December 23, 2019

Maternal Mortality is too high in the US

Most of us in the US tend to think of birth as a joyous, happy occasion and during this season some talk about the miracle of birth.  However, sometimes birth is not a happy event and can be tragic. Thirty years or so ago I received a call in the middle of the night.  “Dr. Leppert,” the person on the call stated, “one of our laboring mothers has died”.   At that time, I was the Chair of the Obstetrics and Gynecology Department at a large regional teaching hospital which was why I was called.  The tragedy of a baby without a mother was incomprehensible to me and I knew that the child as well as the father would suffer.   I immediately got dressed and drove into the hospital.  Of course, the woman’s husband and family where devastated but so were her obstetrician and the nurses and residents.  This was not supposed to happen in the United States or anywhere for that matter.  In the weeks that followed our department held a mortality conference to discuss the death and the state held an inquiry.  The medical reason for the death of the mother was found to be related to anesthesia complications.  The ultimate reason for the death was that our written hospital protocols were not followed.  Our Department enhanced education for staff and instituted means to ensure protocols were strictly adhered to.  

That life experience is a vivid memory for me.  I kept hearing over and over the voice of one of my teachers, a fellow obstetrician/gynecologist who became the Dean of the School of Public Health at Columbia University who taught that “we must put the M back in Maternal and Child Health”.  Meaning that while our country has put a great deal of effort into the care and safety of the unborn and of infants and children, we have often neglected the mother. 

Childbirth is not without risk and in the past women often died.  With the advent of the 20th century continually improving prenatal and obstetrical care was responsible for decreased maternal mortality in the United States.  But then something changed.  Maternal pregnancy related deaths in the United States have been increasing. The CDC reports that maternal deaths more than doubled from 1987 to 2015.  The definition of a maternal death is any death while pregnant or up to 1 year after the end of pregnancy regardless of outcome, duration or site of the pregnancy of any duration that can be attributed to the pregnancy.  Our country has the highest maternal mortality ratio of all the developed countries.  Finland has the lowest maternal mortality (3/100,000).  In published data in 2019, the state with the highest maternal mortality is Louisiana with 58.1/100,000 births which is a bit better than their 2016 maternal mortality of 72.  Utah, now my home state is 16.5 and North Carolina, the state of the Campion Fund incorporation is 18.6.   Overall US maternal mortality was 29.9/100,000 births in 2016.  Importantly, there are tremendous racial and economic disparities.  In 2016 the ratio was 42.4 for blacks, and 30.2 for American Indian/Alaska Natives. The ratio for older women was 16x that of younger women.   Even more concerning, the number of women who become quite sick and who almost die (so called near misses) is extremely high.  This is not right.

The causes of maternal death are many and usually include hemorrhage, infection, hypertensive disorders of pregnancy, cardiovascular and other chronic diseases, thrombotic embolic events as well as unknown causes.  A great many of the deaths are preventable.  It is time to take action. Some action has been taken.  The US Congress voted in June 2018 to request $50 million to prevent pregnancy-related deaths. The CDC would receive $12 million for research and data collection and the federal Maternal and Child Health Bureau would receive $38 million.   The American College of Obstetricians and Gynecologists is working with the Alliance for Innovation on Maternal Health (AIM) and other organizations such as the American College of Nurse-Midwives to reduce preventable maternal deaths. These organizations have brought together health departments, perinatal quality collaborative organizations, hospitals and health care providers to implement live saving best practices to treat conditions such as hemorrhage and hypertension and to encourage maternal mortality reviews and to establish hospital early warning protocols.  The National Institute of Health is calling for more research into basic causes.  The public is being educated.  Harvard Business Review published an article on the topic saying that employers need to act to ensure that women get excellent pregnancy health insurance coverage that is comprehensive and includes both prenatal and labor and delivery care with a focus on good outcomes. The article also called for the increase utilization of nurse-midwives. The Campion Fund thinks that It is also imperative to realize that a woman’s preconception health is important to safe pregnancy. 

The Campion Fund is concerned about reproductive health and research and believes that basic studies of pregnancy, especially on the placental anatomy and function are essential.  We also know that good clinical practice is vital.   We currently know a great deal about how to prevent maternal death and it behooves us to make sure that our health care system delivers best practices to all childbearing women, rich and poor, regardless of race and country of their birth.  Furthermore, we must establish a health care system that will ensure that all women have access to maternity and preconception care that is cost effective.   What we need now is the moral will to provide care to all women.  The health of future generations demands it.  As a nation we must act now.

Further reading:

Pregnancy Mortality Surveillance System | Maternal and Infant Health | CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm.

Strategies to reduce pregnancy-related deaths: from identification and review to action - 53442 | Stephen B. Thacker CDC Library collection. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/53442.

The Rising U.S. Maternal Mortality Rate Demands Action from Employers. By Suzanne Delbanco, Maclaine Lehan, Thi Montalvo, Jeffrey Levin-Scherz .Harvard Business Review. June 28, 2019  https://hbr.org/2019/06/the-rising-u-s-maternal-mortality-rate-demands-action-from-employers

 https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2019/08/structural-inequality-maternal-mortality

 http://worldpopulationreview.com/states/maternal-mortality-rate-by-state/Maternal Mortality Rate by State. Published 2019

Lost Mothers: Maternal Mortality in the U.S.  npr The Last Person You'd Expect to Die in Childbirth. May 12, 20175:00 AM ET The painful truth about maternal deaths.  

Lisa M. Hollier. March 19, 2019 https://www.aamc.org/news-insights/insights/painful-truth-about-maternal-deaths 

The role of the maternal-fetal medicine subspecialist in review and prevention of maternal deaths. Brown HSmall M. Semin Perinatol. 2012 Feb;36(1):27-30. doi: 10.1053/j.semperi.2011.09.006.