There is no event associated with greater joy and happiness than a successful pregnancy resulting in a healthy mother and newborn. Unfortunately, such a “Norman Rockwell” ending, doesn’t always occur.
Despite all of our medical advances, between 700 and 900 women die in the U.S. each year from pregnancy or childbirth-related causes, and nearly 65,000 pregnant women came close to losing their lives. To make matters worse, experts point out that the rate of pregnancy-related complications exceeds any other developed country and are especially high in African American populations. Our rate of maternal mortality continues to rise nationally, erasing decades of improvement. Even more tragic: A recent CDC analysis shows that up to 60 percent of these deaths are preventable.
One of the reasons for this epidemic of poor outcomes is that our focus has been on improving neonatal outcomes at the expense of mothers, especially in terms of funding programs for helping them become healthier. The movement to put “M” back in maternal-fetal medicine supports this inequity of focus. No one would contest that improving the outcomes for babies is important but we need to broaden our perspective and consider maternal good health as well. For example, the federally funded research collaborative known as Maternal-Fetal Medicine Units Network lists only four of its 34 initiatives focused on mothers, compared to 24 aimed at improving outcomes for infants. More urgently, Medicaid, which now pays for approximately 45 percent of births in the U.S., covers mothers for 60 days following childbirth in many states, while infants receive a full year. We know a good number of pregnancy-related problems in the year after childbirth occur after 60 days, including deaths and poor outcomes from cardiovascular deterioration and suicide. The outlook for improving this inequity increases with discussions of reducing Medicaid funding as part of the possible bills currently proposed to replace the Affordable Care Act.
Clearly the reasons for the rising mortality rates is that we as providers are faced with medical risk factors such as increasing maternal age and obesity and the associated rates of hypertension and diabetes. Unfortunately, we also face the problem of record numbers of patients with prior cesarean sections and the risk of placental complications leading to hemorrhage and other problems. In obstetrics we are just beginning to approach these issues in an organized, structured way by applying modern performance improvement techniques. These need to be applied to prenatal care so we can recognize high-risk conditions in women and get the focused care in a timely fashion for conditions like hypertension, cardiac problems and placental abnormalities. Currently, few follow standardized protocols for addressing near-miss issues, a situation that allows treatable complications to become lethal.
We need to be much better at diagnosing problems such as cardiovascular disease or preeclampsia in women during the pre and postnatal periods leading to complications such as heart failure, seizures and strokes. There are many cost-effective tools for decreasing risks of poor outcomes such as the “hemorrhage cart.” While every accredited labor and delivery has a CPR cart, only a fraction have this potentially lifesaving method of making the equipment/medications for responding to hemorrhage readily available. Also, we need to limit the number of unnecessary cesarean sections performed, which have the potential of putting mothers at higher risk.
Cesarean sections are now the most frequent hospital surgery in the United States. According to the CDC, the number of cesarean sections in America increased by 60 percent between 1996 and 2009, without improved outcomes for mothers or their children. Although there are many instances when cesareans help improve outcomes for both mother and baby, far too many are performed for circumstances that have not been shown to improve outcomes. The result is record numbers of women with prior cesarean section being seen with a 2-4 fold risk of most complications. The overuse of cesareans has significant social, economic and health costs, including higher rates of maternal complications and longer recovery times, higher rates of NICU admissions, and more mother-baby breastfeeding difficulties.
I am proud to be a member of the California Maternal Quality Care Collaborative (CMQCC), which has started a state-wide collaborative to promote vaginal birth and reduce cesarean deliveries in California. In addition, I would point to the incredible work of the Partnership for Maternal Safety (a joint effort of the major women’s caregiver societies) which has produced safety bundles addressing most of the major reasons for maternal mortality. In California we have demonstrated that we can reduce severe maternal morbidity through collaboration. Participating hospital teams receive training materials, educational webinars, detailed real-time data reports and on-site assistance from experts to establish evidence-based protocols. Participating clinicians and hospitals can track their efforts by utilizing a perinatal data center which allows for feedback and drives the efforts.
To address the rising cesarean section rate, CMQCC is currently running Round 1 and 2 of a collaborative, with about 70 hospitals participating. Round 3 of the collaborative is tentatively scheduled to begin during Fall 2017 and end in December 2018. Our goal is to reduce the rate of first-birth cesareans (Nulliparous Term Singleton Vertex or NTSV) to 23.9% (currently at 40%).
Every woman who dies during or after childbirth is someone’s mother, daughter, sister or spouse – and her family is damaged with long-lasting effects. We all want every pregnancy to result in both a healthy mother and baby. It’s time to put an end to the shocking statistics on maternal health and start working together as concerned clinicians. California hospitals interested in participating in the outreach collaborative can email info@cmqcc.org.
David Lagrew, MD, is the Executive Medical Director of Women’s Services for St. Joseph Hoag Health, an integrated network of care in Orange County, California.
David Lagrew, MD