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Death After Pregnancy: Why Is U.S. Maternal Mortality Rate So High?

January 21, 2019

It's rare that a woman in America dies because of complications during pregnancy and childbirth, but when this country's maternal mortality rate is the highest in the developed world it's not rare enough. The United Health Foundation forecast 20.7 deaths per 100,000 women in 2018 in the United States that will be classified as a maternal mortality, defined by the Centers for Disease Control and Prevention as the death of a  woman while pregnant or within one year of the end of a pregnancy from a cause related to the pregnancy. Why is this country’s maternal mortality rate so high? A USA Today analysis published last summer of more than 50,000 pages of internal quality records from dozens of hospitals from 2015-16 and comments from 37 birthing hospitals found a "stunning lack of attention to safety recommendations and widespread failure to protect new mothers." The newspaper, using data collected in its investigation, also revealed the states with the lowest (and highest) maternal mortality rate, with Connecticut's 10.5 per 100,000 births the fourth-lowest in the nation, trailing only California, Massachusetts and Nevada. (Louisiana, Georgia, Indiana and Arkansas had the highest maternal mortality rates.) The goal, says Dr. Elizabeth Deckers, medical director of labor and delivery and postpartum services at Hartford Hospital, is to push the state's rate lower and lower. The hospital, for several years, has followed recommendations to reduce pregnancy-related deaths outlined in a November 2018 article in the New England Journal of Medicine. Given the state's already low maternal mortality rate, Hartford Hospital also measures its performance by reviewing all instances of severe maternal morbidity, which can include unanticipated Intensive Care Unit admissions, blood transfusions, renal failure, sepsis and acute respiratory distress syndrome (ARDS). These efforts, since 2010, have resulted in an overall decline in the hospital's Adverse Outcome Index, a report produced by the National Perinatal Information Center (NPIC) that tracks the number of patients with medical complications relative to the total number of deliveries. "It demonstrates what our safety measures have been able to accomplish," says Dr. Deckers. "The index looks at things such as in-hospital maternal death, uterine rupture during labor, maternal transfer to the Intensive Care Unit, unanticipated operative procedures, blood transfusions and fourth-degree perineal lacerations. There has been a significant downward trend in Hartford Hospital's Adverse Outcome Index from 2010 to 2018 despite the fact we are dealing with much more medically complicated patients. This is probably the best measure of the impact of the work we have been doing." The high U.S. maternal mortality rate is often attributed to limited access to healthcare, poverty and untreated chronic conditions such as hypertension, obesity and diabetes. Hartford Hospital and other healthcare systems across the country are adopting "bundles" of best practices created by the Alliance for Innovation on Maternal Health, a coalition led by the American College of Obstetricians and Gynecologists, to enhance patient safety and help hospitals better identify preventable complications and treat high-risk women through childbirth. AIM, formed in 2014, closely follows methods used  by California that reduced the state's maternal mortality rate by 55 percent, from 16.9 to 7.3 deaths per 100,000 live births, between 2006 and 2013 as the U.S. rate increased from 13.3 to 22. Hartford Hospital, following California's lead, has adopted these patient-safety bundles (with year of implementation in parenthesis):

  • Hemorrhage Response Plan (2012-13).
  • Management of Severe Hypertension (2014-15).
  • Thromboembolism Prevention (2016).
  • Supporting Vaginal Birth to reduce C-sections (2017-18).
The hospital has also used Crew resource management training, shown by a 2018 American Journal of Medical Quality study to  improve safety awareness among hospital employees, as a model for collaboration and communication among professionals. Other safety measures include a monthly multidisciplinary team meeting of obstetricians, maternal fetal medicine specialists, nurses and anesthesiologists, as well as surgical and medical subspecialists and intensivists to discuss management of high-risk patients and also patients who have been transferred to Hartford Hospital for specialized care. This specialized care could include treatment for:
  • Abnormal placentation (when the placenta doesn't separate during delivery, causing severe bleeding).
  • Maternal congenital heart disease.
  • Maternal cardiovascular disease.
  • Maternal medical comorbidities (two chronic conditions or diseases at once).
The multidisciplinary teams have also used simulation of obstetric emergencies at the hospital's Center for Education, Simulation and Innovation and training in the labor and delivery unit in:
  • Shoulder dystocia.
  • Postpartum hemorrhage.
  • Management of severe hypertension and eclampsia.
  • Management of maternal cardiac arrest.
Hartford Hospital, recognizing the many maternal deaths that occur nationally in the postpartum period, recently introduced an education program that alerts women to possible complications in the first six weeks after giving birth. Learning to recognize the symptoms below and knowing what to do could save the life of a postpartum woman. When To Call Your Healthcare Provider
  • Headache that does not get better, even after taking medicine, or bad headache with vision changes.
  • Bleeding that soaks through a pad every hour for two hours, or large blood clots.
  • Red or swollen leg that is painful or warm to touch.
  • Temperature of 100.4 or higher.
  • Problems urinating: inability to urinate, burning while urinating or extremely dark urine.
  • Children or a support person with a sore throat, fever, cough or any flu-like symptoms.
When To Call 911
  • Chest pain.
  • Shortness of breath or trouble breathing.
  • Bleeding that is not controlled or stopping.
  • Sudden onset of arm or leg weakness or seizure.
  • Sudden facial drooping, slurred speech or trouble speaking.
  • Thoughts of hurting yourself or your baby.
"Although the education program was just started in November 2018," says Dr. Deckers, "feedback from patients and their family members has been excellent, with many women reporting they feel much more prepared to take care of themselves as well as their infant when they are discharged home." For more information on Childbirth and Pregnancy Services at Hartford Hospital, click here.