Why are maternal mortality rates on the rise?

Mark W TomlinsonMark Tomlinson, M.D., regional medical director, Obstetric Services, Providence – Oregon

One of the great successes resulting from universal prenatal care is the dramatic decrease in maternal mortality. A century ago, death resulting from complications associated with pregnancy and childbirth was a relatively common event. Nearly 1 out of every 100 women died. By 1950, maternal mortality had dropped to less than 1 in 1,000 women and by 1980 to less than 1 in 10,000 (See Figure 1 below).

Alarming trend in maternal mortality

Unfortunately, during the last four decades the trend is reversing with maternal mortality rates increasing, from the low of 7.2 per 100,000 live births to 17.3 in 2013 (Figure 2). The most common conditions leading to this increase in maternal mortality include cardiovascular disease, underlying chronic disease, infection, hemorrhage, pulmonary embolism and hypertensive disorders. A recent NPR investigation highlighted the problem with the tragic story of a healthy professional woman who died shortly after giving birth, pointing out that the problem doesn’t affect just the underserved.

There are a number of reasons for the increase, including higher obesity rates and more new moms who delay childbearing until they’re older – both of which are associated with increased medical complications before and during pregnancy. In addition, there is more complete ascertainment of deaths associated with pregnancy.

U.S. maternal mortality trend is especially troubling

Regardless of why, not only does the United States have the highest rate of maternal mortality among developed countries, it’s the only one where the rate is rising.  Even more concerning is that many mortality reviews report that up to 90 percent or more of these deaths are at least potentially preventable. Not surprisingly, there are multiple factors identified in which appropriate intervention may have improved the outcome, including those related to the birth facility, patients and providers. The overwhelming majority of cases involve factors attributed to the providers, the most common being delayed response and ineffective care. One of the challenges of addressing maternal mortality is that, despite the recent upward trend, it remains a very rare event with many facilities likely to experience a maternal death only every few years. Many clinicians will go through their entire career and fortunately never have to endure such an experience. Another challenge associated with a rare event such as this is the limited amount of accessible data that would help us better understand contributing factors.

What Providence is doing to improve outcomes

Providence Women and Children’s Services in Oregon (led by John V. McDonald, M.D., and Kristine Larison) has been actively engaged for many years in a variety of efforts to improve outcomes for our mothers and their infants. This is illustrated by our work throughout Providence in Oregon as a high reliability organization and our culture of safety, which includes daily safety huddles with doctors and other members of the clinical care team. This important work focuses on ensuring that our patients receive safe, high quality and compassionate care from Providence. Nearly 10,000 babies are born every year at Providence in Oregon.

The Women and Children’s Services team emphasizes evidence-based standardization of care, accurate measurement of clinically relevant processes and outcomes, and a reliable mechanism to adopt and share practice changes.

At the heart of continually improving outcomes for new moms and their babies is a commitment to bringing together multidisciplinary work teams to solve problems and create effective regional solutions that provide the best care for our patients. We created three key leadership positions to oversee this work: regional medical director of Obstetric Services, regional medical director of Newborn Services, and director of Perinatal Services. We also created two key regional committees: the multidisciplinary regional Obstetrics and Newborn Quality Committee (REG OB/NB) and the Maternity Operations Management (MOMS) Committee, which consists of nursing managers from throughout Providence in Oregon.

The REG OB/NB committee consists of representatives from the professional staff in obstetrics, midwifery, family medicine, pediatrics; physician leadership; nursing leadership; pharmacy; anesthesia; and pathology from across Providence in Oregon. The group reports to the Oregon Medical Executive Committee (OMEC). Responsibilities include measuring clinical performance, establishing regional care policies, developing clinical standards, acting as a resource to the professional staff credentialing committee, and setting the quality agenda.

A foundation for the quality agenda of both REG OB/NB and MOMS is that standardized care and accurate measurement of clinically relevant processes and outcomes contribute to high quality care. Long before Epic was implemented, we created evidence-based standard provider order sets and nursing policies in maternity and newborn care at all of our hospitals. We also have emphasized a culture of teamwork to support an understanding and commitment to high-quality and safe care.

Partnering with national quality teams

Providence and our patients also have benefited from our participation in many local, regional and national collaborations. One of the earliest and most sustained collaborations has been with the Council of Women’s and Infant’s Specialty Hospitals (CWISH), which consists of several of the largest hospitals in the U.S. providing obstetric and neonatal care. This group involves administrative, physician and nursing leadership that shares and analyzes data from a large population.

As part of this group, Providence authored and provided stewardship for one of the National Quality Foundation quality metrics until the Joint Commission later adopted it as one of the five perinatal core measures and assumed responsibility. As a result of this effort, we have representation on the Joint Commission Perinatal Technical Advisory Panel. Providence in Oregon is an active participant and has provided leadership across our health system’s clinical performance groups to address management of obstetric hemorrhage and hypertension in pregnancy – two  of the most common causes of maternal morbidity and mortality.

Increasing sophistication of data gathering and analysis is beginning to allow us to measure the efficiency and efficacy of care. The program also provides leadership – along with OHSU, Legacy Health, and the March of Dimes – for the Oregon Perinatal Collaborative (OPC). One of the group’s current efforts is advocating for a statewide maternal mortality review committee with representatives from the Oregon Health Authority. The OPC also is teaming up with the California Maternal Quality Care Committee (CMQCC) and the Washington State Hospital Association (WSHA) to join the individual state databases using common definitions and allowing much broader benchmarking. Providence also is participating as a health system with our hospitals in Alaska and Montana.

Providence Women and Children’s Services has a proud history and commitment to high-quality, safe care of our patients. It is through these efforts, along with an emphasis on awareness and early intervention aimed at preventing maternal morbidity, that we will see a downward trend in maternal mortality.

U.S. Maternal Mortality Rate

Figure 1 

MortalityRateGraph617

Figure 2 

MortalityRateGraph2617

*CDC Pregnancy Mortality Surveillance System; accessed May 2017