The Silent Epidemic in the United States

MATERNAL MORTALITY RATIO

(maternal deaths per 100,000 live births)

Did you know there is a rarely talked about epidemic in the United States? No, I do not mean the COVID-19 pandemic. The epidemic is that the United States of America is the only developed country where maternal mortality is rising. We see 26.4 maternal deaths per 100,000 live deliveries in the United States, per the World Health Organization; whereas in the other 13 developed countries the international agencies note falling maternal mortality. Worldwide we see a 37% decline in maternal mortality except here in the USA. CDC data gives the USA 17.4 maternal deaths in 2018, 20.1 in 2019, and 23.8 in 2020. In 2020, I was privileged to give a Gallery Talk at the College of Physicians of Philadelphia, the oldest US medical organization. There are new laws and policies that may allow improvement if we adopt them fully.

What is maternal mortality? The simplest definition is the death of a woman while she is pregnant or within 42 days of delivery of infant or infants. That definition used by our Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO) misses late maternal deaths that can occur up to one year after a liveborn infant’s birth. Stillborn deliveries are not factored into this; certainly, psychological and physical support are keys for these ladies. Maternal deaths include those women with ruptured ectopic pregnancy and its associated life-threatening hemorrhage, infections and excessive bleeding associated with miscarriage, and both medically supervised and unsupervised pregnancy termination although infection and excessive bleeding is uncommon with medically supervised pregnancy termination.

Some deaths are directly attributable to pregnancy such as postpartum hemorrhage, pregnancy associated hypertension, infection, and blood clots. Pre-existing heart disease, hypertension, diabetes, and obesity often impact pregnancy negatively if not appropriately cared for. It is estimated 60% of maternal deaths are preventable and yet in the USA maternal mortality is rising when worldwide maternal mortality has declined 37%. Suicide, homicide, substance use disorder and motor vehicle accidents also contribute indirectly to maternal mortality. We need to remember that intimate partner violence begins in pregnancy 25% of the time.

Maternal Mortality Review Committees (MMRC) are present in 49 states (Wyoming has Utah review its data), New York City, Philadelphia, the District of Columbia, and Puerto Rico but are widely different in scope and requirements and frequency of reports and to whom they report. Pennsylvania established its MMRC through Act 24 in 2018 with anesthesiologist, Department of Health member, emergency medical service provider, epidemiologist, medical examiner or coroner, mental health expert, midwife, pathologist, substance use expert, social worker or public health professional, and my favorite, other. Pennsylvania only requires a report every three years. There are no recommendations to correct racial disparities. Only California, Louisiana, Maryland, New Jersey, New York, West Virginia, and New York City require recommendations aimed at racial disparity corrections. Nevada and

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MATERNAL MORTALITY is rising in the u.s.

as it declines elsewhere (deaths per 100,000 live births)

Texas do not conform to standardized CDC system in which to review deaths. If the woman is a non-Hispanic black, she has a 55.3/100,000 maternal mortality rate, 2.9 times her non-Hispanic white counterpart. As concerned professionals and citizens, we must change these statistics. Why are American women dying? The usual culprits of hemorrhage, hypertension, and infection persist but noncommunicable diseases (NCD) now contribute greatly to this unwelcome trend. These diseases include heart disease, hypertension, obesity, thromboembolism (clots in lungs or brain from legs or pelvis), diabetes mellitus, thyroid disorders, mental illness, substance use disorders, stroke, multiple sclerosis, autoimmune disorders, and epilepsy. Pregnancy planning occurs in about 50% of all US pregnancies so chronic or sometimes undiagnosed medical conditions are not addressed, preventing optimization of maternal health preconception. A recent Reuters article cited the decreasing access to health services for women by facilities such as Planned Parenthood and subsequent lack of access to contraceptive services as cause of further increase of maternal mortality and severe morbidity or illness. Ethical practitioners who provide health care to women encourage pregnancy prevention before pregnancy occurs. Religious beliefs regarding an unplanned pregnancy dictate counsel and/or referral to a practitioner whose beliefs respect the patient’s autonomy. Philadelphia recently overtook Chicago but not in a good way. Philadelphia now has the highest maternal death rate of any major US city. Late postpartum deaths in Philadelphia (more than 42 days postpartum) occur in more than 50% of women exceeding the 33% observed in most other regions. If you are black or African-American, you are 10 times more likely to die; black women constitute 75% of maternal deaths in Philadelphia. Educational achievement does not protect black women from death; a black woman with a college education or higher is still 5.2 times more likely to die in the pregnancy or in that first year postpartum. Nationally the highest risk group for death is a black woman age 40 or more. Overall, women age 40 or more in 2020 had a death rate of 107.9 with white women still having the lowest death rate in the white, Hispanic, Asian/Pacific Islander, Native American, and black races in each age group. Older women tend to have more chronic medical conditions in part accounting for their higher mortality and morbidity. In US our mothers are older than most other countries.

Some NCDs related to pregnancy are not always evident in the first 6 weeks postpartum. Fatigue and shortness of breath can be normal but may signal cardiomyopathy, thromboembolism, depression, postpartum thyroiditis, autoimmune disease flare or even the unusually delayed postpartum multiple sclerosis flare or onset. In many states Medicaid is terminated 45-60 days postpartum. Pennsylvania has taken steps to prevent this barrier to care (no insurance) by extending Medicaid coverage for the entire first year postpartum as of April 1, 2022 for the next five years. These funds come from monies in the American Rescue Plan Act. It covers women and their infants who live at 138% poverty level or lower. Medicaid covers 30% of Pennsylvania deliveries, somewhat lower than the 40% nationwide. This will prevent maternal deaths due to substance use disorder who have the medication assisted treatment (MAT) abruptly withdrawn at no later than 60 days. Given the stressors of caring for a newborn (they don’t come with instruction manuals, folks!), her own recovery from delivery, and a now unsatiated craving for the substance, she will often return to her drug dealer seeking relief. What she does not realize is her tolerance has been lowered and using that dose will result in her death.

In 2022, the US Congress passed the Maternal Health Quality Improvement Act as part of the omnibus spending bill. Provision of funds to teach evidence based best practices, approaches that address racial and social disparities in care (yes, it is social drivers of health rather than social determinants of health), and improved access to care in rural areas are achievable goals.

So what are the ways we can decrease maternal mortality? It will be one woman at a time. Optimizing her health preconception is important. We need to empower women to take control of their health by getting an adequate history and education. This includes achieving an ideal body weight months before pregnancy begins, having a healthy diet with fresh fruits and vegetables and adequate intake of iron and vitamin B12. Pure vegan diets often lack iron and B12 in sufficient amounts. Adequate exercise and sleep and being part of a supportive and caring community are important pillars of self care. Work environment and hobbies should be discussed. Tobacco, alcohol and recreational drug usage should be strongly discouraged.

A complete review of medical and surgical history is needed in addition to prior pregnancy history. Postpartum hemorrhage in a prior pregnancy is an indicator of increased risk of repeat bleed. Prior postpartum cardiomyopathy is an ultra-high risk setting.

Medications and supplements should be reviewed as some need to be eliminated or changed to an alternative class. Think angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB), valproic acid, and chemotherapeutics to name some agents you should not expose a developing pregnancy to. Some herbals have been contaminated with heavy metals as there is no regulation of what are deemed supplements and herbals.

Family history is important. Did you know a woman whose mother had preeclampsia has a 25% incidence of the same disorder whereas her partner’s mother having preeclampsia gives her only a 5% risk?

Too often the woman gains excessive weight and yet as practitioners, we do not inform her of her increased risks for elevated blood pressure, blood clots, and diabetes where glucose intolerance develops in one out of six pregnancies. Testing for resolution of gestational diabetes at 6 weeks is not done often enough. It sometimes persists. Some practitioners do not discuss weight for fear of patient or family backlash. Some cultures really believe the woman needs to eat for two when caloric increases are 340 calories a day in first trimester and 452 calories a day in second and third trimesters.

If you are caring for a woman in labor, be alert to hemorrhage occurring more frequently in those with prolonged or extremely rapid labor, at emergency Cesarean delivery, in multiple gestation pregnancy or excess amniotic fluid. The hospital or birthing center must be prepared for postpartum hemorrhage with this best done by simulation drills. Since 80% of postpartum hemorrhage is related to uterine atony, familiarity with medications that contract the flabby uterus after vigorous massage and uterine exploration fail, is imperative. There are safety and contraindications to be considered as well as surgical remedies that should be reviewed with all professional staff. Hypertensive emergencies deserve the same careful attention and should be part of drills. Many hospitals now have crash carts where fluids and medications are readily available. Important but subtle signs of excessive blood loss that are often neglected or trivialized are air hunger and restlessness or agitation.

Reducing maternal mortality is a team effort beginning with education and resources. We need to engage women in care before and early on during pregnancy. Providing adequate access to care is both local and national. The social drivers of health include adequate practitioners in the area, transportation to and from care, education of the patient and community, adequate housing and nutrition, and safe environments. We need to act as if lives depended on it because they do.