Specialists Target Preventable Maternal Deaths

Tara Haelle

May 13, 2019

"Louisiana has become one of the most dangerous places to give birth in America," said Rebekah Gee, MD, at the American College of Obstetricians and Gynecologists (ACOG) Annual Meeting in Nashville, Tennessee.

"We are the sickest — and one of the three poorest — states in this country," Gee told Medscape Medical News. And even though the state's expansion of Medicaid dramatically improved healthcare access for tens of thousands of women, there is still a lot of room for improvement.

Gee, who is the secretary of the Department of Health in Louisiana and an obstetrician–gynecologist, was one of three experts who joined Lisa Hollier, MD, past president of the ACOG, to discuss maternal mortality during the President's Panel at the meeting.

"In the United States, four black women die for every white woman. This plays out in the data we see here in Louisiana," Gee reported.

But when her department examined the difference in maternal deaths deemed to be preventable in white and black women, the difference was staggering: 9% vs 59%.

"That is something that should shock us all," she said.

The Louisiana health department has an 18-month plan to reduce maternal morbidity by 20% and to narrow the disparity in outcomes between black and white mothers that plagues both the state and the nation.

The plan involves engaging perinatal leadership in health systems at local and state levels and ensuring that each woman is delivering at a facility that can manage her risk factors, but a cultural shift is needed, said Gee.

"We're also aware that we must change the narrative" that blames women for poor outcomes, she added, including what might account for the different rates between black and white women.

"Our message is don't blame women. People talk about race-related differences, but it's not race-related differences. It's racism," she said.

She pointed to disparities in the treatment of hemorrhage. "It shouldn't matter what color is your skin, how much you weigh, or whether you have high blood pressure." None of that should have "any impact on how long it takes you to get a blood product."

Building Up the Village

Another panelist, Mary-Ann Etiebet, MD, executive director of the Merck for Mothers initiative, explored parallels between American and global maternal mortality, noting the "persistent and stark racial disparities in maternal mortality" in the United States.

Maternal mortality "is one of the most important vital signs of a strong health system, economy, and society," she told Medscape Medical News.

With Merck for Mothers programs in more than 45 countries, lessons have been learned on ways to improve the "quality of maternity services, from understanding and acting on critical patient feedback to embracing a culture of respectful care for all," she explained.

Merck for Mothers is working with partners across the United States to design, test, and scale solutions, such as evidence-based practices — or safety bundles — to improve obstetric care in the five states that account for about one-quarter of all births in the country.

The Institute for Healthcare Improvement is currently working with Merck for Mothers so that these tools are implemented across the country. "Our vision is that safety bundles are implemented in every hospital in the country," Etiebet told Medscape Medical News.

In addition, hospital–community collaborations have led to "integrated care models focused on the role of community health workers and doulas in supporting high-risk women throughout and after pregnancy," she reported.

And Merck for Mothers has launched the Safer Childbirth Cities program, designed to ensure that women have support in all areas of their lives. Grants provided to cities with poor maternal health outcomes can be used to improve overall maternal health and narrow health disparities by providing transportation to prenatal care, doula support, group prenatal care, and community health workers, Etiebet said.

Keeping Women's Voices Central to Solutions

Another panelist, Christy Turlington Burns, is best known for her modeling work but she has used her skills as a storyteller to advocate for global maternal health for more than a decade.

She described her own experience and the painful postpartum complication she experienced in 2003, which led her to found Every Mother Counts. Her 2010 documentary No Woman, No Cry raised awareness about maternal mortality around the world. Her most recent project is the Giving Birth in America series.

Every mother has a birth story she will remember forever — if she survives, said Turlington Burns. "Every person she interacts with throughout her pregnancy, during childbirth, and in the postpartum period has an impact on that story. By listening to women and supporting them, we can improve the health and well-being of their families, communities, and societies," she added.

The aim of Every Mother Counts is to reduce maternal morbidity, both nationally and globally. The organization promotes "respectful and compassionate care" as an integral part of every initiative, and has worked to improve the quality of maternal care in Bangladesh, Guatemala, Haiti, India, Tanzania, and the United States.

"My take-home message for an audience of physicians is to remind them to think about women as more than statistics," Turlington Burns told Medscape Medical News.

"Try to meet women where they are, understand that you may not have the whole picture at any given time, and that trust is earned by listening to women and responding to what they tell you," she explained.

Too often, a mother or family member raised a concern before a tragic outcome but was ignored or dismissed, she said. "If there's one thing every OB and maternal fetal medicine doctor could do, it would be to value the woman as the expert on her own experience," she added. "That means taking women's concerns seriously, recognizing the value of the information they provide, and acting on it."

"We need to work with other providers, nurses, midwives, and doulas to provide women the care they need," Turlington Burns said. "If the common goal is to keep women and their children healthy and safe, we need to think and act like a team that holds women and mothers at the center of their care."

Maternal Mortality Central Focus

The high rates of maternal mortality in the United States must be addressed, said Hollier, who made the issue a central focus of her term in office.

"All of my presidential initiatives have been different parts of our strategy to eliminate preventable maternal mortality," Hollier told Medscape Medical News. "For me, the president's program really is another opportunity to talk about solutions and to raise awareness of what is currently being done so that we can continue to move the conversation forward with action."

There have been some successes on this issue, she said. A critical first step was passage of the Preventing Maternal Deaths Act, as reported by Medscape Medical News. That legislation set up the necessary funding and infrastructure to expand state-based maternal mortality review committees.

State-level work on the issue means that each state can prioritize interventions to meet the needs of the women who live there, because causes of maternal mortality and resources vary by region. The committees will "provide us with the data we need to understand causes and contributing factors so we can develop the right solutions," she explained.

Another area of success is the Alliance for Innovation on Maternal Health (AIM), a program for which ACOG is a lead partner.

AIM works to implement approaches that have been proven to prevent maternal death. It offers tools, training, data, partnerships, and individualized implementation planning to hospitals and states, and aligns hospital and state initiatives with national ones. For example, AIM will take efforts that have been successful in reducing complications from hemorrhage in California and help other states adapt or adopt those strategies for their hospital systems.

Hollier, Gee, Etiebet, and Turlington Burns have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2019 Annual Meeting. Presented May 3, 2019.

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