How Can We Stop New Mothers From Dying?

Linda Brookes, MSc

Disclosures

May 08, 2018

Rising Maternal Death Rates

In 1982, the rate of maternal mortality in the United States was falling so rapidly (by 8.6% annually since 1935[1]) that it seemed set to reach an irreducible minimum before the end of the century. After that time, however, maternal mortality stalled, and around 1999, the rate began to rise and apparently continues to do so.[2] It now exceeds that of almost all other developed countries, including Canada, the United Kingdom, France, Germany, Australia, and Japan,[3,4] and although it is still very low compared with many developing countries, as William Callaghan, MD, MPH, chief of the Centers for Disease Control and Prevention's (CDC's) Maternal and Infant Health Branch, stresses, "There is no acceptable rate of maternal mortality."[5]

Maternal mortality is now the sixth most common cause of death among US women aged 20-34 years, accounting for about 2.8% of all deaths of women in that age group.[6] Maternal mortality goals set every 10 years by the US Department of Health and Human Services' Healthy People campaign were missed in both 2000[7] and 2010,[8] and even the modest 2020 goal of a 10% reduction since 2007[9] now also appears unreachable.

Elliott K. Main, MD, medical director of the California Maternal Quality Care Collaborative (CMQCC) from Stanford University, told Medscape that the "big focus" on fetal mortality in obstetric care in the United States has been detrimental to the health of mothers. (Unlike maternal mortality, fetal mortality continued to decline up to 2006 and has remained almost unchanged ever since.[10,11]) Main endorses the call to action to "put back the 'M' in maternal-fetal medicine."[12]

But Are the Data Reliable?

A major challenge in tackling the problem of rising maternal mortality in the United States has been getting accurate numbers. The CDC, which is responsible for calculating national rates from state-level data, has not published an official figure since 2007. Recent data show rates of US maternal mortality ranging from 14[3] to 26.4 deaths per 100,000 live births.[4]

The CDC calculates maternal mortality in two ways. Its National Center for Health Statistics uses death certificate information to assign ICD-10 codes that are used to identify maternal deaths and produce a maternal mortality rate (MMR) according to the World Health Organization (WHO) definition: deaths while pregnant or within 42 days postpartum per 100,000 live births. The CDC is also responsible for the Pregnancy Mortality Surveillance System, which uses information from death certificates that show a relationship to pregnancy to produce a pregnancy-related mortality ratio: that is, deaths while pregnant or within 1 year postpartum per 100,000 live births. "Deaths related to pregnancy, such as cardiovascular deaths, particular from cardiomyopathy, and suicides, can occur well after 42 days," Main noted. The pregnancy-related mortality ratio, unlike the MMR, has been relatively stable in recent years.

Until 2003, maternal deaths were underreported by at least 30%.[13,14] This problem led to the addition of check boxes on standard death certificates for reporting pregnancy status at the time of death and in the 42 days and the year preceding death. However, the check boxes proved to be vulnerable to false-positive reports, which led to claims of overreporting and suggestions that this accounted for much of the increase seen in the national MMR.[15,16,17] "Whereas death in a women who is pregnant or at delivery is pretty straightforward to report, it is more complicated for deaths that occur after delivery, which is when more than one half of them occur," Main explained. "It gets even more difficult beyond the WHO definition of 42 days, when you get more subjectivity as to whether it is pregnancy-related or not, and you get a lot of, let us say, discussion and disagreement potential."

"The government should do more outreach and training of clinicians in how to accurately fill out the death certificate," said Marian MacDorman, PhD, research professor at the Maryland Population Research Center,[18] "such as more querying of questionable reports back to the person who completed the report. They could also look at the methods used for classification and coding of maternal deaths in an effort to improve data quality," she said.

Changing Causes of Maternal Mortality

It's widely considered unlikely that the observed increase in US maternal mortality is solely due to improved surveillance or overreporting.[19,20,21] It may be due in part to such changes in maternal demographics as maternal age (new mothers are older, on average) and comorbid conditions. For example, between 2008 and 2014, the MMR increased by 90% for women 40 years of age or older.[22] One half of pregnancies in the United States are unplanned, preventing women from addressing chronic health issues beforehand. Lack of access to or avoidance of care also occurs because of gaps in insurance coverage before, during, and after pregnancy.[23] Disproportionate, progressive increases in the burden of chronic health conditions, including hypertension, diabetes, and chronic heart disease, have been identified among women from rural and low-income communities and those with deliveries funded by Medicaid.[23]

In the past 15 years, cardiovascular disease has emerged as the leading cause of maternal mortality, accounting for 15.5% of pregnancy-related deaths in 2011-2013, with cardiomyopathy accounting for another 11%.[24] At the same time, rates of hemorrhage, hypertensive disorders (preeclampsia), infection, and thromboembolic events, previously the most frequent causes of pregnancy-related deaths, have all declined.

Mental health conditions are also now a major cause (7%) of maternal mortality. This link is controversial, Main noted, because mental health conditions (including substance use disorder) do not directly kill women but are underlying factors in suicide, accidental death, or death due to accidental drug intoxication or homicide. They are not included in WHO and CDC definitions of pregnancy-related deaths, but are considered "pregnancy-associated deaths."

Several states have identified opioid use as a major risk factor in pregnancy-associated deaths[25] with 11%-20% of cases involving opioid-related overdoses.[26] In some states, women can be charged with a crime against a fetus or child as a result of substance use during pregnancy,[27] although "putting a woman in jail, where she doesn't get very good medical care, isn't very good for the fetus either," Main observed.

Inaction by healthcare providers has also been implicated in a recent analysis by the CDC Foundation[28] that identified "lack of assessment, resulting in misdiagnosis and delayed or ineffective treatment," among common contributing factors to maternal mortality.

Reversing the Trend: California

Some parts of the United States have succeeded in reversing the rise in maternal mortality, most notably California, where more than half a million women give birth each year, representing one eighth of all US births. Between 2006 and 2013, California saw a 50% decline in maternal mortality, while the national maternal mortality rate continued to rise.[29] This is attributed to state-supported efforts begun in 2006 with the formation of the CMQCC and the first statewide maternal mortality review committee (MMRC), led by Main.

After examining data for 2002-2005, the MMRC found that there was a good to strong chance of altering the outcome in 41% of maternal deaths, particularly those due to hemorrhage (70%) and preeclampsia (60%).[30] Maternal quality improvement toolkits were created to educate physicians and nurses about how to prevent, recognize, and handle these complications. In hospitals that used the hemorrhage toolkit, serious maternal mortality from hemorrhage was reduced by 21% compared with 1.2% in hospitals that did not use it.[30] Toolkits for other complications, including venous thromboembolism and cardiovascular disease, are now also available.[31]

The work done in California has become a model for the rest of the United States. The CMQCC works with several national collaboratives, including the Alliance for Innovation on Maternal Health and the National Network of State Perinatal Quality Collaboratives (PCQs). The Alliance for Innovation on Maternal Health, of which Main is national implementation director, is working with about 30 other states to implement national maternal patient safety bundles similar to those implemented in California. The PCQs work to improve the quality of care for mothers and babies by identifying healthcare processes that need to be improved and using the best available methods to make changes as quickly as possible.

Around 32 states currently have active PCQs. Most states are focusing on collecting severe maternal morbidity data; these are easier to collect in a timely manner than maternal deaths, which take 2-4 years to collect and validate, said Main. Severe maternal morbidity almost doubled between 1993 and 2014,[32] and is now 50- to 100-fold higher than MMRs. "It's nowhere near what it used to be 100 years ago, but it has persisted as a sort of 'canary in the mineshaft,' ie, an indicator of bigger problems and a marker that we are using in our quality improvement projects," Main explained. The Illinois PQC recently demonstrated a 40% decrease in new-onset hypertension with severe maternal morbidity 1 year after introducing a severe maternal hypertension quality improvement initiative.[33]

Is the Government Doing Enough?

There is widespread agreement among healthcare professionals that the US government is not doing enough to improve maternal outcomes and that more investment is needed in maternal healthcare, as well as data collecting and sharing. Many states have established or are in the process of establishing MMRCs, but funding is lacking. Two bipartisan federal bills that would authorize $7,000,000 annual grants to states for fiscal years 2018 through 2022 for creation or expansion of MMRCs were introduced in Congress in 2017.[34,35]Despite endorsement and active support from such organizations as the American College of Obstetricians and Gynecologists[36] and the Preeclampsia Foundation,[37] both bills remain stalled in committee, and it is unclear whether they will ever pass into law.[38]

Meanwhile, recent efforts by legislators to restrict access to primary and reproductive healthcare have raised alarms around the country. Challenges to the Affordable Care Act remain, and proposals to eliminate insurance subsidies and restrict Medicaid eligibility and ideologically motivated regulations cutting family-planning budgets, including funding for Planned Parenthood, will worsen inequities in maternal healthcare.[39] Nationwide, medical, patient, and human rights organizations are lobbying in support of all legislative actions aimed at reversing the current crisis of increasing maternal mortality and against the actions that could worsen it.

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