Improving maternal outcomes before, during and after giving birth
Childbirth-related maternal health outcomes are getting worse in the United States. That’s true not only during the nine months of pregnancy, but also in the so-called “fourth trimester,” that is, those months (some say as many as 12) following birth. Reasons include rising rates of chronic illness, obesity, C-sections and the advanced age at which some women are having children.
“Looking at the numbers, there has been a jump in maternal deaths,” says Ron Yee, MD, MBA, FAAFP, chief medical officer for the National Association of Community Health Centers. But there is a need for better data-gathering, he adds. Prior to taking his current position, Yee was a family physician for 20 years in rural central California, where he estimates he delivered hundreds of babies, primarily those of migrant farm workers.
Rates climbing
After a dramatic reduction in maternal mortality over most of the 20th century, rates began to climb in the late 1980s, reports the Agency for Healthcare Research and Quality (AHRQ). In fact, the United States now lags behind other industrialized countries in maternal mortality. The rate of severe maternal morbidity (e.g., massive blood transfusion, eclampsia, hysterectomy, heart failure) has also risen in recent decades.
The number of reported pregnancy-related deaths in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014, according to the Centers for Disease Control and Prevention. (CDC defines a pregnancy-related death as the death of a woman while pregnant or within one year of the end of a pregnancy – regardless of the outcome, duration or site of the pregnancy – from any cause related to or aggravated by the pregnancy or its management.)
In a study of pregnancy-related deaths from 2011–2013 in the United States, approximately 30 percent occurred before birth, 17 percent during birth, 18 percent one to six days after birth, and 34 percent more than six days after birth.
While controversy exists about the accuracy of measurement of maternal and pregnancy-related mortality, analysis consistently demonstrates that at least 50 percent of deaths are potentially preventable, reports AHRQ. In addition, many more women experience serious pregnancy-related complications during and after childbirth. Such complications are 50 times more common than pregnancy-related mortality.
Some blips can be detected in the statistics. For example, higher pregnancy-related mortality ratios during 2009–2011 have been attributed to an increase in infection and sepsis deaths, reports the CDC. Many of these deaths occurred during the 2009–2010 influenza A (H1N1) pandemic. Influenza deaths accounted for 12 percent of all pregnancy-related deaths during a 15-month period.
Chronic illness
Events such as H1N1 aside, many studies show that an increasing number of pregnant women in the United States have chronic health conditions such as hypertension, diabetes, and chronic heart disease. These conditions can put a pregnant woman at higher risk of pregnancy complications.
Among causes of pregnancy-related deaths, the following groups contributed more than 10 percent:
- Cardiovascular conditions (15.5 percent).
- Other medical conditions reflecting pre-existing illnesses (14.5 percent).
- Infection (12.7 percent).
- Hemorrhage (11.4 percent).
- Cardiomyopathy (11.0 percent).
Government researchers report that compared with reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased.
Pregnancy can unveil and magnify health issues that were previously undetected, says Yee. For example, a prediabetic woman may develop gestational diabetes during pregnancy, which can lead to type 2 diabetes later in life. Similarly, mild hypertension prior to pregnancy can lead to preeclampsia, which is characterized by high blood pressure and high levels of protein in the urine, and which can increase the risk of kidney failure. And in general, the older a woman is, the higher the risk for chronic disease.
There’s one more factor at play, points out Yee. The United States has a higher incidence of C-sections than many other countries, and C-sections present a higher risk of hemorrhage, bleeding, infection and anesthesia-related complications.
The physician’s office and the home
Given the role of chronic illness in maternal health, it’s no surprise that primary care doctors can play a big role in improving maternal outcomes before, during and after giving birth.
“When I was in practice, I treated any woman of child-bearing age as if she might in the future become pregnant,” says Yee. That calls for sensitivity to conditions that can adversely affect the health of the patient as a mother, as well as her child. “We need to try to get things like hypertension, diabetes and weight under control,” he says. “It calls for a lot of discussion about overall health and well-being.” That includes psychosocial factors, such as depression.
The social determinants of health – e.g., the patient’s socioeconomic status, housing status, ability and willingness to eat healthy foods, and the ability to travel to and from a doctor’s office or hospital – must be considered as well, says Yee.
The National Association of Community Health Centers is engaged in a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. The program – PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) – is intended to help providers define and document the increased complexity of their patients, transform care with integrated services and community partnerships, advocate for change in their communities, and demonstrate the value they bring to patients, communities, and payers.
Postpartum issues
The weeks following birth are critical for a woman and her infant, setting the stage for long-term health and well-being, according to the American College of Obstetricians and Gynecologists (ACOG). Postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.
Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders, should be counseled regarding the importance of timely follow-up with their OB-GYNs or primary care providers for ongoing coordination of care, says ACOG. During the postpartum period, the woman and her OB-GYN or other obstetric care provider should identify the healthcare provider who will assume primary responsibility for her ongoing care in her primary medical home.
Heart Safe Motherhood, a program created at the Hospital of the University of Pennsylvania, makes postpartum, at-home blood pressure monitoring easy, so that providers can catch rising blood pressure earlier and keep patients safe at home. HUP created the program because hypertension was the leading cause of seven-day readmissions for obstetrics patients there.
Patients are discharged with digital blood pressure monitors and sent reminders via text message to check their blood pressure twice daily. In 2017, HUP completed a randomized controlled trial comparing Heart Safe Motherhood to the usual care of one-time, office-based blood pressure checks. The organization found an increase in its ability to obtain at least one blood pressure within 10 days of discharge in 92 percent of patients using text messaging, compared to 44 percent in usual care. HUP met ACOG guidelines in 80 percent of its patients, and readmissions dropped to zero percent among remote monitored women in the trial.
Racial disparities
A woman’s race/ethnicity has a big impact on pregnancy-related mortality, according to government researchers. The burden of maternal morbidity and mortality is especially high in the African-American community, reports AHRQ. From 2011 to 2014, the pregnancy-related mortality ratio was more than three times higher among black women than white women (40.0 deaths per 100,000 births vs. 12.4 deaths per 100,000). The pregnancy-related mortality ratio was also higher for women of other races (17.8 per 100,000 live births).
As many as 40 percent of women skip their postpartum visits, according to ACOG, and the rate is higher among low-income women of color. “Meanwhile, their blood pressure can be way out of control,” says Yee. Further, if a woman returns to work too soon after delivery, missing their follow-up visit, “that’s a setup for a chronic disease to spin out of control,” he adds.
Implicit or unconscious bias on the part of individual clinicians or institutions can contribute to morbidity or mortality, says Yee. An individual provider’s attitudes can affect their understanding, actions and decisions in an unconscious manner. Age, race, ethnicity, disabilities, sexual orientation, personal hygiene can all have an impact, not to mention insurance status. “This is something that has to be picked apart,” he says.