Maternal Mortality through the Lens of Psychosocial Theory

The quandary of pregnancy-related death in our country is a complex one with numerous variables at play. Breaking this public health challenge into two broad categories, systems and individuals, allows us to apply the constructs of a few health behavior models to each category.

Maternal Mortality at the Systems Level: Applications of TRA and TPB Models
Many of the drivers of our nation's increasing maternal mortality rate function at the system level. Approaching attitudes of key players within the maternity care system, including maternity care providers (obstetricians, family physicians, midwives & L&D nurses), healthcare insurers and hospital administrators, can aid in decreasing our maternal mortality rates. This construct within the Theory of Reasoned Action and Theory of Planned Behavior models would best be applied at the educational level, by encouraging generally positive attitudes toward pregnancy and childbirth equally amongst medical and midwifery students. By encouraging the perspective that pregnancy and birth are inherently normal, healthy processes (as opposed to disease/dis-ease states) the eventual clinician is more likely to approach patients with a sense of trust in the germane mechanics associated with pregnancy and birth as opposed to a pessimistic assumption that each pregnant patient is a 'ticking time bomb' to be weary of. This attitudinal intervention would be in addition to the clinical training pertaining to the less common, non-iatrogenic causes of morbidity and mortality in puerperal women.

A specific example: inherent trust in the processes of late pregnancy and birth encourages waiting for the onset of spontaneous labor prior to 39, 40 0r 41 completed weeks of pregnancy, as opposed to encouraging early labor induction - an increasingly common practice that is associated with increased risk to both the mother and fetus (Hofmeyr, Gulmezoglu & Alfirevic , 2005). By encouraging this perception of inherent labor and birth-related normalcy at the individual level, positive normative beliefs within the greater system would eventually follow.

As pointed out in the California Pregnancy-Associated Mortality Review (2011. pg.45) high cesarean delivery rates are correlated to increased maternal mortality. With our nation's continued escalation of the c-section rate (Zhang, Troendle, Reddy, Laughon, Branch, Burkman, et al., 2010), now well past 30% of all deliveries, the practice of surgical delivery provides another excellent opportunity for implementation of a TRA construct. By encouraging the personal agency of avoiding the temptations associated with elective cesarean delivery (easy scheduling, accomplishing deliveries prior to the nighttime or weekend hours, increased financial reimbursements) the maternity care provider becomes empowered to guide his or her patients toward less risky childbirth options whenever clinically safe and possible.

Targeting interventions at the management level, including nurse managers and the Chief of Obstetrics within each facility, trends toward motivation to comply with a healthier, more patient-centered model of care can be fostered. Promoting staffing schedules that provide puerperal women with low nurse-patient ratios, and avoiding the 'get 'em in, get 'em out' mentality of speeding up turn over in L&D department patients through the use of labor augmentation, can all ensure closer observation of peripartum women and the decrease of iatrogenic risk factors for postpartum hemorrhage and subsequent maternal death (Sheiner, Sarid, Levy, Seidman & Hallak, 2005).

The above systems-level interventions are a small subset of those needed to help improve the U.S. maternal mortality ratio. While the majority of the work does need to happen at this level, there are elements of individual health behavior change that can also make a difference.

Maternal Mortality at the Individual Level: Application of the Health Belief Model

Applying constructs from the Health Belief Model can inform individual health behaviors which may contribute to a woman's risk of perinatal death. The Centers for Disease Control and Prevention (2010) outlines several worrisome trends pertaining to pregnant women in recent years. Rates of maternal obesity, diabetes and hypertension have all escalated, to the point that one in five pregnant women are considered obese, 2-10% of U.S. pregnancies are complicated by gestational diabetes(GDM) and hypertensive disorders (HTN) occur in 6-8% of pregnancies, accounting for approximately 15% of maternal deaths (Gifford, August, Cunningham, Green, Lindheimer, & McNellis, 2000). Of the three leading causes of maternal mortality in our country, hypertension is most likely to be modifiable through preventative - even preconception - measures at the individual level (Lu, 2009).

Increasing perception of susceptibility among women in their childbearing years becomes important by highlighting the fact that entering pregnancy at a higher than optimal body weight or with a higher than optimal baseline blood pressure increases a woman's overall risk of both morbidity and mortality - not in every case, mind you, but in enough cases that we must pause to consider how we should address this. It is particularly important to focus this message toward African American women, as their rates of hypertension during pregnancy out-pace those of Caucasian women (Bryant, Seely, Cohen, & Lieberman 2005).

By using psychosocial theory constructs in public health messaging interventions, applied to key players at both the individual and systemic level, the rising maternal mortality ratio in our country can be systematically chipped away at. Through this approach, we have the opportunity to bring our country back on track toward helping the global community reach the fifth Millennium Development Goal of decreasing maternal mortality by 75% by the year 2015.

In tomorrow's post, I will share some ideas on how to apply Community Organizing tactics to the maternal morbidity and mortality challenges in our country. To read this series from the beginning, go here.

Posted by: Kimmelin Hull, PA, LCCE, FACCE

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