It was less than a year ago that Atul Gawande spoke at the American College of Obstetricians and Gynecologists’ annual conference in Nashville, Tennessee. As a medical student and voracious consumer of Gawande’s books I listened attentively, breath held, waiting for him to show us the way to improving maternal health and reducing the embarrassingly high maternal mortality rates in the U.S. quoted by the CDC. They more than doubled “from 7.2 deaths per 100,000 live births in 1987 to 16.9 deaths per 100,000 live births in 2016.” He focused on the need to curb ineptitude and the “cowboy” attitude in ob/gyn.
Now, almost a year later I listen attentively at the Society for Maternal Fetal Medicine’s annual meeting. This is a gathering of all those interested in “High Risk Obstetrics.” So, what have we come up with to curb the rising rates of maternal mortality in the US?
Researchers at Baylor utilized the CDC data to demonstrate a “significant and progressive decline in inpatient, outpatient and emergency department deaths.” They cite a reduction of about 20% from 2003-2016. Essentially, their point is that the problem lies with care that occurs outside the clinical setting. Perhaps this has something to do with the increasing rate of home births. Their conclusion, “future progress ... will require successfully addressing social, cultural and financial issues beyond the direct control of the medical community (1).”
If you don’t find that answer satisfying, you may find another argument more compelling: Perhaps we’re not getting all the data. Some states are now notorious for their inability to accurately track maternal death rates. The team at Rochester Medical Center have enlisted the help of a data analysis company, TriNetX, to gather up to 78% more cases of pregnancy-associated death (2). But is it realistic that we all hire TriNetX so we can successfully analyze data that is vital for the health of women of reproductive age in our country?
The researchers at Johns Hopkins insist that the solution to climbing maternal mortality rates is “earlier referral to risk-appropriate maternal care” centers (3). Though it may be true, this mentality appears tragically uncoupled from public health and fails to account for the lack of specialists in resource poor regions. Maybe their next project will involve the provision of discounted bus tickets and telemedicine appointments for patients in need.
Yale looked inward with admirable introspection at cases of severe maternal morbidity (hoping to reduce cases of mortality) at their own institution. They determined that the majority of cases fell into three categories: obstetrical hemorrhage, placental hemorrhage, and non-uterine infections. Cardiovascular disease (CVD) is conspicuously absent. Of all the cases reviewed, two thirds were thought to maybe be preventable while one third certainly was. “Diagnosis” was the largest factor contributing to maternal morbidity. The implication here is that maybe we should be buffing up on our diagnostic skills.
But will we ever get fast enough at diagnosing postpartum hemorrhage? The race is on to take clinician ineptitude out of the equation with machine learning and artificial intelligence (4, 5). Washington University St. Louis’ neural network correctly (and more importantly rapidly) identified 51 out of 89 patients requiring transfusion, while only proposing to transfuse 3 unnecessarily. Only time will tell if Epic and Cerner are listening. Or maybe Athenahealth? Meanwhile, research from Stony Brook suggests we may all be able to begin using physiologic levels of pitocin: 0.3-0.6U/min versus the typical 4U/min (6). They claim their patients lost less blood with this method, but we’ll have to wait for the paper to see how they controlled for dilutional changes. Of note, an alarming multi-center study suggests that IUDs, both copper and hormonal, may predispose women to abnormal placentation and resultant postpartum hemorrhage (7). If this is the case, it’s important to ask why in Europe, where IUDs are even more popular, the maternal mortality rates are still so much better.
The researchers at Rutgers also dove into the CDC’s data, looking at how postpartum hemorrhage related mortality in the US “has remained stagnant over the last 40 years” (8). They attribute our lack of improvement to factors like “obesity and uterine overdistention”. The suggestion here is that the crisis in maternal mortality is likely tied to our frustrating inability as physicians to make a dent in America’s obesity and diabetes epidemics. One thing is certain, Rutgers’ analysis demonstrates that non-hispanic black women bear the largest burden with rates of death due to hemorrhage 3-4 times that of non-hispanic white women. Yet another study found that severe maternal morbidity increased with higher classes of obesity; however racial disparities persisted irrespective of degree of obesity (9). This begs the question: is racism beyond the direct control of the medical community?
A second study using CDC data out of Rutgers demonstrates a steady decline in the number of deaths due to the CDC’s number one cause of maternal mortality: CVD. The maternal mortality ratio (deaths/ 100,000 live births) was 0.47 in 1979 vs. 0.03 in 2017 (10). Despite this, the team at Columbia found that black women have the highest rates of diagnosis of newly acquired cardiac conditions (11). They recommend improved early postpartum surveillance of patients with lupus, hypertension, clots or other severe morbidity at delivery. This is in line with impressive research from Alabama demonstrating that while white women and black women with peripartum cardiomyopathy started out with similar ejection fractions (EFs) fewer black women had myocardial recovery and they had lower EFs in subsequent pregnancies (12).
For methods for improving our screening for acquired cardiac disease in the antepartum period we can look to UC Irvine and the California CVD Toolkit. UC Irvine found that 30% of women who screened positive (and completed follow up) had CVD (13). The toolkit is from the same California Maternal Quality Care Collaborative (CMQCC) that developed the postpartum hemorrhage toolkit and many others.
Maternal mortality in the US is a complicated issue that will take significant time and effort to resolve. We are making progress in data collection and screening, but further resources need to be directed to preventative interventions and specifically towards interventions aimed at eliminating racism from our healthcare system. Perhaps CMQCC can develop a racism toolkit.
Jen Franks is a resident in Obstetrics and Gynecology at Kern Medical in California. She received her MD/MPH from Keck School of Medicine of USC.