Hospitals seek to address troubling increase in maternal mortality across US

Feb. 26-- Feb. 26--Bringing a life into the world can be deadly.

A woman giving birth in the U.S. in 2014 was 50 percent more likely to suffer a pregnancy-related death than her mother was, according to U.S. Centers for Disease Control and Prevention data.

The numbers: 7.2 maternal deaths per 100,000 live births in 1987; 18.0 deaths in 2014.

Although the rate of maternal mortality is far higher in many lesser developed countries, it's higher in the U.S. than in other developed countries, U.S. Reps. Jaime Herrera Beutler, R- Wash., and Raja Krishnamoorthi, D-Ill., wrote in The Hill last July. The U.S. ranks only 47th best in the world in terms of maternal mortality, they wrote, and it is the only industrialized nation in which the rate has been rising in recent years.

Why is that?

"We don't really know why our rate is so much higher than other countries," said Dr. Claire Mallof, an OBGYN at St. Luke's hospital in Duluth.

But Mallof, an OBGYN for 11 years and for five years at St. Luke's, points to the bigger picture. If it's more risky for a woman to give birth today in the U.S. than it was for her mother, it's much safer than it was for her great-great-grandmother.

"We're better off than we were a hundred years ago," she said. "So in 1900, it was 850 deaths per 100,000 births. Then it was down to 7.4 in the '80s. Now it's doubled. ... So from a relative standpoint, we've come a long way, actually."

There's also a surprising amount of discrepancy in how the data are defined. Dr. Neel Shah, an OBGYN in Boston who teaches at Harvard, posted a Harvard Health Blog in October prompted by the near-death maternity experiences of celebrities Serena Williams and Beyonce. He defined maternal mortality as deaths occurring to complications of pregnancy or childbirth, or within six weeks after giving birth.

But Mallof said the CDC expands the definition to include the mom's death up to one year of giving birth. "You could have a car accident," she said. "And that would still count because you've given birth within one year."

California standards

In any event, maternal mortality is uncommon. Lori Swanson, birth center manager at St. Luke's, said there hasn't been a single instance in her eight years there. Last year, 865 babies were born at St. Luke's.

Still, the possibility is taken seriously.

"Maternal mortality is not common, thankfully, but you want to never have a preventable death occur," Mallof said.

Among U.S. states, California has led the way in implementing steps to reduce maternal mortality, Swanson said. The state's maternal mortality rate declined by 55 percent between 2006 and 2013, reports the California Maternal Quality Care Collaborative, an organization developed by the state and the Stanford University medical school to create standards to improve safety.

California's standards were a model, Swanson said, when the Minnesota Hospital Association developed its own "perinatal roadmap," a document giving birthing hospitals guidance in best practices for delivery as well as prenatal and postnatal care.

Dr. Rahul Koranne, chief medical officer for the hospital association, said the roadmap came from a variety of sources and was revamped over the past 18 months. That the issue is taken seriously is supported by the fact that 64 Minnesota hospitals -- 75 percent of those providing labor and delivery services -- are participating.

The key issues

Swanson, Koranne and Mallof all said that two of the key issues being addressed are bleeding and high blood pressure.

The amount of blood loss during childbirth now is measured precisely, as opposed to being eyeballed in the past, Mallof said.

St. Luke's also has two "postpartum hemorrhage carts" stocked and ready to go in the birth center so that the team attending a birth can respond immediately to excessive blood loss, Swanson said.

Also, pregnant women are screened during their first visit, again in 30 weeks and again on admission to determine if they are a hemorrhage risk, she said. If so, additional precautions are taken.

New procedures also have been implemented to manage hypertension, Mallof said.

Of the hospitals participating in the roadmap, 84 percent "have a process to provide immediate access to medication required any time a mom has high blood pressure," Koranne said.

After care

At St. Luke's, drills are staged frequently, Mallof said, so everyone knows what to do if an emergency occurs during labor. "The way you get good at those ... occurrences that only happen very infrequently is that you practice for them."

Although the term maternal mortality probably evokes an image of a medical emergency during childbirth, very few deaths actually occur then, Shah noted in his blog.

Other potential cause of maternal mortality, Mallof said, are postpartum depression and domestic abuse, which has been shown statistically to increase during pregnancy.

High blood pressure following release from the hospital might go unnoticed, she said. The mother might think she's experiencing a headache because she's tired, but it might actually be an indication of hypertension.

To limit after-birth risks, St. Luke's implemented a program that Mallof said she hasn't seen in any other hospital. Two days after the mom and baby are discharged from the hospital, they come back to the clinic for a visit.

"They are checked for their vital signs, monitoring their blood pressure, their heart rate, looking for fevers," she said.

Six out of 10 instances of maternal mortality are preventable, according to a 2018 report from the CDC Foundation. But that means no matter what steps are taken, on infrequent occasions the joy of childbirth will turn into tragedy.

Mallof was involved in one such tragedy, before she came to St. Luke's. Years later, the hurt lingers.

"It still is hard," Mallof said. "We do everything we can in medicine to try to prevent harm to our patients. And sometimes there's not enough medicine in the world to catch up with something that's happening."

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