Dying After Giving Life
A recent call to action from the Society for Maternal-Fetal Medicine urges clinicians to "put the 'M' back in maternal-fetal medicine" and to take immediate steps to reduce preventable maternal deaths, which are particularly high among minority women. Lead author Joses A. Jains, MD, clinical fellow in the Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, at Columbia University Medical Center in New York explained what is being done, and what more can be done, to reverse this crisis.
Medscape: We hear a lot about the rising rates of maternal mortality and the debate about whether this is real or a consequence of overreporting. What are your thoughts on this?
Jain: The answer isn't abundantly clear. Unfortunately, because the United States as a country does not have a uniform and reliable system of reporting pregnancy-associated deaths, there is always an element of the unknown in the estimate of maternal mortality.
Several interval reports over the past few decades have shown a steady increase in rates of pregnancy-related mortality in the United States. But until recently, not all states had a means for providers to document pregnancy information on death certificates. Still, it doesn't appear that improvements in reporting can fully account for the increase in maternal mortality that we're seeing.
We can all agree that the maternal mortality rate in the United States is unacceptably high, especially when we consider that 60% of maternal deaths are preventable. The reasons for this increase include, among others, increases in the rates of obesity and other chronic health problems, increased rates of cesarean section, increased access to assisted reproductive technologies which leads to more cases of advanced maternal age, and health disparities in the population.
Medscape: What are the leading causes of maternal mortality, and what is being done to address them?
Jain: The leading causes of maternal death are obstetric hemorrhage, complications from severe hypertension, and venous thromboembolism, and we know of identifiable risk factors that predispose women to these complications. Through the use of maternal mortality review committees, a few states have taken what we know about the causes of maternal mortality one step further.
For example, the California Maternal Quality Care Collaborative (CMQCC) designed hospital toolkits and safety bundles based on preventable causes of maternal death in their state. One bundle focuses on identifying women, upon admission to the hospital, who are at moderate or severe risk for obstetric hemorrhage. Depending on the woman's level of risk, actions and safety precautions are taken. After employing these toolkits and safety bundles, California's maternal mortality rate was cut in half over the next 10 years.
Similarly, the Safe Motherhood Initiative in New York State is an ongoing multicenter program in partnership with the American College of Obstetricians and Gynecologists. This involves the development and implementation of standardized clinical protocols to prevent the three leading causes of maternal death in New York state.
New York also recently launched a new Task Force on Maternal Mortality and Disparate Racial Outcomes, which will work with the state's Maternal Mortality Review Board. It is just an example of how we are now beginning to recognize the need for a uniform approach to identify high-risk women, and that through early screening and intervention, we can reduce the disparities in morbidity and mortality experienced by these women. Efforts to reduce maternal mortality in the United States are ongoing, but there is still much work to be done.
High Maternal Mortality in Black Women
Medscape: Are the causes of maternal mortality different among minority populations?
Jain: Although the overall causes of mortality are similar, some important issues make this subject more complicated when considering minority populations. For example, black women in the United States are three to four times more likely than white women to die from pregnancy-related complications, and they are also more likely to have a preventable death.
Across the population, racial and ethnic differences exist in the frequency of underlying medical conditions, and these contribute to disparities in pregnancy-related mortality. Black women of childbearing age have higher rates of chronic diseases that can contribute to pregnancy-related complications when compared with non-Hispanic white women; these include rates of obesity, diabetes, hypertensive diseases, and cardiovascular diseases, all of which are also more likely to be underdiagnosed and undertreated.
Significant disparities exist in the access to care, and black women have higher rates of unintended pregnancy, which is related to a lack of access to contraception, family planning, and preconception counseling. Black women are also more likely to present late for prenatal care, and they are disproportionately affected by the availability of quality care.
There is also some research to suggest that environmental factors play a significant role—not just in terms of the physical environments in which women live, with respect to issues like safety and environmental toxins, but also in terms of the early and chronic physical and psychosocial life stresses that disproportionately affect black women. These types of ongoing stresses may have a significant impact on a woman's physiologic state by the time she becomes pregnant, and may impart downstream effects on her reproductive outcome.
Strategies to Prevent Maternal Death
Medscape: In your recent report, you discuss algorithms and standard approaches in maternity care. These tools are designed to treat patients in a more uniform manner, but you suggest that they contribute to differences in outcomes. Can you explain that further?
Jain: Algorithms and checklists have an important role in maternal healthcare, and we've seen improvements in outcomes after employing them in obstetrics. But, as with any guideline, care needs to be individualized to the patient, and applying a one-size-fits-all approach to the care of minority women can pose significant risks. An example we gave in our report was the treatment of women whose pregnancies are complicated by chronic hypertension. For any given duration of hypertension, a black woman is more likely to have end-organ complications of the disease when compared with a white woman. We also know that black women differ in their response to certain antihypertensive medications. So in a case like this, a standard and equal approach to the management of hypertension that encompasses both women runs the risk of suboptimally or undertreating minority women, and that can contribute to a disparity in the outcomes. Ultimately, in an effort to reduce these disparities, we want to encourage the authors of clinical protocols and algorithms to include a step that recognizes women who are high risk based on their racial or ethnic background.
Medscape: What else can clinicians do right now to prevent minority women from dying after they give birth?
Jain: There are a few things that the clinicians who are providing care to minority women can begin to do immediately to address disparities in outcomes, starting with the recognition that minority women are at higher risk for pregnancy-related complications. This allows clinicians to employ preventive strategies early.
These women can benefit from early screening and heightened surveillance for conditions like hypertension, diabetes, and sleep apnea, and the downstream end-organ effects of these conditions. This can reduce the burden of disease in addition to lowering healthcare costs and improving outcomes.
Clinicians can also address specific barriers to care that disproportionately affect these women. For example, many minority women have difficulty with transportation to in-person visits. Clinicians can explore transit programs—such as taxi vouchers—that may help women get to their appointments. These women would benefit from a multidisciplinary approach to care that involves such services as social work, behavioral health, nutrition, visiting nurses, and subspecialists. But if they have to make separate appointments for each of these, they are likely to be noncompliant. Clinicians can work to try to consolidate appointments and reduce the overall number of visits the women must make.
Unintended pregnancy rates and the lack of access to contraception are further drivers of healthcare disparities among minority women. Clinicians can encourage reproductive life planning. A simple question such as, "How many children do you see yourself having?" can open the dialogue and provide an opportunity for education.
On a personal level, providers can also take steps to recognize their own implicit biases. The available evidence suggests that healthcare providers exhibit the same levels of implicit bias as the general population, and that biases have an effect on clinical decision-making. Some practical strategies include recognizing the impact of unconscious biases, identifying situations that might magnify these biases, and making an effort to practice individuation, which refers to seeing a patient as an individual rather than as a stereotype.
The 'Fourth Trimester'
Medscape: Among the many action items in your report, you mention a redesign of the standard 6-week postpartum visit. What would this entail?
Jain: The postpartum period can be easily overlooked in terms of its value as an opportunity to optimize a woman's long-term health and make plans for her reproductive future. For many minority women, pregnancy is the only time in their lives that they will actually seek professional healthcare. When we speak of redesigning the standard 6-week postpartum visit, we're referring to tailored changes in both the content and the timing of the postpartum care that is provided to reduce long-term health disparities. Colloquially, the postpartum period is now being referred to as the "fourth trimester" of pregnancy, to underscore the need for continued care and health optimization during this time.
We have seen estimates that upwards of 40% of women who have given birth don't attend the standard 6-week postpartum visit. Attendance rates are the lowest for high-risk minority women, who are arguably the women who need follow-up the most. An approach to optimizing postpartum care for these women may include such efforts as making earlier appointments with more frequent follow-up—not necessarily in-person visits, but ongoing telephone contact with a nurse or care coordinator. New mothers are busy. If, on top of transportation barriers or work instability, a new mother needs to have her blood pressure or glucose checked, it becomes a perfect setup for that mother to become overwhelmed and forego an appointment for herself. When a minority woman misses an appointment, she is at a disproportionately higher risk for significant downstream health morbidity. So there is a need to improve and increase the delivery of timely postpartum care among minority women who are at the highest risk for complications.
The postpartum period is an opportune time to involve the multidisciplinary team in a patient's care, if they are not involved already. Providers need to address and reduce barriers to follow-up care for chronic conditions. We need to establish and secure continuity of care with appropriate primary care providers and specialists, recognizing that many of these women would not seek healthcare outside of pregnancy.
Medscape: In the title of your report, you state that we need to "put the M back in maternal-fetal medicine." Can you explain what you mean by this?
Jain: Our report is part of a series that uses this title in an ongoing effort to highlight the importance of reducing maternal morbidity and mortality. Putting the "M" back in maternal-fetal medicine refers to placing a renewed emphasis on maternal care. We recognize that by improving a mother's health, we really are improving the infant's health as well.
It is important to recognize, however, that although our report focused on mothers and maternal care, racial and ethnic health disparities exist among infants as well. Black infants are more than twice as likely to die compared with white infants. That disparity actually persists even after accounting for a mother's level of education and income. Ultimately, we hope that by addressing maternal health disparities and optimizing the health of minority mothers, we also make a downstream impact and improve the health of the entire future population.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Saving Black Mothers' Lives - Medscape - May 17, 2018.