Maternal

Mortality :Closing the

Disparity Gap

Haywood L. Brown, MD
Professor Obstetrics Gynecology
Duke University
President ACOG 2017-2018
Maternal Mortality Rate: Rising in the U.S.

Source: MacDorman. Recent Increases in US Maternal Mortality.

Obstetrics and Gynecology. 2016
Pregnancy Related Maternal Mortality Ratio

Year # All white black other

1987-90 1453 9.1 6.2 22.9 9.8

1991-97 3201 11.5 7.9 29.6 11.1

1998-05 4693 14.5 10.2 37.5 13.4

** Risk 3-4 fold higher for black women

Callaghan. Sem Perinatol 2012;36:2-6
Maternal Mortality Among Black Women

Source: Centers for Disease Control and Prevention

Graphic: Tiffany Farrant-Gonzalez, Scientific American
 Cesarean Delivery
Morbidity/Mortality
Deneaux-Tharaux et al Obstet Gynecol
Risk of postpartum maternal death was 3.6 times higher after
cesarean than vaginal delivery (odds ratio 2.64, 2.15-6.19)
Complications of anesthesia, puerperal infection,
thromoboembolism as leading causes of death.
Canadian Institute for Health Informations
Discharge Abstract Database compared 46,766
women with planned cesarean to 2,292,420
women with planned vaginal birth
overall severe morbidity of 27.3/1000 compared to 9.0/1000 for
cesarean vs. vaginal delivery, respectively.
Planned cesarean delivery had increased risk for postpartum cardiac
arrest (OR 5.1, 95% CI 4.1-6.3
Cesarean delivery morbidity
Lydon-Rochelle et al JAMA, 2000;283:2411-2416)
women with cesarean delivery RR of 1.8 (95% CI, 1.6-1.9)
for re-hospitalization within 60 days after adjusting for
maternal age
Reasons for readmission included
uterine infection
obstetrical surgical wound complications,
cardiopulmonary
thromboembolic conditions.
Understanding Racial Disparities:
The Big Picture

Source: Elisabeth Howell, MD, MPP. Reduction of

Peripartum Disparities Bundle. 2017.
Severe Maternal Morbidity: Near Misses
For every maternal death, over 100 women experience
severe maternal morbidity:
The physical and psychological conditions that result
from, or are aggravated by, pregnancy and have an
adverse effect on the health of a woman.
Affects 60,000 women annually in the U.S.

Rates are rising: nearly doubled over the last decade.

Racial and Ethnic disparities exist.

 Alliance for Innovation on Maternal Health
(AIM)
National alliance of clinicians, public health
officials, hospital administration, patient
safety organizations, and advocates
working to:
Reduce maternal mortality by 1,000
deaths by 2018
Reduce severe maternal morbidity
Offers assistance to states and hospitals to assess culture
of safety in maternity care and employ resources to
improve outcomes.

Creates condition-specific bundles evidence based

action steps endorsed by major maternity care provider
organizations to guide the best care.
Michigan AIM
Alliance for Innovation on Maternal
Health (AIM)

OB Safety Bundles
Severe Hypertension
Reducing Disparities in Maternity Care
in Pregnancy

Maternal Mental Health Safe Reduction of Primary Cesarean Births

Patient, Family and Staff Support Obstetric Hemorrhage

 Reducing Peripartum Racial Disparities
Bundle
Consider racial/ethnic disparities broadly

Acknowledge complex causes: social determinants, behaviors,

quality of care

Focus on quality of care, modifiable factors

Important attributes of the bundle:

Actionable
Evidence-based
Feasible
Impactful
U.S. Maternal and Infant Mortality
U.S. has higher maternal and infant
mortality rates than other developed
countries:

Ranks 25th in infant mortality

Ranks > 21th in maternal mortality
Maternal Mortality Historical Interventions
Between 1930-1950 maternal mortality decreased from 600/100,000 to
40/100,000 in US
1930 ABOG incorporated
1951, ACOG founded
1938-1948, shift from home to hospital deliveries
Hospital deliveries increased from 55% to 90%
Shift slower in rural areas and the South
Maternal mortality decreased by 71%

Legalized abortion in 1960s contributed to 89% decline in death from septic

illegal abortions during 1950-1973

1988 CDC began Maternal Mortality Surveillance

Maternal Mortality Callaghan (O&G 2010)
Maternal Mortality

Overall global maternal mortality is 430

per 100,000 live births
North America: 11 per 100,000
West Africa: 1,020 per 100,000
 Causes of Maternal Mortality in US
2001 (Clark et al)
Causes of Death %
Complications of preeclampsia 15
Amniotic Fluid Embolism 14
Obstetric hemorrhage 11
Pulmonary embolism 11
Cardiac disease 11
Nonobstetric infection 7
accident/suicide 7
Obstetric infection 7
Medication Error or reaction 5
Ectopic 1
Other 11
Postpartum Hemorrhage
 Recent US Data on PPH
(based on ICD9 codes from nationwide inpatient sample)
PPH implicated in 2.9% all deliveries
Uterine atony present in 79% of cases
PPH associated with 19.1% all in-hospital deaths after
delivery
Overall rate of PPH 27.5% from 1995-2004 due to
incidence atony

Bateman et al Anesth Analg 2010; 110:1368-73

22
Postpartum Hemorrhage

Management
Treatment of Obstetrical Bleeding
Evacuation of the uterus
Delivery the placenta, or
Removal of the placenta manually
Stimulation of the uterus to contract (uterotonics,
massage)
myometrial compression of the vasculature
Balloon tamponade or compression sutures if
necessary
If uterus is unresponsive, devascularization
Finally hysterectomy
 Active Versus Expectant
Management
Management of Third Blood Loss * Blood loss *
Stage of Labor > 500 mls > 1000 mls

Expectant (n=3126) 13.6% 2.6%

Active (n=3158)** 5.2% 1.7%

* Clinical estimation generally thought **Oxytocin, ergometrine

to be underestimates by about 34-50% or both IM/IV

Prendiville, Elbourne, McDonald, The Cochrane Library issue 3, 2003

Obstetric Emergencies
Preeclampsia/Eclampsia
Management of Preeclampsia
with Severe Features
34 wk or <23 wk
Delivery
< 34 wk
Individualize
< 34 wk
Individualize
Counsel

Fetal /
Maternal Newborn
Risk Benefit
Postpartum HTN-Preeclampsia
Recommendations
All women with hypertensive disorders

BP check at 3 days ( hospital, office or home)

BP check again at 5-7 days
Daily Sxs. of preeclampsia
No non-steroidal anti-inflammatory agents
Impacts platelet function

All women

Education about signs / symptoms

Symptoms to report
Office and L&D phone #
 Maternal Morality in the US
HCA examination of Maternal Death among 1.5 million
birth in 124 hospitals over 6 years (Clark SL et al. Am J
Obstet Gynecol 2008)
Most common preventable errors
Failure to adequately control BP in hypertensive women
Failure to adequately diagnose and treat pulmonary edema in
women with preclampsia
Failure to pay attention of vital signs following cesarean
Hemorrhage following cesarean delivery
 Rates of VTE (DVT + PE)
4,000
Per 100,000 woman-years

3,000 DVTor PE

2,000

1,000

0
1st 2nd 3rd Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6
Trim Trim Trim PP PP PP PP PP PP

* Heit et al, Ann Intern Med, 2005

Obstetric emergencies

Sepsis
Sepsis Bundle
Obstetric Morbidity
Pregnancy in Women > 45
Rural vs Urban Care and Maternal
Morbidity
Lisonkova et al. CMAJ 2016
Results
British Columbia, Canada comparing mortality and severe
morbidity
death and severe maternal morbidity ( OR-1.15, Ci 1.03-1.28) in
rural vs urban
Rural had Higher rate of eclampsia (OR-2.70, Ci 1.79-4.08),
embolism (OR-2.16, CI 1.14-4.07), uterine rupture (OR-1.96, CI
1.42-2.72) than urban women
Infant in rural more likely to have severe neonatal morbidity (OR-
1.14, CI 1.10-1.19
Conclusions
Providers in rural areas need to be aware of potential morbidities
and mortality risk.
A collaboration between
The American Congress of
Obstetricians and
Gynecologists, Society for
Maternal-Fetal Medicine,
Centers for Disease Control,
Arizona Perinatal Trust, and
Prevention, and National
Perinatal Information Center.
Levels of Maternal Care Program
Objectives for 2016-2017

1. Facilities understand their maternal care capabilities

consistent with ACOG/SMFM Levels of Maternal Care
guidelines.
2. Translation of risk appropriate care policies that are
consistent with ACOG/SMFM Levels of Maternal Care.
3. Formalized system support where women deliver at
facilities appropriate for their risk.
Levels of Maternal Care Objectives
for 2016-2017
How will we accomplish these objectives? (continued)

2. Pilot studies
CDC has been testing LOCATe since 2012
On Site verification assessments (target: 3 states, 12
facilities)
3. Validate Assessment Instruments
CDC LOCATe (facility self-assessment)
ACOG/SMFM On-Site Assessment
4. Test and finalize site review and verification process
5. Use formative assessment process to improve program
ACOG Presidential Initiatives
Avera Health e-Care
E- emergency
E- ICU
E - Obstetrics
Psychiatry/Mental Health
Telehealth
Periscope Program (Milwaukee, WI)
Resource information
Support
Psychotherapy
22 year old with anxiety/depression stops taking
medication when she learns of pregnancy now with
increasing anxiety seen by midwife in public health
clinic
Next step (tele consult)
Maternal Mortality

Opiate overdose
Maternal Mortality NC
Presidential Initiatives
Pregnancy and Long Term Health
Pregnancy and Long Term Health
Cardiovascular risk reduction should be addressed annually through blood pressure
monitoring, body mass index calculation, and lifestyle modification involving exercise and
dietary instruction. Lipid and glucose measurements should be measured every five years
PARITY
For women with more than five pregnancies, the CVD increases by 60%

BIRTHWEIGHT
Low birthweight doubles the risk of cardiovascular disease

PRETERM DELIVERY
Preterm delivery doubles the risk of cardiovascular disease

OBESITY
Two fold risk of cardiovascular disease

GESTATIONAL DIABETES
Seven-fold risk of diabetes later in life and seventy percent increased risk of cardiovascular disease
Recommend: Repeat screening for diabetes, at a minimum interval of every three years and more
frequently if pregnancy is considered

HYPERTENSION
Twice the risk of cardiovascular disease
Recommend: yearly assessment of blood pressure, lipids, blood glucose, and body mass index.
Medications to consider while breastfeeding: Methydopa, Labetalol, captopril and calcium channel
blocker
In South Asia
22% of worlds population
50% of all maternal deaths
Maternal Mortality Rates in South Asia
 Heart Disease 32
Respiratory Disease 22
Medical other 10
Hypertensive Disorders 10
Obstetric Haemorrhage 9
Amniotic fluid embolism 9
Liver disease 5
Suicide 4
Sepsis - Reproductive 4
Septic Abortion 3
Anaesthesia Complications 3
Other 2
DVT 2
* Number of deaths Anaphylaxis 2
Surgical Mishap 1
Sepsis - other 1
0 5 10 15 20 25 30 35

Cause of Death - 2013

Almost 25% of maternal deaths are due to un met
need for contraception

Main barriers facing promotion of FP services

Certain religious groups not practicing FP methods
instill fear into other ethnic groups with regard to a
possible ethnic imbalance in the future
Lack of facilities in government institutions for
sterilizations
Resistance to introduction of newer contraceptive
methods such as PPIUD
Maternal Mortality Review Committees
(MMRCs)
State MMRCs are a key piece of the puzzle:
Interdisciplinary groups of local ob-gyns, nurses, social
workers, and other health care professionals to review
individual maternal deaths and recommend solutions to
prevent these tragic events in the future.

Every state should have an MMRC.

17 states have not yet established an MMRC.

In order for a state to join the AIM program, it must have or be
in the process of developing an MMRC.
Cosponsor H.R. 1318, Preventing
Maternal Deaths Act!
Sponsors:
Representatives John Conyers (D-MI), Jaime Herrera Beutler (R-WA),
Diana DeGette (D-CO), and Ryan Costello (R-PA).
What the bill does:
Authorizes the CDC to assist states to create or expand MMRCs.
Collect consistent data to help our Nation understand what causes
maternal mortality.
Recommend locally relevant strategies for State Departments of
Public Health to prevent pregnancy deaths and reduce disparities.
Report to Congress on maternal mortality data to track successes
and setbacks.
HHS to research disparities in maternal health outcomes.
Senate Companion Bill: S. 1112, the Maternal Health
Accountability Act, sponsored by Senators Heidi Heitkamp (D-
ND) and Shelley Moore Capito (R-WV).
CDC Maternal Mortality
Review Action Cycle
Identification of
cases

Data Collection
Evaluation

Data Review
Action and analysis
Global Maternal Mortality