View as “PDF version”
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” highlighted the dire status of maternal mortality in the US. Tikkanen 2020CDC 2020 (The persistently high maternal mortality rates in the US have garnered the attention of many US media entities USA Today, Bloomberg, Vox, US News & World Report.
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” also highlighted the disparities in maternal mortality in the US. The maternal mortality rate for 2018 was 17.4 deaths per 100,000 live births, and the rate for non-Hispanic black women (37.1) was 2.5 to 3.1 times the rates for non-Hispanic white (14.7) and Hispanic (11.8) women Hoyert 2020).
The Annals of Internal Medicine recently devoted a whole supplement to maternal mortality. But it was an article for the Commonwealth Fund that caught our attention Tikkanen 2020the timing of the maternal deaths as reported by Petersen et al. (Petersen 2019) somewhat surprised us. About a third of U.S. pregnancy-related deaths occur during pregnancy. Seventeen percent of deaths occur on the day of delivery. But 52 percent occur after delivery:
Petersen et al. (Petersen 2019) also looked at causes of maternal death. They noted that approximately sixty percent of pregnancy-related deaths from state MMRC’s (maternal mortality review committees) were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. Causes of death did vary by timing of death related to the pregnancy. Most deaths caused by amniotic fluid embolism occurred on the day of delivery or within 6 days postpartum. Approximately 60% of deaths caused by hypertensive disorders of pregnancy occurred 0–6 days postpartum, whereas those caused by cerebrovascular accidents occurred most frequently 1-42 days postpartum. Deaths caused by cardiomyopathy most commonly occurred 43-365 days postpartum; deaths caused by other cardiovascular conditions occurred most commonly during pregnancy and within 42 days postpartum. Multiple factors contributed to pregnancy-related deaths and they categorized contributing factors and prevention strategies at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.
Between 2003 and 2016, inpatient maternal mortality fell by 20%. There was a similar (24%) decline in maternal deaths in outpatient facilities and emergency departments. But, there was a significant increase in mortality in other settings, particularly within the descendant’s home with a doubling in maternal mortality rate over this time period (Burgess 2020). The authors suggest that future progress in lowering maternal mortality in the US will require successfully addressing social, cultural, and financial issues beyond the direct control of the medical community.
We do many presentations on the fact that the high cost of healthcare in the US does not result in better health outcomes compared to other countries. We often highlight the high infant mortality and maternal mortality rates in the US as examples. But we also point out that statistics on infant and maternal mortality are somewhat misleading, since social and economic issues are as important as the strictly medical ones. Other countries spend significantly more on social issues that we do in the US.
Tikkanen and colleagues point out the US has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports. Ob/Gyn’s are overrepresented in the US maternity care workforce relative to midwives, but there is an overall shortage of maternity care providers (both Ob/Gyn’s and midwives) relative to births. In most other countries, midwives outnumber Ob/Gyn’s by severalfold, and primary care plays a central role in the health system. They also note that, although a large share of its maternal deaths occur post-birth, the US is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. Tikkanen et al. note that home visits give providers an opportunity to address mental health concerns and allow them to assess social determinants of health, including needs for food, housing, financial security, and protection from domestic violence. They also note that the US is the only high-income country that does not guarantee paid leave to mothers after childbirth.
Tikkanen et al. point out a number of features of the Affordable Care Act (ACA) that have been beneficial to maternal care (expanded access to insurance coverage, expanded Medicaid, covered preventive services, better reimbursement rates for some providers, etc). But they also point out that the COVID-19 pandemic is likely to exacerbate the disparities, given that the pandemic has disproportionately impacted minorities economically.
Most quality improvement and patient safety efforts have focused on prenatal care and inpatient care. But the statistics noted above would suggest, as emphasized by Tikkanen et al., that we need to be focusing much more on what happens after the mothers and infants leave the hospital.
ACOG recognized the role of cardiovascular disease as a leading cause of maternal mortality in a 2019 Practice Bulletin (ACOG 2019). In a discussion of that ACOG Practice Bulletin, it was pointed out that a key barrier to adequate care is that 40% of women do not return for post-partum visits (Nackerdien 2019).
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” discussed many of the social issues related to maternal mortality and disparities in care. But there we also mentioned the plight of women living in rural areas. Over 100 rural hospitals have closed since 2010 and about a quarter of rural hospitals are at risk of closing today. Rural hospitals have great difficulty recruiting doctors, nurses, and other healthcare professionals. As these hospitals hemorrhage financially, many cannot afford to staff labor & delivery units 24x7 when there are few actual deliveries, so this service is often dropped and women are forced to seek their obstetrical care elsewhere. That often leads to discontinuity between their obstetrical care and their overall medical care.
Though inpatient maternal mortality rates have been improving, TJC 2019
February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”).
One way to address the inpatient portion of obstetrical care has been introduction of obstetrical hospitalist programs. Internal medicine hospitalist and Ob/Gyn laborist programs have been around for a couple decades. OB hospitalist programs have been envisioned as a potential way to address issues such as physician burnout, unpredictable work schedules, fragmentation of care, lack of standardization, and patient safety. Decesare and colleagues (Decesare 2020) recently reported that implementation of an OB hospitalist program significantly reduced patient safety events.
e have, in fact, been doing a better job at reducing maternal mortality in hospitalized patients. But the real message in today’s column is that much maternal mortality occurs after the pregnancy has ended and is potentially preventable. We clearly need better focus on those system features that could address factors contributing to those deaths.
Some of our previous columns on maternal and ob/gyn issues:
February 5, 2008 “Reducing Errors in Obstetrical Care”
February 2010 “Joint Commission Sentinel Event Alert on Maternal Deaths”
April 2010 “RCA: Epidural Solution Infused Intravenously”
July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
August 2010 “Surgical Case Listing Accuracy”
September 7, 2010 “Patient Safety in Ob/Gyn Settings”
January 2011 “Surgical Fires Not Just in High Risk Cases”
February 8, 2011 “Inducing Too Early”
April 2011 “Ob/Gyn Patient Safety Programs”
April 24, 2012 “Fire Hazard of Skin Preps Oxygen”
July 2012 “WHO Safe Childbirth Checklist”
December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”
September 2013 “Full-Time Laborists Reduce C-Section Rates”
October 2013 “Challenging the 39-Week Campaign”
November 2013 “The Weekend Effect: Not One Simple Answer”
January 2014 “It MEOWS But Doesn’t Purr”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
August 19, 2014 “Some More Lessons Learned on Retained Surgical Items”
November 3, 2015 “Medication Errors in the OR - Part 2”
February 7, 2017 “Maternal Safety Bundles”
January 23, 2018 “Unintentional Hypothermia Back in Focus”
January 8, 2019 “Maternal Mortality in the Spotlight”
USA Today. Deadly Deliveries. USA Today 2020
Flam F. American Mothers Are Dying Because of the U.S. Health Care System. The U.S. has an inexcusably high maternal mortality rate. Bloomberg 2020; February 9, 2020
Belluz J. We finally have a new US maternal mortality estimate. It’s still terrible.
Among 10 similarly wealthy countries, “the US would rank 10th.” Vox 2020; Jan 30, 2020
Petersen EE, Davis NL, Goodwin D, et al. Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR 2019; 68(18): 423-429 Published May 10, 2019
Hoyert DL, Miniño AM. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, National Vital Statistics Report 2020; 69(2): 1-18
Burgess A, Clark S, Dongarwar D, SalihuH. Hospital maternal mortality rates are falling,overall maternal mortality still rises: Implications forforward movement. Amer J Obstet Gyn 2020; 222(1): Supplement S5
Annals of Internal Medicine. Maternal Health in the United States: Findings From the Health Resources and Services Administration and Partners. Annals of Internal Medicine 2020’ 173(11): Supplement
ACOG (American College of Obstetricians and Gynecologists). ACOG Practice Bulletin No. 212 Summary: Pregnancy and Heart Disease. Obstetrics & Gynecology 2019; 133(5): 1067-1072
Nackerdien Z. ACOG Plan Addresses Cardiovascular Disease as Top Killer of Pregnant Women in U.S. MedPage Today 2019; May 12, 2019
Decesare JZ, Bush SY, Morton AN. Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit. Journal of Patient Safety 2020; 16(3): e179-e181
Print “PDF version”