maternal deaths and was analyzed using IBM SPSS, with variables such as education level, race, and cause of death. Findings revealed a concerning trend: 75% of maternal deaths occurred among individuals without a college degree. Of the 25 Native American maternal deaths, 76% also lacked a college degree. These findings demonstrate a clear association between lower education levels and increased maternal mortality risk. Native American communities, already facing higher rates of poverty, unemployment, and limited healthcare access, appear disproportionately affected. This study highlights the urgent need for targeted, multifaceted interventions that address systemic inequities in education, socioeconomic opportunity, and healthcare access. Improving maternal health outcomes in rural and underserved populations will require collaboration across healthcare systems, policymakers, and community leaders. Maternal mortality race education socioeconomic factors North Dakota health disparities public health Figures Figure 1 Figure 2 Figure 3 Intro Although the reasoning for the overall increase in maternal deaths in the United States may be unclear, using maternal death records to investigate potential risk factors is one way in which we can start to research this topic. In this paper, the focus will be on the mother's highest level of education and her race. These criteria were selected based on the lack of information regarding maternal mortality that may correlate with a mother's level of education, and separating these results by race can help see if certain populations are being disproportionately affected. This field must be studied to decrease the maternal mortality rate in the United States. A country as wealthy and with such an advanced medical system as the United States should not have high rates of maternal mortality. The goal of this paper is to bring us one step closer to solving this problem. There is not a single factor affecting maternal mortality rates, realistically it is a multifactorial issue we are dealing with. This paper will test if lower levels of education completed are associated with higher rates of maternal mortality in North Dakota. While examining this, we will specifically be looking at the comparison of statistics between Native Americans and Caucasians in North Dakota since these are the two most prominent groups or people within the state. According to the CDC’s Pregnancy Mortality Surveillance System (PMSS), a pregnancy-related death, or maternal mortality, is defined as a death while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy ( 1 , 3 ). The maternal mortality rate is calculated as the number of maternal deaths per 100,000 live births. In the United States, maternal mortality rates have nearly tripled between 1990 (8.0 deaths per 100,000 live births) and 2019 (20.1 deaths per 100,000 live births). By the year 2000, the rate rose to 12 deaths per 100,000. In 2010, that number had gone up to 14 deaths per 100,000. In 2015 there were 17 deaths per 100,000. That number increased by about 1 death per year and reached about 20 deaths per 100,000 by the year 2019. Despite being one of the wealthiest countries, the United States is one of the very few countries worldwide to report a significant increase in maternal morbidity since 2000. Along with an increase in the number of maternal deaths, the cause of these deaths has also shifted in recent years. Compared to the 1990s, traditional causes of maternal mortality [such as hemorrhage, hypertensive disorders of pregnancy (HDPS), thromboembolism, and anesthesia complications] have steadily declined, whereas deaths due to diseases of the cardiovascular system (peripartum cardiomyopathy, myocardial infarction, and cerebrovascular conditions) and other medical conditions (e.g., endocrine, hematologic, immunologic, and renal) have increased ( 2 ). In 2003, a revised death certificate was released and included a box to check if the individual was pregnant at the time of death. This caused an increase in the identification of maternal deaths, and thus an increase in the maternal mortality rate. The check box wasn’t universally used by all states right away. It started with 4 states in 2003 and by 2017 was used in 50 states plus Washington DC. This gradual rollout caused a gradual increase in maternal deaths and could be identified as one of the reasons for the increase in maternal mortality within the US ( 4 ). That said, the rate of maternal mortality has been rising since 2017. This leads to the most likely conclusion that the change in death certificate statistic collection in the United States has led partly to the increase in maternal mortality rates, but there are also other factors affecting mothers and causing an increase in maternal mortality rate. The maternal mortality rate is rising, but maybe not as aggressively as we originally thought ( 5 ). The unknown factors affecting maternal deaths are what our continued research must be focused on moving forward. In the future, it is crucial that our data collection methods become more consistent and accurate. To have better data and make more definitive conclusions going forward we must be more diligent and uniform in our data collection. Valid statistics start with proper data collection methods. Education Traditionally, it has been thought that an increase in education level will lead to an increase in an individual’s socioeconomic status (SES). Primary and secondary education are very important for an individual to complete and are highly correlated with SES because in these years you are learning many skills that are important throughout the entirety of your life. Education gives people the opportunity to live fulfilling lives. Without a high school education or a GED, it can be very hard to find a job that can support a family. Education allows people to earn living wages which in turn can allow them to live in better and safer areas that have access to more quality healthcare. It has been shown that people with lower SES are at higher risk for most health conditions including physical and mental illnesses. Less education has been linked to lower income, and lower income has a significant association with poor health. Lower income can negatively affect health in several ways. One way is that lower-income jobs often have more safety risks than higher-paying jobs. A second way is that lower income allows for less money to be spent on food, and this can lead to poor nutrition and obesity. Another effect of low income is that you may live in a worse neighborhood which may be closer to environmental toxins and farther away from quality healthcare ( 6 )( 7 ). Once through High school, the relationship between SES and Higher education performance weakens. There is still a positive correlation between the two, but the weaker correlation suggests that although higher education can undoubtedly help raise your SES, it is most important to at least complete high school. SES can be most accurately evaluated using indicators including education level, occupation, income, household resources, and neighborhood resources. How these variables interact to measure SES is complex and not the focus of this paper, but it is essential to know that these are some of the main factors influencing SES ( 8 ). It has been shown that children from lower SES homes and communities develop academic skills slower than their counterparts who grew up in a higher SES home. This can lead to a cycle of poverty. As low SES children are consistently behind their higher SES classmates in cognitive development, language, memory, and socioemotional processing, and consequently poor income and health in adulthood. Low SES communities are often disproportionately affected as well because they are often under-resourced. To stop this cycle, there must be a focus on early intervention and improving schools that are in under-resourced areas ( 6 ). The state of North Dakota has been the fourth fastest-growing state from 2010–2020. During this time, the state grew by 106,503 people to reach a total population size of 779,094 people. Of these people, 7.2% identified as either partially American Indian or Alaskan native. This means that about 56,000 people identify as being at least partially Native American. This is the largest minority group within the state. There are 5 federally recognized reservations within the state. 82.9% of people within the state identified as being only white. This means that there are about 645,000 people in the state that identify as being only white ( 9 ). In 2020 there were 10,059 births in the state of North Dakota. Of these births, 771 of them were of American Indian or Alaskan Native descent. These numbers match the census values from 2010–2020 as expected. In a ten-year time frame, the state grew by roughly 100,000 people, and in 2020 about 10,000 children were born in the state. We can assume that there are about 10,000 children born each year in the state. Of the 10,000 children born in North Dakota in 2020 about 7.7% of them were American Indian or Alaskan native. In 2020 American Indians and Alaska natives made up 7.2% of the population in North Dakota so the number of births correlated with the total population of American Indian and Alaska natives within the state ( 10 ). The state of North Dakota makes for a good longitudinal study group because as you can see above, there is not a lot of population movement within the state. Compared to other states North Dakota has relatively small numbers of people leaving and entering the state. American Indian and Alaskan Native (AI/AN) peoples' health care is federally funded for federally recognized tribal nations and is carried out by the Indian Health Services. This sounds like a good thing and is supposed to be, but these health services on reservations are often hard to access and underfunded which results in diminished quality of care. Since these Indian Health Services are usually underfunded, they commonly don’t have obstetric care. This means for many AI/AN women they must search out some other place to receive obstetric care. This can cause problems in several ways. One way is that it may deter women from receiving any obstetric care which could result in more dangerous pregnancies for the mother and child. Another issue is that if an AI/AN woman does seek out care from another institution that the cost may not be covered by Indian Health Services. This can leave a massive bill for the mother and can create a ton of financial burden. Moreover, there is still systemic racism within the US and this does not exclude the healthcare system ( 11 ). In a retrospective study conducted in Minnesota using data from 1989–2018, it showed that AI/AN individuals in 2018 make an average of $ 34,986 less than white individuals. This decrease in wages contributes to a lower average SES between AI/AN compared to white individuals which can lead to lower quality of healthcare that's obtainable and less money to spend on necessities such as good food and hygiene. From 2010–2019 in Minnesota, about 50% of AI/AN people owned houses while 75% of white people owned houses in that same time frame. Owning a house is a large social determinant because it can greatly affect an individual's health and well-being by providing stability for housing. The U.S. Department of Health and Human Services defined poverty for a single person as earning less than $ 12,460 per year Federal poverty line). This definition indicates the estimated minimum level of income needed to secure the necessities of life. This amount of money needed to survive has increased since 2012, indicating that the cost of living is becoming more expensive. Salaries, federal benefits, and cost assistance programs have not increased in coordination with this trend. This has moved more people into poverty in recent years. AI/AN are consistently four times as likely to be living in poverty when compared to white Minnesotans. In 2019, the percentage of American Indians living in poverty was 31.3 percent whereas the percentage of white individuals living below the Federal Poverty line was 7.3 percent. Along with this, AI/AN people are 3–4 times more likely to be unemployed and about twice as likely to be uninsured as a white person in Minnesota. From 2015–2019 in Minnesota, it was shown that about 83% of AI/AN people are high school graduates or better while about 95% of white people are. In the same time frame, about 12% of AI/AN individuals have a bachelor's degree or higher which is about 36% of white individuals have a bachelor's degree or higher ( 12 ). As you can see, there is a large gap between how white people and how AI/AN people are treated in this country. We must work to close this gap and increase the quality of life for everyone. Materials and Methods Maternal mortality data was obtained from the North Dakota Department of Health and Human Services. In North Dakota, maternal mortality is defined as a death while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy. The number of maternal deaths reported in North Dakota each year may be slightly skewed compared to other states or countries that define a maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” ( 18 ). The data set consists of 119 unique records of North Dakota residents who died during pregnancy or within one year of pregnancy from the years 2008 to 2022. From 2008–2022, there were 86 deaths with the decedent being listed as 16 through 57 years of age at the time of pregnancy or within 1 year of pregnancy. From the same period, there were 33 decedents listed as being 60 years or older at the time of pregnancy or within 1 year of pregnancy. Information regarding descendants 60 years of age or older has been excluded due to likely errors upon data entry or the use of a surrogate. Clinical trial number: not applicable. The North Dakota Department of Health and Human Services included the following categories of race; White, Black or African American, Asian Indian, Chines, Filipino, Japanese, Korean, Vietnamese, other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, other Pacific Islander, other, or refused/unknown. Due to the lack of racial diversity and small population size in North Dakota, all races, except Caucasians and Native Americans, are excluded due to statistical insignificance. For maternal mortality, underlying causes of death are grouped into accidents, cancer, cerebrovascular disease, cirrhosis, COPD, Covid-19, diabetes, diseases of the heart, other causes, septicemia, or suicide. The greatest level of education completed at the time of death was obtained. Education level was assigned to one of the following: 9th-12th grade education but no high school diploma, high school graduate or had GED completed, some college credit but no college degree, associate’s degree, bachelor's degree, master’s degree, or refused/unknown. Information collected regarding education levels may differ from CDC guidelines due to differing data collection methods. The information collected from the North Dakota Department of Health and Human Services is private. Due to the small population size, certain cases could be indirectly identifiable; therefore, the datasets generated and analyzed during the current study are not publicly available. Results In 2020, the maternal mortality rate in the United States was 23.8 deaths per 100,000 live births ( 15 ). For the same year, North Dakota had a maternal mortality rate of 52.3 deaths per 100,000 live births, over double the national average. To investigate whether lower levels of education are associated with higher rates of maternal mortality in North Dakota, information regarding the decedent's race, level of education, year of death, and underlying cause of death was cross tabulated using IBM SPSS software. From 2008 to 2022, there were 86 maternal deaths in North Dakota. When looking specifically at education levels, most mothers did not have a college degree. The most significant percentage of maternal deaths came from those whose highest level of education completed was a high school diploma or equivalent GED. The 15-year data set has been broken up into 3-year intervals to better assess potential trends. From 2008 to 2011, there were a total of 19 maternal deaths in the state. Of those 19 individuals, 16 did not have a college degree. From 2012 to 2015, there was a slight decrease in the number of maternal deaths, only 16 recorded for that time period. Those with only a high school or equivalent GED level education had the highest rates of maternal mortality. From 2016 to 2019, the number of maternal deaths rose to 26. In those three years, over 73% of mothers had no college degree, with the greatest number of maternal deaths arising from those with only a high school diploma or equivalent GED. Lastly, from 2020 to 2023, there were 25 maternal deaths. The trend continued during this time, as the greatest number of maternal deaths occurred in those with only a high school diploma or equivalent GED. Native American Data In North Dakota, Native Americans make up the largest minority group. With such a large Native American presence throughout the state, it is essential to look at their specific maternal mortality rates and make comparisons to the overall population statistics. Information specific to the Native American race, level of education, year of death, and underlying cause of death was used to investigate potential associations between lower education levels in Native American mothers and higher rates of maternal mortality in North Dakota. In the past 15 years, 25 of the 86 maternal deaths have been Native American. The 15-year data set specific to the Native American race has been broken down into 3-year intervals to better evaluate potential associations. From 2008 to 2011, there were a total of seven Native American maternal deaths. All of whom in this specific period, did not have a college degree. From 2012 to 2015, there were five Native American maternal deaths, a slight decrease from previous years. Only one of the mothers in this cohort had an associate's degree, the remaining four did not have a college degree. From 2016 to 2019, there were nine Native American maternal deaths, the highest recorded in the 15-year data set. Eight out of the nine deaths during those years had no college degree or upper-level education completed. In the last data set, from 2020 to 2022, there were four deaths from Native American mothers. From the most recent time interval, two of the decedents had a 9th to 12th-grade education level without a high school diploma and the other two were high school graduates or had an equivalent GED. Caucasian vs. Native American Data The status dropout rate, reported by the National Center of Education Statistics, represents the percentage of 16 to 24-year-olds who are not enrolled in school and have not earned a high school diploma or GED certificate. In 2018, the status dropout rates were the highest for American Indian/Alaska Natives, with a dropout rate of 9.5%. For Caucasian 16 to 24-year-olds, the dropout rate is 4.2%, lower than that of every other racial group except Asians. ( 19 ). In the same year, Native Americans comprised 24% of 18-to-24-year-olds enrolled in college, while Caucasians represented over 42%. Post Baccalaureate degree programs include master’s and doctoral programs, as well as professional doctoral programs such as law, medicine, and dentistry ( 19 ). In the fall of 2018, of the 3 million students enrolled in a postbaccalaureate program, roughly 1.6 million were Caucasian and 13,600 were Native American/Alaska Native ( 19 ). In North Dakota, approximately 93.3% of individuals over the age of 25 have graduated high school or completed a GED program, which is higher than the national average (88.9%). However, North Dakota is below the national average in the number of people over the age of 25 who have a bachelor’s degree or higher. In summary, there is a negative correlation between the number of maternal deaths and the level of education completed. Irrespective of race, about 75% of maternal deaths came from mothers who did not have a college degree. The highest percentage of deaths came from mothers who had a high school diploma or GED, while the lowest percentage of deaths derived from mothers with a master’s degree. Discussion/Conclusions In conclusion, this study explored the critical issue of maternal mortality in the United States, focusing on North Dakota and examining the complex interplay between education levels, race, and maternal deaths. The North Dakota Department of Health and Human Services provided access to 15 years of maternal death records to help investigate potential causes for increased maternal mortality rates seen throughout the country. Information regarding race, underlying cause of death, year of death, and education level was collected from 86 maternal death certificates. Our investigation revealed an association between lower education levels and higher maternal mortality rates, mothers without a college degree made up 75% of all maternal deaths in North Dakota. The findings indicated the need for specific interventions aimed at improving educational opportunities and socioeconomic conditions. The statistical integrity of the data collected must be questioned due to the small sample size, errors that occurred while filling out the death certificate, and differing definitions of maternal death. This research has been conducted with the goals of benefiting other states by giving them the framework to reproduce similar research, minimizing incorrect information on death certificates, and bringing more awareness to the subject of maternal mortality. The study highlights the necessity of addressing education, race, and socioeconomics as fundamental aspects of maternal health. To properly address these issues and improve maternal mortality rates, more research and education needs to be done. Declarations Ethical Approval and Consent to Participate This study was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by University of North Dakota’s Institutional Review Board. Given the use of de-identified secondary data from the North Dakota Department of Health and Human Services, the requirement for informed consent was waived. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Authorship All authors contributed to the study conception and design. Maternal preparation, data collection, and analysis were performed by M.J, J.M, T.A, S.C, and D.L. M.J and J.M wrote the main manuscript text and prepared the figures. All authors contributed to gathering and reviewing the data. All authors read and approved of the final manuscript. Availability of data and material Not applicable. The information collected from the North Dakota Department of Health and Human Services is private. Due to the small population size, certain cases could be indirectly identifiable; therefore, the datasets generated and analyzed during the current study are not publicly available. References Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC [Internet]. 2023 [cited 2023 Jul 24]. Available from: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-s urveillance-system.htm Wang S, Rexrode KM, Florio AA, Rich-Edwards JW, Chavarro JE. Maternal Mortality in the United States: Trends and Opportunities for Prevention. Annu Rev Med. 2023;74(1):199–216. https://doi.org/10.1146/annurev-med-042921-123851 . CDC. (2019, September 5). Preventing Pregnancy-Related Deaths | CDC. Www.cdc. gov.https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html Joseph KS, Boutin A, Lisonkova S, Muraca GM, Razaz N, John S, et al. Maternal Mortality in the United States. Obstet Gynecol. 2021;137(5):763–71. National Vital Statistics Reports Volume 69. Number 1 January 30, 2019 Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths. https:/. /www.apa.org [Internet]. [cited 2023 Jul 25]. Education and Socioeconomic Status Factsheet. Available from: https://www.apa.org/pi/ses/resources/publications/education Social Determinant of Health. Education Is Crucial [Internet]. 2021 [cited 2023 Jul 25]. Available from: https://publichealth.tulane.edu/blog/social-determinant-of-health-education-is-cru cial/ Rodríguez-Hernández CF, Cascallar E, Kyndt E. Socio-economic status and academic performance in higher education: A systematic review. Educational Res Rev. 2020;29:100305. Bureau UC. Census.gov. [cited 2023 Jul 25]. North Dakota Was Fourth Fastest Growing State Last Decade. Available from: https://www.census.gov/library/stories/state-by-state/north-dakota-population-cha nge-between-census-decade.html National Vital Statistics Reports. Volume 70, Number 17, February 7, 2022. Burns A, DeAtley T, Short SE. The maternal health of American Indian and Alaska Native people: A scoping review. Soc Sci Med. 2023;317:115584. Social and economic factors. American Indian health status in Minnesota [30-year retrospective]. CDC. (2019, September 5). Preventing Pregnancy-Related Deaths | CDC. Www.cdc. gov.https://www.cdc.gov/reproductivehealth/maternal-mortality/preventi ng-pregnancy-related-deaths.html Wang S, Rexrode KM, Florio AA, Rich-Edwards JW, Chavarro JE. Maternal Mortality in the United States: Trends and Opportunities for Prevention. Annu Rev Med. 2023;74(1):199–216. https://doi.org/10.1146/annurev-med-042921-123851 . Hoyert D. (2020). Maternal Mortality Rates in the United States, 2020. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/E-stat-Maternal-M ortality-Rates-2022.pdf. CDC. (2019, September 5). Preventing Pregnancy-Related Deaths | CDC. Www.cdc. gov.https://www.cdc.gov/reproductivehealth/maternal-mortality/preventi ng-pregnancy-related-deaths.html Wang S, Rexrode KM, Florio AA, Rich-Edwards JW, Chavarro JE. Maternal Mortality in the United States: Trends and Opportunities for Prevention. Annu Rev Med. 2023;74(1):199–216. https://doi.org/10.1146/annurev-med-042921-123851 . Hoyert DL. (2023). Maternal mortality rat18. Hoyert United States, 2021. The Condition of Education 2020 A Publication of the National Center for Education Statistics at IES. (2020). https://nces.ed.gov/pubs2020/2020144.pd Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7401115","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516628447,"identity":"27426201-8299-4317-8963-7bcdb4aafc12","order_by":0,"name":"Madelyn V 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1","display":"","copyAsset":false,"role":"figure","size":30502,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Results section.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7401115/v1/e644a6dbf59266742e5dec85.png"},{"id":91863884,"identity":"83c5ea8c-44ab-4da6-97cb-ba4708adab80","added_by":"auto","created_at":"2025-09-22 12:55:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37908,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Results section.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7401115/v1/b2ea80ed06b352c28fecab45.png"},{"id":91863895,"identity":"c9d8ba74-ecd2-4db3-9a35-ac3ccb4a8080","added_by":"auto","created_at":"2025-09-22 12:56:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28457,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Results section.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7401115/v1/5c819ff498ac0713b198f001.png"},{"id":94133370,"identity":"fa5c7613-2894-4b82-9557-ccebed1e3446","added_by":"auto","created_at":"2025-10-22 18:16:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":454906,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7401115/v1/413507ec-ecde-44ef-bfeb-852e4c488b2e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Correlation Between Education Level and Maternal Death Rates in North Dakota","fulltext":[{"header":"Intro","content":"\u003cp\u003eAlthough the reasoning for the overall increase in maternal deaths in the United States may be unclear, using maternal death records to investigate potential risk factors is one way in which we can start to research this topic. In this paper, the focus will be on the mother's highest level of education and her race. These criteria were selected based on the lack of information regarding maternal mortality that may correlate with a mother's level of education, and separating these results by race can help see if certain populations are being disproportionately affected. This field must be studied to decrease the maternal mortality rate in the United States. A country as wealthy and with such an advanced medical system as the United States should not have high rates of maternal mortality. The goal of this paper is to bring us one step closer to solving this problem.\u003c/p\u003e\u003cp\u003eThere is not a single factor affecting maternal mortality rates, realistically it is a multifactorial issue we are dealing with. This paper will test if lower levels of education completed are associated with higher rates of maternal mortality in North Dakota. While examining this, we will specifically be looking at the comparison of statistics between Native Americans and Caucasians in North Dakota since these are the two most prominent groups or people within the state.\u003c/p\u003e\u003cp\u003eAccording to the CDC\u0026rsquo;s Pregnancy Mortality Surveillance System (PMSS), a pregnancy-related death, or maternal mortality, is defined as a death while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The maternal mortality rate is calculated as the number of maternal deaths per 100,000 live births.\u003c/p\u003e\u003cp\u003eIn the United States, maternal mortality rates have nearly tripled between 1990 (8.0 deaths per 100,000 live births) and 2019 (20.1 deaths per 100,000 live births). By the year 2000, the rate rose to 12 deaths per 100,000. In 2010, that number had gone up to 14 deaths per 100,000. In 2015 there were 17 deaths per 100,000. That number increased by about 1 death per year and reached about 20 deaths per 100,000 by the year 2019. Despite being one of the wealthiest countries, the United States is one of the very few countries worldwide to report a significant increase in maternal morbidity since 2000. Along with an increase in the number of maternal deaths, the cause of these deaths has also shifted in recent years. Compared to the 1990s, traditional causes of maternal mortality [such as hemorrhage, hypertensive disorders of pregnancy (HDPS), thromboembolism, and anesthesia complications] have steadily declined, whereas deaths due to diseases of the cardiovascular system (peripartum cardiomyopathy, myocardial infarction, and cerebrovascular conditions) and other medical conditions (e.g., endocrine, hematologic, immunologic, and renal) have increased (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn 2003, a revised death certificate was released and included a box to check if the individual was pregnant at the time of death. This caused an increase in the identification of maternal deaths, and thus an increase in the maternal mortality rate. The check box wasn\u0026rsquo;t universally used by all states right away. It started with 4 states in 2003 and by 2017 was used in 50 states plus Washington DC. This gradual rollout caused a gradual increase in maternal deaths and could be identified as one of the reasons for the increase in maternal mortality within the US (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). That said, the rate of maternal mortality has been rising since 2017. This leads to the most likely conclusion that the change in death certificate statistic collection in the United States has led partly to the increase in maternal mortality rates, but there are also other factors affecting mothers and causing an increase in maternal mortality rate. The maternal mortality rate is rising, but maybe not as aggressively as we originally thought (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The unknown factors affecting maternal deaths are what our continued research must be focused on moving forward. In the future, it is crucial that our data collection methods become more consistent and accurate. To have better data and make more definitive conclusions going forward we must be more diligent and uniform in our data collection. Valid statistics start with proper data collection methods.\u003c/p\u003e\n\u003ch3\u003eEducation\u003c/h3\u003e\n\u003cp\u003eTraditionally, it has been thought that an increase in education level will lead to an increase in an individual\u0026rsquo;s socioeconomic status (SES). Primary and secondary education are very important for an individual to complete and are highly correlated with SES because in these years you are learning many skills that are important throughout the entirety of your life. Education gives people the opportunity to live fulfilling lives. Without a high school education or a GED, it can be very hard to find a job that can support a family. Education allows people to earn living wages which in turn can allow them to live in better and safer areas that have access to more quality healthcare. It has been shown that people with lower SES are at higher risk for most health conditions including physical and mental illnesses. Less education has been linked to lower income, and lower income has a significant association with poor health. Lower income can negatively affect health in several ways. One way is that lower-income jobs often have more safety risks than higher-paying jobs. A second way is that lower income allows for less money to be spent on food, and this can lead to poor nutrition and obesity. Another effect of low income is that you may live in a worse neighborhood which may be closer to environmental toxins and farther away from quality healthcare (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOnce through High school, the relationship between SES and Higher education performance weakens. There is still a positive correlation between the two, but the weaker correlation suggests that although higher education can undoubtedly help raise your SES, it is most important to at least complete high school. SES can be most accurately evaluated using indicators including education level, occupation, income, household resources, and neighborhood resources. How these variables interact to measure SES is complex and not the focus of this paper, but it is essential to know that these are some of the main factors influencing SES (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt has been shown that children from lower SES homes and communities develop academic skills slower than their counterparts who grew up in a higher SES home. This can lead to a cycle of poverty. As low SES children are consistently behind their higher SES classmates in cognitive development, language, memory, and socioemotional processing, and consequently poor income and health in adulthood. Low SES communities are often disproportionately affected as well because they are often under-resourced. To stop this cycle, there must be a focus on early intervention and improving schools that are in under-resourced areas (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe state of North Dakota has been the fourth fastest-growing state from 2010\u0026ndash;2020. During this time, the state grew by 106,503 people to reach a total population size of 779,094 people. Of these people, 7.2% identified as either partially American Indian or Alaskan native. This means that about 56,000 people identify as being at least partially Native American. This is the largest minority group within the state. There are 5 federally recognized reservations within the state. 82.9% of people within the state identified as being only white. This means that there are about 645,000 people in the state that identify as being only white (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In 2020 there were 10,059 births in the state of North Dakota. Of these births, 771 of them were of American Indian or Alaskan Native descent. These numbers match the census values from 2010\u0026ndash;2020 as expected. In a ten-year time frame, the state grew by roughly 100,000 people, and in 2020 about 10,000 children were born in the state. We can assume that there are about 10,000 children born each year in the state. Of the 10,000 children born in North Dakota in 2020 about 7.7% of them were American Indian or Alaskan native. In 2020 American Indians and Alaska natives made up 7.2% of the population in North Dakota so the number of births correlated with the total population of American Indian and Alaska natives within the state (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The state of North Dakota makes for a good longitudinal study group because as you can see above, there is not a lot of population movement within the state. Compared to other states North Dakota has relatively small numbers of people leaving and entering the state.\u003c/p\u003e\u003cp\u003eAmerican Indian and Alaskan Native (AI/AN) peoples' health care is federally funded for federally recognized tribal nations and is carried out by the Indian Health Services. This sounds like a good thing and is supposed to be, but these health services on reservations are often hard to access and underfunded which results in diminished quality of care. Since these Indian Health Services are usually underfunded, they commonly don\u0026rsquo;t have obstetric care. This means for many AI/AN women they must search out some other place to receive obstetric care. This can cause problems in several ways. One way is that it may deter women from receiving any obstetric care which could result in more dangerous pregnancies for the mother and child. Another issue is that if an AI/AN woman does seek out care from another institution that the cost may not be covered by Indian Health Services. This can leave a massive bill for the mother and can create a ton of financial burden. Moreover, there is still systemic racism within the US and this does not exclude the healthcare system (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn a retrospective study conducted in Minnesota using data from 1989\u0026ndash;2018, it showed that AI/AN individuals in 2018 make an average of \u003cspan\u003e$\u003c/span\u003e34,986 less than white individuals. This decrease in wages contributes to a lower average SES between AI/AN compared to white individuals which can lead to lower quality of healthcare that's obtainable and less money to spend on necessities such as good food and hygiene. From 2010\u0026ndash;2019 in Minnesota, about 50% of AI/AN people owned houses while 75% of white people owned houses in that same time frame. Owning a house is a large social determinant because it can greatly affect an individual's health and well-being by providing stability for housing. The U.S. Department of Health and Human Services defined poverty for a single person as earning less than \u003cspan\u003e$\u003c/span\u003e12,460 per year Federal poverty line). This definition indicates the estimated minimum level of income needed to secure the necessities of life. This amount of money needed to survive has increased since 2012, indicating that the cost of living is becoming more expensive. Salaries, federal benefits, and cost assistance programs have not increased in coordination with this trend. This has moved more people into poverty in recent years. AI/AN are consistently four times as likely to be living in poverty when compared to white Minnesotans. In 2019, the percentage of American Indians living in poverty was 31.3 percent whereas the percentage of white individuals living below the Federal Poverty line was 7.3 percent. Along with this, AI/AN people are 3\u0026ndash;4 times more likely to be unemployed and about twice as likely to be uninsured as a white person in Minnesota. From 2015\u0026ndash;2019 in Minnesota, it was shown that about 83% of AI/AN people are high school graduates or better while about 95% of white people are. In the same time frame, about 12% of AI/AN individuals have a bachelor's degree or higher which is about 36% of white individuals have a bachelor's degree or higher (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). As you can see, there is a large gap between how white people and how AI/AN people are treated in this country. We must work to close this gap and increase the quality of life for everyone.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eMaternal mortality data was obtained from the North Dakota Department of Health and Human Services. In North Dakota, maternal mortality is defined as a death while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy. The number of maternal deaths reported in North Dakota each year may be slightly skewed compared to other states or countries that define a maternal death as \u0026ldquo;the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes\u0026rdquo; (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe data set consists of 119 unique records of North Dakota residents who died during pregnancy or within one year of pregnancy from the years 2008 to 2022. From 2008\u0026ndash;2022, there were 86 deaths with the decedent being listed as 16 through 57 years of age at the time of pregnancy or within 1 year of pregnancy. From the same period, there were 33 decedents listed as being 60 years or older at the time of pregnancy or within 1 year of pregnancy. Information regarding descendants 60 years of age or older has been excluded due to likely errors upon data entry or the use of a surrogate. Clinical trial number: not applicable.\u003c/p\u003e\u003cp\u003eThe North Dakota Department of Health and Human Services included the following categories of race; White, Black or African American, Asian Indian, Chines, Filipino, Japanese, Korean, Vietnamese, other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, other Pacific Islander, other, or refused/unknown. Due to the lack of racial diversity and small population size in North Dakota, all races, except Caucasians and Native Americans, are excluded due to statistical insignificance.\u003c/p\u003e\u003cp\u003eFor maternal mortality, underlying causes of death are grouped into accidents, cancer, cerebrovascular disease, cirrhosis, COPD, Covid-19, diabetes, diseases of the heart, other causes, septicemia, or suicide.\u003c/p\u003e\u003cp\u003eThe greatest level of education completed at the time of death was obtained. Education level was assigned to one of the following: 9th-12th grade education but no high school diploma, high school graduate or had GED completed, some college credit but no college degree, associate\u0026rsquo;s degree, bachelor's degree, master\u0026rsquo;s degree, or refused/unknown. Information collected regarding education levels may differ from CDC guidelines due to differing data collection methods.\u003c/p\u003e\u003cp\u003eThe information collected from the North Dakota Department of Health and Human Services is private. Due to the small population size, certain cases could be indirectly identifiable; therefore, the datasets generated and analyzed during the current study are not publicly available.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn 2020, the maternal mortality rate in the United States was 23.8 deaths per 100,000 live births (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). For the same year, North Dakota had a maternal mortality rate of 52.3 deaths per 100,000 live births, over double the national average. To investigate whether lower levels of education are associated with higher rates of maternal mortality in North Dakota, information regarding the decedent's race, level of education, year of death, and underlying cause of death was cross tabulated using IBM SPSS software.\u003c/p\u003e\u003cp\u003eFrom 2008 to 2022, there were 86 maternal deaths in North Dakota. When looking specifically at education levels, most mothers did not have a college degree. The most significant percentage of maternal deaths came from those whose highest level of education completed was a high school diploma or equivalent GED.\u003c/p\u003e\u003cp\u003eThe 15-year data set has been broken up into 3-year intervals to better assess potential trends. From 2008 to 2011, there were a total of 19 maternal deaths in the state. Of those 19 individuals, 16 did not have a college degree. From 2012 to 2015, there was a slight decrease in the number of maternal deaths, only 16 recorded for that time period. Those with only a high school or equivalent GED level education had the highest rates of maternal mortality. From 2016 to 2019, the number of maternal deaths rose to 26. In those three years, over 73% of mothers had no college degree, with the greatest number of maternal deaths arising from those with only a high school diploma or equivalent GED. Lastly, from 2020 to 2023, there were 25 maternal deaths. The trend continued during this time, as the greatest number of maternal deaths occurred in those with only a high school diploma or equivalent GED.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eNative American Data\u003c/h3\u003e\n\u003cp\u003eIn North Dakota, Native Americans make up the largest minority group. With such a large Native American presence throughout the state, it is essential to look at their specific maternal mortality rates and make comparisons to the overall population statistics.\u003c/p\u003e\u003cp\u003eInformation specific to the Native American race, level of education, year of death, and underlying cause of death was used to investigate potential associations between lower education levels in Native American mothers and higher rates of maternal mortality in North Dakota.\u003c/p\u003e\u003cp\u003eIn the past 15 years, 25 of the 86 maternal deaths have been Native American. The 15-year data set specific to the Native American race has been broken down into 3-year intervals to better evaluate potential associations. From 2008 to 2011, there were a total of seven Native American maternal deaths. All of whom in this specific period, did not have a college degree. From 2012 to 2015, there were five Native American maternal deaths, a slight decrease from previous years. Only one of the mothers in this cohort had an associate's degree, the remaining four did not have a college degree. From 2016 to 2019, there were nine Native American maternal deaths, the highest recorded in the 15-year data set. Eight out of the nine deaths during those years had no college degree or upper-level education completed. In the last data set, from 2020 to 2022, there were four deaths from Native American mothers. From the most recent time interval, two of the decedents had a 9th to 12th-grade education level without a high school diploma and the other two were high school graduates or had an equivalent GED.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eCaucasian vs. Native American Data\u003c/h3\u003e\n\u003cp\u003eThe status dropout rate, reported by the National Center of Education Statistics, represents the percentage of 16 to 24-year-olds who are not enrolled in school and have not earned a high school diploma or GED certificate. In 2018, the status dropout rates were the highest for American Indian/Alaska Natives, with a dropout rate of 9.5%. For Caucasian 16 to 24-year-olds, the dropout rate is 4.2%, lower than that of every other racial group except Asians. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the same year, Native Americans comprised 24% of 18-to-24-year-olds enrolled in college, while Caucasians represented over 42%. Post Baccalaureate degree programs include master\u0026rsquo;s and doctoral programs, as well as professional doctoral programs such as law, medicine, and dentistry (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the fall of 2018, of the 3\u0026nbsp;million students enrolled in a postbaccalaureate program, roughly 1.6\u0026nbsp;million were Caucasian and 13,600 were Native American/Alaska Native (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In North Dakota, approximately 93.3% of individuals over the age of 25 have graduated high school or completed a GED program, which is higher than the national average (88.9%). However, North Dakota is below the national average in the number of people over the age of 25 who have a bachelor\u0026rsquo;s degree or higher.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn summary, there is a negative correlation between the number of maternal deaths and the level of education completed. Irrespective of race, about 75% of maternal deaths came from mothers who did not have a college degree. The highest percentage of deaths came from mothers who had a high school diploma or GED, while the lowest percentage of deaths derived from mothers with a master\u0026rsquo;s degree. Discussion/Conclusions In conclusion, this study explored the critical issue of maternal mortality in the United States, focusing on North Dakota and examining the complex interplay between education levels, race, and maternal deaths. The North Dakota Department of Health and Human Services provided access to 15 years of maternal death records to help investigate potential causes for increased maternal mortality rates seen throughout the country. Information regarding race, underlying cause of death, year of death, and education level was collected from 86 maternal death certificates. Our investigation revealed an association between lower education levels and higher maternal mortality rates, mothers without a college degree made up 75% of all maternal deaths in North Dakota. The findings indicated the need for specific interventions aimed at improving educational opportunities and socioeconomic conditions. The statistical integrity of the data collected must be questioned due to the small sample size, errors that occurred while filling out the death certificate, and differing definitions of maternal death. This research has been conducted with the goals of benefiting other states by giving them the framework to reproduce similar research, minimizing incorrect information on death certificates, and bringing more awareness to the subject of maternal mortality. The study highlights the necessity of addressing education, race, and socioeconomics as fundamental aspects of maternal health. To properly address these issues and improve maternal mortality rates, more research and education needs to be done.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by University of North Dakota’s Institutional Review Board. Given the use of de-identified secondary data from the North Dakota Department of Health and Human Services, the requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Maternal preparation, data collection, and analysis were performed by M.J, J.M, T.A, S.C, and D.L. \u0026nbsp;M.J and J.M wrote the main manuscript text and prepared the figures. All authors contributed to gathering and reviewing the data. All authors read and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The information collected from the North Dakota Department of Health and Human Services is private. Due to the small population size, certain cases could be indirectly identifiable; therefore, the datasets generated and analyzed during the current study are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePregnancy Mortality Surveillance System | Maternal and Infant Health | CDC [Internet]. 2023 [cited 2023 Jul 24]. 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Annu Rev Med. 2023;74(1):199\u0026ndash;216. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1146/annurev-med-042921-123851\u003c/span\u003e\u003cspan address=\"10.1146/annurev-med-042921-123851\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoyert DL. (2023). Maternal mortality rat18. Hoyert United States, 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe Condition of Education 2020 A Publication of the National Center for Education Statistics at IES. (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nces.ed.gov/pubs2020/2020144.pd\u003c/span\u003e\u003cspan address=\"https://nces.ed.gov/pubs2020/2020144.pd\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal mortality, race, education, socioeconomic factors, North Dakota, health disparities, public health","lastPublishedDoi":"10.21203/rs.3.rs-7401115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7401115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study examines the relationship between maternal mortality rates and socioeconomic factors, particularly education level and race, in North Dakota. Lower educational attainment is often linked to reduced socioeconomic status and limited access to healthcare, potentially contributing to the rising maternal mortality rates observed in this rural state. North Dakota\u0026rsquo;s unique demographic makeup, with significant Native American and Caucasian populations, provides a lens through which to explore persistent health disparities.\u003c/p\u003e\u003cp\u003eMaternal mortality data from 2008 to 2022 were obtained from the North Dakota Department of Health and Human Services. The dataset included 119 maternal deaths and was analyzed using IBM SPSS, with variables such as education level, race, and cause of death.\u003c/p\u003e\u003cp\u003eFindings revealed a concerning trend: 75% of maternal deaths occurred among individuals without a college degree. Of the 25 Native American maternal deaths, 76% also lacked a college degree. These findings demonstrate a clear association between lower education levels and increased maternal mortality risk. Native American communities, already facing higher rates of poverty, unemployment, and limited healthcare access, appear disproportionately affected.\u003c/p\u003e\u003cp\u003eThis study highlights the urgent need for targeted, multifaceted interventions that address systemic inequities in education, socioeconomic opportunity, and healthcare access. Improving maternal health outcomes in rural and underserved populations will require collaboration across healthcare systems, policymakers, and community leaders.\u003c/p\u003e","manuscriptTitle":"The Correlation Between Education Level and Maternal Death Rates in North Dakota","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 12:54:55","doi":"10.21203/rs.3.rs-7401115/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"29547b9b-573b-4b50-815c-4befc0d97bd5","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T18:08:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-22 12:54:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7401115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7401115","identity":"rs-7401115","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}