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May 19, 2017

Maternal mortality in the US is high—and rising. Here's one state's 'toolkit' to fight back.

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Even as the U.S. infant mortality rate has fallen markedly, the maternal mortality rate has increased, suggesting that the U.S. health system "has focused more on fetal and infant safety and survival than on the mother's health and well-being," Nina Martin and Renee Montagne write for ProPublica.

The Perinatal Patient Safety Toolkit

U.S. rate exceeds other developed countries

Between 700 and 900 women die from pregnancy or childbirth-related causes each year in the United States, and about 65,000 "nearly die," the authors write, which means the United States, "by many measures, [has] the worst record in the developed world" for maternal mortality. And while other countries have seen their maternal mortality rates decline over the past roughly 15 years, the U.S. rate has risen, Martin and Montagne report.

According to Martin and Montagne, possible explanations for the United States' high mortality rate include:

  • Women are becoming mothers at older ages, and with more complex medical conditions;
  • About half of pregnancies are unplanned, which means many women do not address chronic health issues prior to pregnancy;
  • C-sections are more prevalent in the United States, resulting in more life-threatening complications;
  • The U.S. health system is fragmented, which makes it harder for new mothers to access care; and
  • Caregivers may be confused about how to recognize symptoms of obstetric emergencies.

A focus on infant health—and a failure to account for maternal health

According to Martin and Montagne, the U.S. maternal mortality rate stands in sharp contrast to the nation's infant mortality rate, which CDC said hit an all-time low in 2014. As Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists, put it, "We worry a lot about vulnerable little babies. ... We don't pay enough attention to those things that can be catastrophic for women."

Report ranks best states for women's, children's, infants' health

For instance, in most states, Medicaid covers infants for a year after birth—but covers new mothers for only 60 days postpartum.

Martin and Montagne also point out that as recently as 2012, medical students training to specialize in maternal-fetal medicine were not required to learn to care for birthing women. And while at least 20 hospitals have established multidisciplinary fetal care centers for high-risk infants, only one hospital—NewYork-Presbyterian/Columbia—has established a comparable program for expecting mothers.

How some states—and providers— are fighting back

But some states are taking steps to change course, Martin and Montagne write.

For instance, California, which sees the most births per year of any state, launched a protocol modeled after the United Kingdom's national review process for maternal deaths. The decade-old California Maternal Quality Care Collaborative (CMQCC) aims to reduce mortality as well as life-threatening complications and racial disparities in obstetric care.

The effort involved creating "toolkits" to help doctors and nurses respond to emergencies, such as one aimed at obstetric bleeding. The kit recommended "hemorrhage carts" for holding medications and supplies, crisis protocols for major transfusion, and regular drills and training. Hospitals that adopted the toolkit saw near-deaths from maternal bleeding fall 21 percent in the first year. By 2013, maternal deaths in California dropped to 7 per 100,000—a rate comparable to Canada and the Netherlands.

The state launched another toolkit, aimed a preeclampsia, in 2014. And according to Martin and Montagne, the effort has inspired ACOG and advocates to launch their own initiatives.

CMQCC Founder Elliott Main, a professor of obstetrics and gynecology at Stanford and the University of California-San Francisco, noted, "Prevention isn't a magic pill. It's actually teamwork (and having) a structured, organized, standardized approach" to care.

Barriers to implementation

Despite the success of the CMQCC toolkit, about half of the hospitals in California that deliver babies haven't adopted it, according to Main, who said inertia was largely to blame. Similarly, in New Jersey, only 31 of the state's 52 birthing hospitals have adopted measures to reduce postpartum blood loss, despite recorded improvements in health outcomes.

According to the Institute of Medicine, it takes an average of 17 years for new medical protocol to become widely adopted. In addition to inertia, cost and training can also be barriers to change.

In addition, Mary D'Alton, chair of OB-GYN at Columbia University Medical Center, said that some hospitals in New York have questioned a need for what they describe as "cookbook medicine." To that, she said, "Variability is the enemy of safety. Rather than have 10 different approaches to obstetric hemorrhage or treatment of hypertension, choose one or two and make it consistent. … When we do things in a standardized way, we have better outcomes" (Martin/Montagne, ProPublica, 5/12).

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