MATERNAL MORTALITY: NEW MODELS

FOR PREVENTION

Cornelia R. Graves, MD

Medical Director, Perinatal Services, St. Thomas Health

Medical Director, Tennessee Maternal-Fetal Medicine

Professor, University of Tennessee

Nashville, Tennessee

DISCLOSURES

• I have no conflicts to disclose

OBJECTIVES

• At the end of this session, the participant should be able to:

• Identify the patient at risk for maternal complications

• Discuss issues the contribute to disparities

• Implement a management plan to reduce maternal morbidity and complications

DEFINITION OF MATERNAL MORTALITY

• World Health Organization

• The death of a woman whilst pregnant or within 42 days of delivery

or termination of pregnancy, from any cause related to, or

aggravated by pregnancy or its management, but excluding deaths

from incidental or accidental causes.

• Late pregnancy deaths are 43 days up until 1 year.

OTHER WHO DEFINITIONS

• Maternal mortality ratio

• The number of maternal deaths per 100,000 live births.

• Maternal mortality rate

• The number of maternal deaths (direct and indirect) in a given

period per 100,000 women of reproductive age during the same

time period.

PREGNANCY ASSOCIATED AND RELATED VS. UNRELATED

• Pregnancy-related death:

• The death of a woman during pregnancy or within one year of the end of

pregnancy from a pregnancy complication, a chain of events initiated by

pregnancy, or the aggravation of an unrelated condition by the physiologic

effects of pregnancy. (Example: death from eclamptic seizure)

• Pregnancy-associated, but not related death:

• The death of a woman during pregnancy or within one year of the end of

pregnancy from a cause that is not related to pregnancy. (Example: Fatal motor

vehicle accident in an unrestrained pregnant patient)

World Health

Organization, 2015

CDC, 2016

MATERNAL MORTALITY

TENNESSEE MATERNAL MORTALITY

• Tennessee Maternal Mortality

• Review of 2017 Maternal Deaths

• 78 deaths reported

• 85% considered preventable

• 56% occurred >42 days

• Lower educational level associated with 2 fold increase in maternal death

• Racial disparities not demonstrated in risk of maternal death in 2017

Tennessee Department of Health, Division of Family

Health and Wellness, Maternal Mortality Review

Program 2019.

AT FIRST GLANCE….HOWEVER

• Pregnancy related deaths

• Non-Hispanic White-1/100,000

• Non Hispanic Black-2/100,000

• Pregnancy related but not associated

• Non Hispanic white-0.67/100,000

• Non-Hispanic black-0.6/100,0000

WHAT IS DRIVING THE DISPARITIES IN

MATERNAL MORTALITY

• Poor Maternal Health

• Hospital Systems and Access to Care

• Social Determinants of Health

• Social Systems

• Political Agendas

ADDRESS MATERNAL MORBIDITY

• Addresses maternal morbidity

• Failure to control blood pressure

• Failure to diagnose and treat pulmonary edema in

patients with preeclampsia

• Failure to pay attention to vital signs after C-section

• Hemorrhage following C-section

ADDRESSING NEAR MISSES

2

Table 3

INTERSECTION OF MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY

1. ICU admission

2. Invasive ventilation

3. Cardiac Condition

4. Complications of obstetric surgery

5. Postpartum hemorrhage

6. Acute renal failure

7. Cerebrovascular disease

8. Hysterectomy

9. Obstetric shock

10. Obstetric embolism

1. Post partum hemorrhage

2. ICU admission

3. Puerperal sepsis

4. Severe preeclampsia

5. Hysterectomy

6. Curettage with RBC transfusion

7. Eclampsia

8. Cardiac condition

9. Complication of obstetric surgery

10. Invasive ventilation

Joel G. Ray, MD, et al JAMA Netw Open. 2018

Maternal death <42

days post delivery (N=

181)

No Maternal death <42

days post delivery

(N=1,953,762)

US TODAY, JULY 2018

RACE AND ADVERSE PREGNANCY OUTCOMES

Race-

Ethnicity

Adverse Pregnancy Outcome

Any Preterm

birth

Iatrogenic

preterm birth

Spontaneous

Preterm birth

Hypertensive

disorders of

pregnancy

Small for

gestational

age

Non Hispanic

white

464/5,721

(8.1)

185/5,720

(3.2)

274/5,720

(4.8)

764/5,712

(13.4)

490/5,702

(8.6)

Non Hispanic

black

161/1,307

(12.3)76/1,306 (5.8) 83/1,306 (6.4)

218/1,304

(16.7)

223/1,296

(17.2)

Hispanic128/1,586

(8.1)51/1,584 (3.2) 75/1,584 (4.7)

167/1,579

(10.6)

185/1,580

(11.7)

Asian 24/379 (6.3) 8/379 (2.1) 16/379 (4.2) 32/378 (8.5) 62/379 (16.4)

Other 47/477 (9.9) 18/477 (3.8) 29/477 (6.1) 63/476 (13.2) 57/474 (12.0)

Grobman et al Obstet & Gyncecology 2018

RACE AND SEVERE MATERNAL MORBIDITY IN POST-PARTUM READMISSION

• In a study that looked at post-partum admissions, (96,670 white, 47,015 black, and

33,410 Hispanic women).

• Compared with non-Hispanic white women, non-Hispanic black women were:

• More likely to be readmitted.

• Had a 27% increased change of severe maternal morbidity compared to non-Hispanic

white women (95% confidence interval, 10%-22%)

Creanga. Severe maternal morbidity and race. Am J Obstet

Gynecol 2014Aziz, et al. Am J Obstet Gynecol. 2019 2019 Feb 1

ADDRESSING MATERNAL HEALTH

MATERNAL HEALTH

National Center of Health Statistics,

2016

PREGNANCY COMPLICATIONS

SEVERE OBESITY (>120 KG)

• Pregnancy Induced HTN OR 3.00 (2.49 - 3.62)

• Thromboembolism OR 4.13 (1.26 – 13.54)

• Labor Induction OR 2.77 (2.39– 3.21)

• Cesarean Delivery OR 2.46 (2.15 – 2.81)

• Wound Infection OR 4.79 (3.30 – 6.95))

• Anesthesia Complication OR 2.01 (1.33 -3.06)

Robinson Obstet Gynecol 2005

MORTALITY ASSOCIATED WITH

CESAREAN SECTION

• Risk for postpartum death 3.6x higher than with a vaginal delivery

(Deneux-Tharaux, et al. Obstet Gynecol 2006; 108:541-8)

• Associated with prepartum and intrapartum cesarean delivery

• Causes

• Anesthesia

• Puerperal infection

• Venous thromboembolism

ADDRESSING ACUTE COMPLICATIONS

HEMORRHAGE

OBSTETRIC HEMORRHAGE

In the third trimester of pregnancy, blood flow to the uterus is increased to about 600 cc per minute.

Most of this blood flows to the underside of the placenta where it bathes the cotyledons

Injury to the birth canal or uterus or failure of the uterus to contract properly after delivery can have the same hemorrhagic effects.

• Placenta accreta

• Incidence increasing with increased C-section rate

• Data suggest rates as high as 44% with 3 previous C-section

• Provider should keep a high level of suspicion

• PREPARATION IS THE KEY!!

CAUSES OF MATERNAL DEATHS

DUE TO HEMORRHAGE

• Inadequate resources and personnel – for example, home delivery

attempts.

• Failure to prepare for obstetric hemorrhage –for example, no IV

site started on admission.

• Delay in recognition of hemorrhage.

• Delay in treatment of hemorrhage.

• Treatment failures.Haeri S, Dildy DA. Semin Perinatol

2012 Feb;36(1) 48-55

RACIAL AND ETHNIC DISPARITIES IN MATERNAL

MORBIDITY AND OBSTETRIC CARE

Grobman, Obstet Gynecol, 2015

HEMORRHAGE PROTOCOLS

HYPERTENSION

BACKGROUND

• Prevalence of maternal hypertension in the United States is ~7%

• 5.3% of women had pregnancy-related hypertension

• 1.6% of women have chronic hypertension

• Substantial racial/ethnic differences exist

MATERNAL HYPERTENSION RATES

Race/Ethnicity Prevalence percent (%)

Non-Hispanic White 7.17

Non-Hispanic Black 9.92

Native Americans 8.93

Hispanic 6.00

Chinese 2.16

Singh et al, 2018

• Hypertensive disorders have increased 25% since 1987

• Leading driver of maternal morbidity and mortality

• Racial and ethnic disparities in diagnosis, treatment and outcome

• National Longitudinal Study of Adolescent to Adult Health

• 6576 non-pregnant women between the ages of 24-32

• The rate of hypertension in non-Hispanic black women was 6x higher than non Hispanic

white women

• HOWEVER

• Black women

• were less likely to be diagnosed

• Less likely to receive treatment

TREATMENT OF SEVERE HYPERTENSION

A NEW CAUSE OF MATERNAL MORTALITY

STRATEGIES TO IMPROVE MANAGEMENT

• Change perceptions of opioid and substance use disorder by using

common language

• Given the severity of the epidemic, we need to reduce the stigma

associated with this disease

• Develop and offer education to health care providers in caring for

patients with opioid use disorder

• Create better engagement and communication between providers

with the continuum of care and across service areas, including the

justice system

• Resources are often in multiple places.

• Enhance patient and family engagement

NYS Health

Foundation, 2017

ADDRESSING MATERNAL LEVELS OF CARE

HOSPITAL SYSTEMS

LEVELS OF MATERNAL CARE (LOMC)

• NOT about closing small or rural maternity care centers

• Is about role of Level III/IV (regional) Centers to support

education and quality improvement among their referring

facilities

• Is about building a culture of collaboration

PURPOSE FOR DEFINING LOMC

• To introduce uniform designations, with standardized definitions

for levels of maternal care that complementary but distinct from

levels of neonatal care

• To provide consistent guidelines according to level of maternal

care for use in quality improvement and health promotion

• To foster the development and equitable geographic distribution

of full-service maternal care facilities and systems that promote

proactive integration of risk-appropriate antepartum, intrapartum,

and postpartum services.

DEFINITIONSBirth Center

Low-risk w/ uncomplicated singleton term pregnancies, vertex presentation; Expected to have uncomplicated birth

Level I Uncomplicated pregnancies; Can detect, stabilize, and initiate antepartum, intrapartum, or postpartum period until patient can be transferred

Level II Level I facility plus care of appropriate high-risk conditions, both directly admitted and transferred from another facility.

Level III Level II facility plus care of more complex maternal medical conditions, obstetric complications, and fetal conditions

Level IV Level III facility plus onsite medical and surgical care of the most complex maternal conditions and critically ill women and fetuses

ADDRESSING SYSTEMIC RACISM AND SOCIAL DETERMINANTS OF HEALTH

SOCIAL DETERMINANTS OF HEALTH

SOCIOECONOMIC STATUS

• 10,755 women with Medicaid insurance, who gave birth during calendar years 1994-2004.

• Compared to Whites, Hispanic women had lower odds for preterm birth (odds ratio, 0.66; 95%

CI, 0.54-0.80), and African-American women had greater odds for preeclampsia (odds ratio,

1.30; 95% CI, 1.07-1.58) and small-for-gestational-age infants (odds ratio, 1.74; 95% CI, 1.29-

2.36).

• With the use of African-American women as the reference, Hispanic women were less likely

than African-American women to experience any adverse pregnancy event, with the exception

of gestational diabetes mellitus.

Brown, Haywood et al. Am J Obstet Gynecol.2007.

SOCIAL SYSTEMS

CALL TO ACTION

Leaving our towers and walls

WOMEN’S HEALTH PROVIDERS

• We must learn to put aside our prejudices and preferences to

advocate for

• Evidence based women’s health care

• Preconception counseling

• Contraception

• Breastfeeding

• Women’s Rights

• Time off when needed for pregnancy

• Ability to have family without penalty

• Family Rights

• Involvement of partners in the parenting process

• Cultural issues

ADDRESSING LONG TERM OUTCOMES

ADVERSE PREGNANCY OUTCOMES TRANSLATE TO INCREASED LONG-TERM CARDIOVASCULAR

DISEASE

Short term effects

Adverse Pregnancy outcome

Preterm birth

Preeclampsia

Fetal Growth restriction/IUFD

Placental abruption

Gestational diabetes

Long-term effects

Cardiovascular disease

Preterm birth

Preeclampsia

Fetal growth restriction

Placental abruption

Gestational diabetes

Neiger J Clin Med. 2017 Aug; 6(8): 76.

REFERENCES

Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery

and postpartum hospitalizations in the United States. Obstet Gynecol.

2012;120:1029–1036

Hankins GDV, Clark SL, Pacheco LD, O'Keeffe D, D'Alton M, Saade GR. Maternal

mortality, near misses and severe morbidity: lowering rates through designated

levels of maternity care. Obstet Gynecol. 2012;120(4):929–934.

Careanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-

related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5–12.

The Joint Commission. Preventing maternal death. Sentinel Event Alert. 2010;44.

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert

REFERENCES

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels

and causes of maternal mortality during 1990-2013: a systematic analysis for the Global

Burden of Disease Study 2013. Lancet. 2014;384:980–1004

Kuklina EV, Avala C, Callaghan WM. Hypertensive disorders and severe morbidity in the

United States. Obstet Gynecol. 2009;113(6):1299–1306

Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the

21st century: causes, prevention, and relationship to caesarean delivery. Am J Obstet

Gynecol. 2008;199(1):91–92

Mackintosh N, Watson K, Rance S, Sandall J. Value of a modified early obstetric warning

system (MEOWS) in managing maternal complications in the peripartum period: an

ethnographic study. BMJ Qual Saf. 2014;23:26–34