Three reasons why maternal mortality rates are rising

Between 1990 and 2013, the maternal mortality ratio more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births in the United States; the country now has a higher ratio than most high-income countries, according to the World Health Organization (WHO).

Each year an estimated 1,200 women in the United States suffer complications during pregnancy or childbirth that prove fatal and 60,000 suffer complications that are near-fatal-even though costs of maternity care in 2012 exceeded $60 billion, the WHO reports. About half of all maternal deaths are preventable.

The WHO identified three factors that most likely contribute to the upward trend in maternal mortality and morbidity in the United States. Experts weigh in on the reasons for these problems, and offer solutions.

1. Inconsistent obstetric practices.

“As obstetrical care providers, we do not currently have standard approaches or protocols when it comes to managing obstetrical emergencies and pregnancy complications,” says Jeffrey Chapa, MD, director of maternal-fetal medicine, Cleveland Clinic, Cleveland, Ohio. “Across facilities in the United States that offer childbirth services, there is significant variability in the resources available to patients dealing with critical emergencies.”

Elliott Main, MD, medical director, California Maternal Quality Care Collaborative (CMQCC), Stanford University, Stanford, California, points out that some work has been done to improve standardization. For example, CMQCC in conjunction with the California Department of Public Health has created quality improvement toolkits for key obstetric emergencies. These have become prototypes for national safety bundles supported by national professional organizations, including the American Congress of Obstetricians and Gynecologists, who are working together in the Council on Patient Safety in Women’s Health Care. In turn, the national Alliance for Innovations in Maternal Health, which is supported by the Maternal Child Health Bureau, is supporting implementation projects to get every hospital in the country to adopt these bundles.

Chapa believes that improving training for nurses and physicians, standardizing care, and developing appropriate referral networks to get patients the care they need would be significant steps toward addressing these problems.

2. More pregnant women have chronic conditions.

Chronic conditions such as hypertension, diabetes, and obesity contribute to pregnancy-related complications. “There needs to be better coordination of care between obstetrical care providers and primary care physicians, with a greater focus on preconceptual and postpartum care for women with chronic diseases,” Chapa says. “Access to effective contraception and optimization of maternal health prior to conception would go a long way toward improving outcomes for these patients, as would promoting wellness and preventative care prior to pregnancy.”

Randy P. Fiorentino, MD, St. Joseph Hospital, Orange, California, notes that women are starting and continuing their childbearing later in life, at times when they are naturally more predisposed to chronic health conditions. Compounding these factors are general health concerns such as poor preconception diet and exercise, as well as lack of proper attention to chronic health conditions in the preconception time period. 

3. Lack of analysis on maternal health outcomes.

In the 1970s almost every maternal mortality review committee was shut down because it was felt that maternal mortality had been conquered. Now, 33 states have taken the CDC’s advice to revamp these committees. “These state review committees are critically important, as all of the key data is state-based-medical records, autopsy, and coroner reports, and the ability to carefully link birth and death certificates,” Main says.

Fiorentino says that while historically data collection, analysis, and application have been slow to evolve for purely logistical reasons, there have been recent improvements in these efforts, particularly in California. The development and implementation of the California Maternal Quality Care Collaborative has opened up groundbreaking approaches to collecting maternal outcomes data, analyzing it, and developing recommendations for standard care models to be used across obstetrical practices nationwide, he says. These recommendations for standard care come in the form of obstetrical toolkits-a set of evidence-based practice guidelines to be used by all clinicians and hospitals which guide current best practices related to specific maternal health issues.

Next: Five key action items

Five key action items

So what can health insurers do to help decrease maternal mortality rates? Chapa cites five key steps:

1. Make sure all patients have access to maternity care.

2. Ensure and encourage standards in hospitals for obstetric emergencies and pregnancy complications. This could include requiring mandatory training programs and a certification process to be in network.

3. Provide coverage for telemedicine for subspecialty care such as maternal fetal medicine.

4. Provide coverage for wellness programs and effective contraception

5. Offer preconception care and post-delivery management for patients with chronic diseases.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.