The relatively high percentage of American women who die as a result of pregnancy, which exceeds that of other developed nations, is prompting a new national prevention campaign that relies on the states to take a leading role in preventing such deaths.
The effort encourages states to go beyond the information provided on a typical death certificate by having mortality review panels investigate the causes behind every maternal death that occurs during pregnancy or in the year after delivery. The hope is that the investigations will reveal causes for at least some of the deaths and lead to preventive measures to save the lives of more women.
A number of studies suggest that a third of deaths related to pregnancy are potentially preventable.
“It’s hard to do anything about a problem if you don’t have the problem fully defined,” said Cynthia Shellhaas, an associate professor in the division of maternal-fetal medicine at the Ohio State University Wexner Medical Center who supports the campaign.
The effort is led by the Association of Maternal & Child Health Programs (AMCHP), an advocacy group, and the Centers for Disease Control and Prevention. They want every state that doesn’t have one to create a maternal mortality panel of medical and forensic experts. They want the panels to collect as much information as possible related to every maternal death, including matters related to prenatal care, other health conditions, use of medications, drug and alcohol abuse, violence and previous medical procedures.
They also are encouraging states to standardize the data they collect. And they will provide a digital application to help them collect it, to make it easier to analyze the data for possible trends and remedies.
About half the states — including Maryland and Virginia — have such panels, although each devises its own ways of classifying information and determining which cases to investigate. For example, some look at any woman’s death up to 42 days after a pregnancy. Others examine any death up to a year after delivery.
In the United States, there are 18.5 maternal deaths for every 100,000 live births, according to the Institute for Health Metrics and Evaluation at the University of Washington, which tracks mortality trends worldwide. The CDC says that about 700 maternal deaths occur in the United States every year, with the rate for African American women three times higher than the overall national figure. Typical causes include hemorrhage, infection, hypertensive disorders and obstructions in labor.
Maternal mortality is down from a recent peak — in 2009, when it was 22 deaths per 100,000 — after rising steadily for more than a decade. But preliminary numbers suggest that the rate began to rise after 2013, the institute said. The figure is significantly higher in the United States than in other developed countries. For example, the rate is 8.2 in Canada and 6.1 in the United Kingdom and Japan.
Possible reasons for the higher U.S. rate include better reporting, mothers giving birth at older ages (which increases the odds of pregnancy-related complications) and the growing percentage of expectant mothers with chronic conditions such as obesity, hypertension and diabetes. The upsurge in opioid overdoses also may be a factor.
Maternal deaths often signal broader health problems. The Joint Commission, a nonprofit that accredits health-care organizations and programs, calls maternal deaths “sentinel” events. “For every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy, labor and delivery,” William Callaghan, a senior CDC scientist who studies maternal morbidity, said in an alert issued by the Joint Commission in 2010.
The notion of investigating the deaths of mothers to prevent further fatalities isn’t new.
Medical societies in some large cities and states began establishing maternal mortality panels in the 1930s, when the maternal mortality rate was more than 600 deaths for every 100,000 live births. Even then, there was a strong sense that many deaths could be prevented through improved medical and hygienic practices.
The work of those panels, combined with the Social Security Act of 1935, the advent of antibiotics, advances in obstetrics and medicine in general, and the trend toward more hospital births led to a precipitous drop in the mortality rate through the early 1960s.
Many of the review panels disappeared. But as rates started rising again in the late 1990s, they began to resurface. David Goodman, the senior scientist for the CDC’s Maternal and Child Health Epidemiology Program, estimates that a dozen states are creating them in addition to the 20 or so that already have them.
Most of the mortality panels are appendages to state health departments, although Goodman said most operate with little state revenue. They rely instead on the financial contributions and participation of its volunteer members, who usually include doctors, coroners, lawyers and even police officers.
Although death certificates usually provide a cause of death, the quality of the information varies greatly from state to state.
The certificates lack the detail that would help hospitals and other providers make adjustments that could prevent further deaths, Goodman said.
For example, he said, a death certificate may indicate that a new mother died as a result of an infection. But a deeper examination might reveal deficiencies in the sterilization of surgical equipment in hospital obstetrics units.
Something like that happened in California. Evidence revealed by the California mortality review panel led to revised protocols in the handling of post-delivery hemorrhages in all California hospitals beginning in 2008.
Barbara O’Brien, program director of the Office of Perinatal Quality Improvement at the University of Oklahoma Health Sciences Center, said that evidence collected by her state’s mortality review panel has led to the use of compression devices for all pregnant women undergoing Caesarean sections to reduce the risk of developing a deep vein thrombosis — a blood clot, usually in the leg, that can be fatal.
The panels review autopsies, hospital and provider medical records, and, in some cases, records from police and social service agencies. Some states have laws that give the panels access to those records, but not always. “If you want to go to the provider’s office who provided prenatal care [in Oklahoma], they aren’t required to give you the records,” O’Brien said.
Ohio State’s Shellhaas, who oversees her state’s maternal mortality panel, said it usually waits two years before delving into a case to allow any civil lawsuits to be resolved, which removes an impediment to getting the necessary documents.
AMCHP and the CDC are testing the new data collection system in a dozen states. Eventually it will be made available to all states, thanks in part to funding from the pharmaceutical giant Merck, which is engaged in a $500 million, worldwide campaign to improve maternal health.