US Maternal Mortality Rate Unacceptable, ACOG Says

Stephanie Cajigal; Barbara S. Levy, MD


June 11, 2015

Editor's Note:
When the nonprofit organization Save the Children published a report last month showing that a woman delivering in the United States faces a 1 in 1800 risk for maternal death, the American Congress of Obstetricians and Gynecologists (ACOG) issued a statement calling for, among other things, more comprehensive prenatal care and thorough postpartum monitoring.

Medscape spoke with Barbara S. Levy, MD, ACOG's Vice President for Health Affairs, about what the organization is doing to help lower the maternal mortality rate, which, according to Save the Children, is the worst among all developed countries.

Medscape: Much of the Save the Children report focused on infant mortality, but this is an issue that can be tied back to maternal mortality. Can you explain where ACOG stands on this issue?

Dr Levy: High rates of infant mortality are tied to high rates of maternal mortality. When moms die, babies die—so from our perspective at ACOG, we think we need to begin with addressing maternal mortality so that we can change infant and newborn mortality.

As women's healthcare providers, we're focused on those very high maternal mortality rates—particularly the disparities in the maternal mortality rates between African American women and other women in this country, as well as the unacceptably high maternal high mortality rate in the United States as a high-income country. We have an unacceptable, and an increasing, rate of maternal mortality.[1]

Barbara S. Levy, MD

Medscape: The Save the Children report noted that among capital cities in high-income countries, Washington, DC, where ACOG is located, has the highest infant death risk and greatest inequality. How might differences in maternal care be contributing to high infant death risks within certain areas of the United States?

Dr Levy: There are many system and root-cause factors that contribute. Clearly, some of it relates to inner-city people without access to care, people without trust in the healthcare system, and people with mental illness and substance abuse problems. The issue is multifactorial, but ACOG and our Washington, DC, section have been working with the city to set meetings with stakeholders and see what we can do to form committees and improve access to care.

Access to care can be improved by doing a lot of things, one of which is expanding Medicaid. That's not an issue in DC. We actually do have expanded Medicaid coverage, but if the women don't have access to providers or they're trying to work three jobs in order to pay the rent, then they don't have any time to go get care.

Some of the systems that others have looked at, and that we'll probably be thinking about, are such things as community health workers and outreach to women in really highly stressful situations, to try to ensure that they're getting the care they need. We do know that centering care and community health workers can decrease prematurity, and if we decrease the prematurity rate, we're going to decrease the rate of infant deaths. For the maternal mortality rate, we also have to increase care before pregnancy so that underlying health conditions are addressed before a woman becomes pregnant.

Medscape: You've already touched a bit upon this issue, but the report also noted that in many US cities, poor, unmarried and young African American mothers are losing their babies at much higher rates than the US average of 6.1 deaths per 1000 live births. What can the healthcare industry do to address racial disparities in maternal care?

Dr Levy: That's where our Alliance for Innovation on Maternal Health (AIM) grant and project comes in. It's an alliance of many groups, including neonatal and women's health nurses, nurse-midwives, physicians, and state and territorial health offices—the Medicaid providers—and it's focusing on maternal health and safety before, during, and after pregnancy.

We're trying, for example, to ensure that women get adequate postpartum follow-up for chronic conditions identified during pregnancy and contraception so that they can space births appropriately. One of the causes of prematurity and, we think, infant mortality is rapid spacing of pregnancies. So the AIM project is a large group of agencies coming together to try to improve both maternal and child health, focusing on the very high-risk communities.

Medscape: What are some of these high-risk communities?

Dr Levy: Obviously, we can't get everywhere all the time, but one of the things we need to do is understand where the disparities are. Some studies have shown that they're not actually socioeconomic and that they may be related to other things. We have a partner—Dr Elizabeth Howell, working out of Mount Sinai Hospital in New York—who has a forthcoming study showing that [maternal] outcomes are worse in hospitals that deliver more African American women, regardless of whether you're African American or not. If they deliver 75% of their births to African American women, then those are places where we can start to work hard, using our partners and our collaboration to institute the AIM bundles of care and try to improve care rapidly.

What we've done is try to prioritize. We're working in states that have the highest levels of maternal mortality and then drilling down, from those states, into communities and areas where we can have the most impact.

Medscape: Could you describe what an AIM care bundle is?

Dr Levy: The Institute for Healthcare Improvement has developed their concept of a bundle: It is a set of actions that will allow hospitals and providers to address a particular problem. It's not a protocol or a checklist.

We want the hospitals to take the guidance from the action elements in the bundles and develop their own. They have to have ownership of what they adopt in their individual hospital. Something that might be appropriate for a hospital in the middle of Washington, DC, with lots of resources may be completely inappropriate for a rural hospital 300 miles from anywhere that doesn't have the same medical staff, the same equipment, and the same access to medications and other things; however, the safety actions are the same.

What we basically do is put together a toolkit of things that must be in place in every hospital. For example, there needs to be a readiness for maternal hemorrhage—meaning that when a woman comes in, her medical history is looked at and she has a standardized assessment of some kind that says, "This is a woman who's had three previous cesarean sections. She might be at risk for postpartum hemorrhage, so be ready for it."

The second part of the bundle is recognition. What are the steps that you need to take to recognize that you've got an emergency going on? The physiologic changes of pregnancy in young women generally make recognition of a problem a very late step. They don't show the typical signs and symptoms of bleeding that a nonpregnant older person would show, such as blood pressure going down and the heart rate going up.[2]

The third step is responding, and the last step is reporting. That means debriefing at the end: What went well? What didn't go well? What are we going to learn for next time? We need to apply these to not only the worst-case scenario, which is a death, but also to every near-miss, every situation in which something happened and we either did very well or we didn't do well. We're asking facilities to do drills and simulations and practice, and have everything at their fingertips and available to handle these emergencies when they occur.

Medscape: Are there any success stories to report?

Dr Levy: AIM is new, so we're just rolling out our program. But the bundles of care and the systems that we're using have been rolled out in California, and more recently in New York. Using exactly the maternal safety approaches that we are incorporating into the AIM program, California has been able to reduce its maternal mortality by 50% in 2013 from when it started in 2008.[3]

Medscape: What kind of roadblocks have you faced along the way?

Dr Levy: It's always challenging to get a large group of people together and to agree. One of the things we think is very important is that the care bundles we are disseminating are bundles that all stakeholders agree on, and we can spread these nationwide with the endorsement of a large group of organizations. We don't want people working at cross-purposes, which so often happens in situations where one group has a guideline but another group has a different guideline. So we've worked very hard to use the available medical evidence and come up with evidence-based care bundles so that we've got endorsement from all the stakeholders. We think it'll be very important to have that consistency in messaging as it rolls out. That's a lot of infrastructure work to get done, and it takes time. But I think it's well worth it.

The other big piece that's most challenging is data. If we don't have good data from the states or the hospitals, then we don't know where to focus our efforts. Unfortunately, data collection in maternal mortality is inconsistent. It's not a requirement to report it in any sort of consistent format nationally, so each state has its own mechanism on how to do that. Trying to roll that into a unified reporting mechanism where we could benchmark and compare one hospital system with another is a significant challenge.

You don't want the hospitals to have to use staff time to pull charts, abstract records, and upload data. You want to be able to use data that they're reporting anyway and then, using IT, be able to put that into a data warehouse or translate it into a consistent, cohesive spreadsheet that everybody can look at. That's one of those in-the-trenches, grueling, difficult things to do that has to get done.

Medscape: Would you advocate for a mandatory maternal mortality reporting system?

Dr Levy: I would love it. I would also love a requirement for maternal mortality review. Fewer than one half of the states have a mandated and protected maternal mortality review. It seems to me that in 2015, if a mother dies during pregnancy, that should be reviewed. We should all learn as much as we possibly can from that so that we can make an effort to prevent it. I don't see that we're going to move the needle and change maternal mortality in this country if we don't systematically review every single case. And there aren't so many cases that we can't do that.

Medscape: Do you think medical liability might play a part in the reason this system hasn't been created yet?

Dr Levy: It's why we need to have protection—why the states need to mandate it in a peer-reviewed, protected way, because the purpose is not to lay blame. The purpose is to learn.

Medscape: What sort of responses have you been getting from hospitals?

Dr Levy: Change is hard, and two thirds of hospitals in this country deliver fewer than 1000 babies annually, so they don't see these catastrophic events very often.[4] Sometimes, it's challenging to get hospital administrators to understand how important this is. We're spending a lot of time and advocacy efforts showing them the burning bridge, showing them the numbers. The Save the Children report is really very helpful in that regard because it highlights the problem that we have in the United States.

The problem is that any one hospital is not going to see a lot of it. It's distributed among many hospitals in many parts of the country.

Medscape: Do you think ob/gyns have an obligation to address some of the issues that poor patients struggle with—for example, ensuring that they meet with a social worker, or connect with community resources?

Dr Levy: Yes, I do. I think that's getting us outside of the medical model and into the patient-centered model of care. That's definitely where healthcare is moving. It's the patient-centered medical home concept that we take care of the entire patient, not just her specific obstetric medical needs.

Medscape: Are there any resources ob/gyns should check out?

Dr Levy: We have a website for the AIM project and for the Council on Patient Safety. It will have some samples, protocols, and things that people might pick and choose from to institute in their own hospitals.

We at ACOG are always available to any ob/gyn who wants to do a quality or safety improvement effort at his or her institution. However, I think that this has got to be a national campaign. It's got to be, as our past president Jeanne Conry said, "every woman, every time." It's got to be at the forefront of our minds with every delivery, with every pregnant patient that we see. We need to consider the totality of a woman's care, not just the medical issues, and that has to do with domestic violence and gun violence, other medications, and other medical conditions. There are all kinds of things we need to consider as part of that patient-centered approach.


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