Conclusion & Future Perspective
Several major factors have changed dramatically in the last 20 years which undoubtedly affect maternal morbidity and mortality. Obesity has increased with now 36% of women over age 19 meeting criteria for obesity.[36] The mean maternal age during pregnancy has significantly increased with 3% of pregnancies now in women over 40, and the birth rate for women aged 40–44 has increased 2% per year since 2000.[37] The cesarean delivery rate in the USA is now 33% as compared with 19.7% in 1996.[38] However, of these factors only advancing maternal age has been shown to have an increased association with maternal mortality with women in their 40s having a mortality ratio 4–5-fold higher than women in their 20s.[1] Therefore, better research is needed to explore the likely deleterious impact of these factors on pregnancy outcomes and how to reduce that impact. In addition, better epidemiologic data about individual deaths and severe morbidities would be very beneficial to understanding how to reduce death and morbidity. Unfortunately, possibly due to lack of a universal healthcare system in the USA, potential fear of medical legal risk for any poor outcome and lack of dedicated resources, obtaining detailed accurate information per case has been difficult. It is hoped that eventually the severe maternal morbidity forms could be collected at the regional and national level in a patient safety organization format and thus analyzed to obtain more specific data to inform efforts to reduce maternal morbidity and mortality.
Another area to address is hospital levels of maternal care. Although there are required levels of care designations for neonatal hospital care and the call for maternal hospital levels of care was made in the 1970s, there are still no requirements for maternal levels of care designation. The concept is that the best maternal outcomes would occur when the level of hospital care for a mother matches her specific need for care. The potential importance of designating clear levels of maternal care for improving maternal outcomes has been noted.[39,40] For example a mother with a known placenta accreta who will likely have a hysterectomy at the time of delivery and require a large amount of blood should be delivered at a hospital that has the providers and system needs to manage massive hemorrhage and its inherent complications such as ventilation ICU care and extended surgical needs. Pertinent to this example, maternal mortality from peripartum hysterectomy was 71% lower in high volume sites compared with low volume sites suggesting better care.[40] The concept of designation and utilization of maternal levels of care is an area that needs further exploration and development in the future. The importance of this topic was just highlighed by a call to implement maternal levels of care supported by multidisciplinary national organizations including ACOG, the Society for Maternal Fetal Medicine, American College of Nurse-Midwives, Association of Women's Health, Obstetric and Neonatal Nurses, American Association of Birth Centers, and Commission for the Accreditation of Birth Centers.[41] Finally, disparities in maternal outcomes are woefully understudied and clearly should be a focus of future research.
US maternal severe morbidity and mortality must decrease. Finally, essentially all the healthcare organizations that are focused on maternal health are aligned in these efforts. The recognition that a substantial proportion of severe morbidity and mortality is preventable, and with the better understanding of the causes of morbidity, the multidisciplinary work to focus on systems of care, develop bundles to guide care, and continue to research focused on maternal care and outcomes should result in reduced morbidity and mortality. These efforts will take the commitment of all providers of obstetric care, the healthcare institutions, public health institutions and the public to successfully make obstetric care safer.
Women's Health. 2015;11(2):193-199. © 2015 Future Medicine Ltd.
