Maternal Deaths in the United States: Sounding a Call to Action

Every 10 minutes, a women in the United States nearly dies from complications during childbirth. In 2015, the rate was 14 per 100,000 live births. Alarmingly, this is an increase from 1990, when it was 12.¹ This statistic in striking contrast with nations such as Canada (7 in 2015 and 1990), Estonia (42 and 9, respectively), and Japan (14 and 5, respectively). The United States was 1 of only 8 nations with an increased maternal mortality rate.¹

In a 2016 study analyzing US maternal mortality trends, Marian F. MacDorman, PhD, and colleagues reported that despite the United Nations Millennium Development Goal to reduce the maternal mortality rate by 75% by 2015, the estimated rate for 48 states and Washington, DC, has increased from 2000 to 2014.² The international rates, however, have reversed. “There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million US women giving birth each year,” the authors concluded.

Why does the United States, 1 of the wealthiest nations in the world, and the 1 that spends the most on health care, have such dismal results? Equally alarming is that studies suggest that approximately one-third of these deaths are preventable.

There are certainly multiple reasons. Part of the increase may be caused by the addition of a check-off box for death resulting from pregnancy-related issues on US death certificates. Other etiologies include the rising numbers of cesarean deliveries, as well as obstacles to accessing consistent prenatal healthcare. There are also preventable causes such as obesity, diabetes, and hypertension.

A recent study by Eliza Miller, MD, and colleagues found that women suffering from preeclampsia were up to 6 times more likely to experience a stroke than women without preeclampsia. They studied the medical records of 591 women with preeclampsia without stroke, and 197 women with a stroke secondary to preeclampsia.³

What can we do to combat this?

The Alliance for Innovation on Maternal Health (AIM) is a program funded by the Health Resources and Services Administration’s Maternal and Child Health Program, with leadership from the Council on Patient Safety in Women’s Health Care and the American Congress of Obstetrics and Gynecology (ACOG).^4,5 With a $4 million, 4-year grant, the goal is to prevent 1000 maternal deaths as well as 100,000 severe complications during admissions for delivery during this time. AIM is seeking to develop and implement multiple patient safety bundles, which are evidence-based practices that together have been shown to improve patient outcomes.^4,5

The bundles include action measures specifically for obstetrical hemorrhage, severe hypertension/preeclampsia, prevention of venous thromboembolism, reducing low-risk primary cesarean births and supporting intended vaginal birth, reducing peripartum racial disparities, and postpartum care standards and access.⁴

In 2015, ACOG reported that pilot programs in California and New York successfully reduced the maternal mortality rate from 16.9 per 100,000 live births to 6.2 from 2006 to 2012.⁴

The president of ACOG, Mark S. DeFrancesco, MD, stated, “ACOG has long recognized the need to address maternal mortality in the United States, and our practice recommendations present a wide variety of tactics to improve obstetrical outcomes. But we know that we need to do more regarding implementation of these best practices. AIM’s efforts to implement bundles at the institutional level will certainly have a meaningful impact on patient care and, we hope, on the US maternal mortality crisis.”⁴

I agree, and applaud AIM’s and others’ vital work in this area of prime concern. We cannot, and should not, accept the situation we find ourselves in. We must address not only the disparities between maternal mortality in this country compared with others but also disparities that cut across racial and socioeconomic lines, such as [those that exist for] African Americans. We must make changes at multiple levels, including our systems. Prevention is a crucial component, as is identifying those women at high risk for complications.

Although these efforts will not be easy, they must be concerted, and will take a team of committed individuals, including nurses, nurse-midwives, and physicians, as well as public health officials and policymakers at all levels.

References

1. Maternal mortality ratio (modeled estimate, per 100,000 live births). WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015. Geneva: World Health Organizations; 2015. http://data.worldbank.org/indicator/SH.STA.MMRT. Accessed June 2, 2017.

2. MacDorman MF, Declercq E, Cabral H, Morton C. Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstet Gynecol. 2016;128(3):447-455. doi:10.1097/AOG.0000000000001556

3. Miller EC, Gatollari HJ, Too G, et al. Risk factors for pregnancy-associated stroke in women with preeclampsia [published online May 25, 2017]. Stroke. doi:STROKEAHA.117.017374

4. Leading health organizations launch state-based care programs through the Alliance for Innovation on Maternal Health. Washington, DC: American Congress of Obstetricians and Gynecologists. http://www.acog.org/About-ACOG/News-Room/News-Releases/2015/Leading-Health-Organizations-Launch-State-Based-Care-Programs-Through-theAIM-on-Maternal-Health. Published June 4, 2015. Accessed June 2, 2017.

5. What is AIM. Washington, DC: Alliance for Innovation on Maternal Health; American Congress of Obstetricians and Gynecologists. http://www.acog.org/About-ACOG/ACOG-Departments/Patient-Safety-and-Quality-Improvement/What-is-AIM. Accessed June 2, 2017.