By: Bill Frist, M.D.
This piece is coauthored by Saketh R. Guntupalli, MD, FACOG, FACS. Dr. Guntupalli is assistant professor of gynecologic oncology at University of Colorado School of Medicine, Denver.
This past year, the United States received the dubious distinction of being one of only 7 countries in the world, including Somalia and Afghanistan, which have seen an increase in maternal mortality.
While countries with far fewer resources such as India and Brazil have made great strides to decrease the number of women who die each year as a result of pregnancy, our nation has more than doubled its rate of maternal mortality in the last twenty-five years (28 maternal deaths per 100,000 births in 2013, up from 12 in 1990). Since 2005, it has increased more than 20%. According to the World Health Organization (WHO), as many as half of these maternal deaths are preventable. This begs the question: How can we lead the world in cutting-edge health innovation and medical discoveries, yet fall behind in this telling public health metric?
The reasons for the increase are complex.
The first is tied to our nation’s leading public health problem: obesity. While traditional causes of maternal mortality such as hemorrhage and eclampsia have remained relatively flat, obesity-related illnesses such as hypertension, diabetes, and heart disease have increased the risk associated with pregnancy, and led to labor complications, higher-risk surgical procedures, and in-utero fetal death. As our nation’s obesity rate has skyrocketed, so has our maternal death rate. And underserved, low-income, and inner-city communities—which tend to have higher obesity rates—have been hardest hit. The death rate for African-American women in pregnancy is nearly four times that of white women—even after correcting for differences in other medical conditions.
We must modify our approach to recognize the health of the woman prior to conception is just as important, if not more important, than health during pregnancy. Women who are uninsured and haven’t benefitted from primary care services are three to four times more likely to die of pregnancy-related complications than those who have insurance coverage. While Medicaid provides emergency coverage for uninsured pregnant women, this can take time to go into effect in some states, and often doesn’t last long after birth. Many deaths occur in the post-delivery period after the expiration of emergency Medicaid benefits. While the WHO defines maternal mortality as the death of a woman during pregnancy or within 42 days of birth, miscarriage or termination of pregnancy, studies have found mortality is still “significantly elevated” in the three months following pregnancy. Because many post-partum deaths result from diseases such as hypertension and other chronic medical conditions, the loss of coverage can substantially increase the risk for death. In addition to further expanding coverage for our nation’s uninsured, women should receive emergency coverage for a longer post-partum period to decrease rates of maternal mortality and better offer their children the care that they deserve.
Another growing issue that must be better addressed prior to pregnancy is the rising rate of opioid abuse, which has increased tremendously among all demographic groups in the last decade. Pregnant women are no exception, seeing a 127% increase in opioid use from 1998 to 2011, which translates into significant risk for maternal death. This also increases the risk for neonatal abstinence syndrome (NAS) or withdrawal of the newborn from narcotics, which can cause long term cognitive and developmental delays in children. Connecting these women to support services in the community through a coordinated care approach—which is increasingly covered under value-based models of reimbursement—can help them detox and get off opiates for the duration of their pregnancy.
Lastly, federal and state funding for maternal health must be a priority, and policies must be enacted to ensure our expecting mothers get the best possible care. This year, Texas achieved the sad distinction of being one of the most dangerous places in the industrialized world for a woman to have a baby. Like many public health challenges, the causes are multifactorial. The state’s decision not to expand Medicaid, significant cuts in funding to women’s health clinics, and shortage of substance abuse treatment resources and mental health coverage likely all played a role.
Other nations have put in place frameworks to improve care for high-risk pregnancies. Since 1990, the global maternal mortality rate fell by almost half while ours doubled. A 2010 study published in The Lancet, which looked at international maternal mortality data over three decades, found over 180,000 fewer maternal deaths annually in 2008 compared to 1980. This significant progress is attributed to varying factors including higher income (translating into better nutrition and healthcare), better education access for women, increase in health providers, and access to antiretrovirals in areas with high rates of HIV/AIDS. Improved family planning and healthy timing and spacing of pregnancies also played a role, something Nashville-based humanitarian organization Hope Through Healing Hands has helped advocate with support from the Bill and Melinda Gates Foundation.
In Europe, countries such as Denmark, the U.K. and the Netherlands have adopted national hospital guidelines for high-risk pregnancies—an area where the U.S. lags behind. While national bodies such as the American Congress of Obstetricians and Gynecologists publish guidelines for managing many disorders in pregnancy, hospitals are not required to adopt them. Therefore we have “patchwork” in the U.S. of inconsistent management particularly for high-risk pregnancies. National standards for hospitals should be adopted to ensure that women around the country with similar problems receive a baseline of care that is validated by experts. Additionally, a national database of maternal deaths should be implemented to best observe trends and adopt needed changes.
For the small but increasing number of pregnant women today experiencing deadly complications, it reminds us that pregnancy is not without risks and should be managed under the care of a trained provider. Setting the above standards, in addition to establishing a new approach to women’s health that focuses on the social determinants prior to pregnancy, will be vital to reducing maternal mortality. The U.S. should be the safest place in the world to have a child, but we have work to do to make that goal a reality.
