Maternal Death: the Rising National Crisis of Maternal Morbidity and Mortality
By Niran S. Al-Agba, MD (Mom, pediatrician, and Associate Editor at The Deductible); Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety) and John Bianchi (Vice President, Finn Partners)
In May 2012, Tommy Scott came home from work and found his pregnant wife, Amber, unconscious. She was rushed to Louisiana’s Slidell Memorial Hospital, where evaluation revealed that she had suffered a stroke due to a clot in her brain. Her daughter, Adeline, was quickly delivered by emergency Caesarian section so neurosurgeons could remove the clot and stabilize Amber.
On July 1, 2012, a difficult and harrowing six weeks later, Amber held her daughter in her arms for the very first time. Amber was lucky. She had survived. With time and hard work, she has overcome many physical limitations, but since the stroke, her life has never been the same, and neither have the lives of her family.
Stories like the Scotts’ are becoming increasingly common in the U.S. prompting many in public health to declare that we are in the midst of a maternal morbidity and mortality epidemic. The numbers back that up; while maternal mortality rates have declined in poorer countries like Romania and Iran, the Centers for Disease Control (CDC) report that the maternal death rate in the U.S. has more than doubled since 1987.
William M. Callaghan, M.D., M.P.H. — Chief of the Maternal and Infant Health Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention — told the Physician-Patient Alliance for Health and Safety that this trend may actually be under-reported; “These statistics may represent a conservative estimate of the problem. Why? Not all pregnancy-related deaths are accurately identified and reported. Hence, pregnancy-related deaths identified at the national level likely under count the true number.”
According to a CDC study, the leading causes of maternal death are: hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease).
When she faced her crisis, Amber Scott had actually had a brush with the leading cause of maternal death in the United States — and also, it turns out, in developing countries — embolic disease, most often due to a venous thromboembolism (VTE.) These events are often unpredictable and fatal, and can leave survivors with long-term physical and cognitive disabilities. Women are nearly five times more likely to develop a deep vein thrombosis (DVT) when pregnant compared to when they are not pregnant. As maternal age for first pregnancy continues increasing, so does the risk of developing a life-threatening an embolism. Suffering a venous thromboembolism event can be particularly devastating to the family that is anticipating the joyous arrival of a baby.
Congress knows that we’re facing a crisis. Two years after its bipartisan introduction, HR 1318 was signed into law by the President on December 21st of last year. Known as The Preventing Maternal Deaths Act, the bill was passed unanimously by both the House of Representatives and the Senate. The new law establishes and supports Maternal Mortality Review Committees at the state level and provides $12 million each year in new funds for each state for the next five years. It’s a positive step, but really only a recognition by the government that this issue needs to be addressed nationally.
When addressing the underlying causes of maternal mortality, clinicians and safety advocates need to work together to implement concrete actions. In that spirit of collaboration, the Physician-Patient Alliance for Health & Safety,the Institute for Healthcare Improvement, and the National Perinatal Association developed OB VTE Safety Recommendations with the advice and counsel of a panel of experts. OB VTE Safety Recommendations provide four concise steps:
● Assess patients for VTE risk with an easy to use automated scoring system
● Provide the recommended prophylaxis regimen, depending on whether the mother is antepartum or postpartum.
● Reassesses the patient every 24 hours or upon the occurrence of a significant event, like surgery.
● Ensures that the mother is provided appropriate VTE prevention education upon hospital discharge.
These recommendations focus on prevention measures that can easily be adopted and used by healthcare facilities and professional to prevent VTE and help ensure that delivering mothers go home safely with their babies.
In addition to health care professionals, pregnant mothers and their partners need to understand the risks of VTE. For example, pregnancy and delivery by cesarean section brings a nearly doubled risk of VTE. They should also be aware of the risk of VTE only only prior to delivery, but continued risk upon discharge and up to six weeks postpartum.
Now that the Preventing Maternal Deaths Act has been signed into law, we must prioritize the safety and health of pregnant women. Protocols have already been developed for maternal hemorrhage and pre-eclampsia and are in use in hospitals across the country. In order to reverse increasing maternal mortality, venous thromboembolism — the leading medical cause of maternal death in pregnancy — warrants our attention. Prioritizing venous thromboembolism will help lower maternal morbidity and mortality.
And, to further ensure that this message is heard, the Scotts are sharing their story. They hope to increase awareness about the risk of life-threatening blood clots for other pregnant women, and the need to adopt prevention measures that can save live, and reverse this harmful trend, which seems to put the U.S. in the same category as some of the world’s poorest developing nations.