The advance publication of an analysis of United States maternal mortality data back in August created a stir that has been reverberating through the internet ever since, spurred on by the publication of other relevant studies and a report during the same time period. The analysis looks at trends in maternal mortality while pregnant or within 42 days of termination of pregnancy between 2000 and 2014. Evaluating trends in the U.S. maternal mortality rate has been hampered by changes in pregnancy ascertainment on state death certificate forms over the time period as well as variations among the states. To adjust for this, the analysts applied a correction factor that enabled them to aggregate data among states, thereby increasing the ability of the study to determine trends.

The findings were extremely disturbing. Over recent decades, the maternal mortality rate (MMR) has fallen in 157 out of 183 countries worldwide. The United States was not one of them. Trend calculation, which involves smoothing out year-to-year variations by determining their slope, revealed that the U.S. rate in 48 states plus Washington, D.C rose from 19 per 100,000 live births in 2000 to 24 per 100,000 in 2014. The current rate puts the U.S. next-to-last among the 31 member countries of the Organization for Economic Cooperation and Development that report maternal mortality data, ahead only of Mexico.

California and Texas were analyzed separately because they are populous enough that trends can be determined without the need to pool data. These two states differed from the common run. California bucked the trend. The California MMR, which includes deaths up to one year after pregnancy ends, stood at 22 per 100,000 in 2003 and declined thereafter to 15 per 100,000 in 2014. The Texas pattern raises eyebrows. The Texas MMR changed little between 2000 and 2010, rising from 17 to 19 per 100,000, but then it leapt up to 33 per 100,000 in 2011 and continued rising sharply to 36 per 100,000 in 2014.

First, the Bad News

The online commentary has focused exclusively on explanations for the bad news in the overall trend and what happened in Texas. In addition to the U.S. analysis, commentary referred to a Texas biennial state-wide report on maternal mortality (from this page, click on "Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report") in the years 2011 and 2012, a U.S. analysis of health-care disparity and state-specific maternal mortality from 2005-2014 (Moaddab 2016), and to articles in an issue of Lancet devoted to maternal health. Let's see how the discussion unfolded on these findings, together with a look at these other sources.

Starting with the U.S. MMR paper itself, the analysts bring up the closing of several women's health clinics in Texas beginning in 2011 as a possible factor, but as they write, "Still, in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a 2-year period in a state with almost 400,000 annual births seems unlikely." They promise a future paper examining Texas data by race/ethnicity along with an investigation into specific causes of death.

Immediately, of course, media articles raised health care disparities as an issue. One of the great shames of our maternity care system is that for decades, Black women have been shockingly more likely to die of maternity-related causes, and no progress has been made in closing the gap. The Texas report, which examined maternal deaths up to 1 year after pregnancy, makes clear the severity of this problem. Black women accounted for 11% of the births in the years 2011 and 2012 but 29% of maternal deaths. Black women were also far more likely to experience severe morbidity, morbidity of the kind that increases risk of death. Forty-one per 1000 hospital stays involving severe morbidity were in Black women compared with 23-27 per 1000 among other races/ethnicities. Moaddab and colleagues' analysis of state-specific disparities in MMR likewise documents that while maternal mortality between 2005 and 2014 rose overall, it started at a much higher level and rose much faster in Black women and that state ethnic composition and MMR correlated tightly.

Black women are at greater risk, but nothing intrinsic about the amount of melanin in one's skin confers increased risk of maternal death, although Moaddab et al. actually propose "ethnic genetic differences" as a possible factor. Race/ethnicity is a marker for socioeconomic issues. Moaddab acknowledges this as well. They report associations with unintended pregnancy, being unmarried, and fewer than 4 antenatal visits. The Texas report finds that drug overdose, responsible for 12% of deaths, was the second most common cause of maternal death and that homicide (7%) and suicide (5%) were contributors.

Socioeconomic factors don't let the maternity care system off the hook, however. Access to care is one problem, as the U.S. study analysts suggest, even if it's not the only explanation. Cuts in funding in 2011 led to the closure or reduction in services of more than 80 women's health care clinics, according to an Austin newspaper article. These clinics, the article goes on to say, provided family planning services as well as screening for cancer, hypertension, and diabetes, all of which could impact maternal outcomes. An article in Mother Jones connecting the dots includes interviews with two of the Texas Task Force members. They draw attention to the fact that the majority of deaths occurred six weeks or more after hospital discharge and that Medicaid coverage ends at 60 days postpartum. The Texas report found that the most common cause of death was "cardiac event," and as we saw above, suicide was a contributor." The task force members ask, "What happens when you can't afford your blood pressure or antidepressant medication?" and "If you're not under the care of a doctor, do you even know your blood pressure is high?" They also deplore the lack of mental health and drug and alcohol addiction services and point out that people may use drugs and alcohol to self-medicate when they can't get mental health treatment.

Quality of care is another issue. A commentary in the Inquisitr points out that white women develop life-threatening complications too, but black women are much more likely to die of them, and as Gene Declercq observes in a Boston radio station interview, the MMR has risen in white women too. An obstetrician writes in a newspaper opinion piece that the U.K. and Canada have the same maternity care challenges of diverse population, high BMI women, and opioid use, but they have much lower maternal mortality rates. The Texas report shows a map of rates of hemorrhage and/or blood transfusion by county. None of the counties with the highest rates were adjacent to metropolitan areas such as Dallas-Ft. Worth, Houston, or Austin, cities that surely have their share of Black women residents and low-income women of every skin color. Something must be going on with care that has nothing to do with socioeconomic factors.

The obstetrician also brings up another problem: it isn't just a matter of "too little, too late" but of "too much, too soon." All too many women are being exposed to non-evidence based practices, including, and especially, the avoidable use of cesarean surgery. Citing a Lancet systematic review of evidence-based maternity practice guidelines, a World Health Organization piece highlights this issue in middle-income countries, but as the Lancet reviewers make clear, while low-income countries often suffer from inadequate care and middle-income countries increasingly overuse medical intervention in general and cesarean in particular, subsets of populations in high-income countries may experience the former and the latter may be common in the population overall.

What about the Good News?

What about California? What could explain the steep decline in maternal mortality? Only the analysts of trends in the U.S. MMR had something to say about that. They speculate that the efforts of the California Maternal Quality Care Collaborative (CMQCC) may have played an important role.

Under the auspices of the California State government, the CMQCC carried out a case review of every California maternal death in 2002 and 2003. It then used what it learned to develop evidence-based tool kits to improve response to two of the most common causes of preventable maternal death: pre-eclampsia and hemorrhage, followed by promoting implementation of those toolkits throughout the state. Rapid and appropriate response to these complications would no doubt save lives. (More recently, the CMQCC has issued a tool kit to promote vaginal birth and safely reduce first cesarean surgeries, the complications of cesarean surgery being another source of preventable mortality and severe morbidity in the current and future pregnancies. It is too soon to tell whether this will have any effect on reducing cesarean rates, let alone the adverse consequences of cesarean surgery, but it holds that potential.)

The Take-Away

Preventing maternal deaths requires a multi-faceted, sustained approach. A serious effort requires that we:

• Provide public health and social services, including assistance with nutrition and other health maintenance behaviors, mental health, substance abuse, and domestic violence. As Dr. Thomas Strong, Jr. puts it in Expecting Trouble: The Myth of Prenatal Care in America (2000), "Medicalized prenatal care has been no more able to surmount the social ills which contribute to America's poor pregnancy outcomes than emergency rooms have been able to solve our nation's violent crime problem."


• Remove barriers to accessing care. Childbearing women should have access to the full range of reproductive health and medical services in their local communities without regard for ability to pay.


• Improve quality of care. As the authors of the Lancet review of evidence-based guidelines write: "Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights." Interestingly, many of the review's recommendations align with those of Lamaze International:
  
  
  
  • "Provide one-on-one continuous supportive care"
  
  
  • "Offer intermittent auscultation of the fetal heart rate to women in established first stage of labour in all birth settings"
  
  
  • "Encourage women to adopt any upright position they find comfortable throughout labour"
  
  
  • "Advise women that breathing exercises, immersion in water, and massage might reduce pain during first stage of labour, and that breathing exercises and massage might reduce pain during second stage of labour"
  
  
  • "Inform women about risks and benefits and potential implications of epidural analgesia during labour"
  
  
  • "Allow and encourage women to drink water, juice, or isotonic drinks, and eat light meals or snacks during labour"
  
  
  • "Encourage and help women to move and adopt any position they find most comfortable throughout labour and childbirth, except supine or semi-supine"
  
  
  • "Inform women that in the second stage they should be guided by their own urge to push"
  
  
  • "Delayed cord clamping (done 1-3 min after birth) is recommended for all births while initiating essential newborn care"
  
  
  • "Encourage women to have skin-to-skin contact with their babies as soon as possible after birth"
  
  
  • "Avoid woman-baby separation before the first hour following birth, unless at the mother's request; delay postnatal routine procedures (eg, weighing, bathing, and measuring); monitor the neonate's condition during skin-to-skin contact"
  
  
  • "Encourage and support breastfeeding initiation within first hour"
  
  
  • "Facilitate rooming-in (mother and baby should stay in the same room 24 h a day)
  
  
  • "Promote exclusive breastfeeding from birth until 6 months of age"
  
  
  
  

• Treat severe complications optimally. Last but not least, while prevention is better than cure, cure is still needed. All hospitals should adhere to the policies and practices outlined in the CMQCC tool kits or something like them.

About Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is an acknowledged expert on evidence-based maternity care. Her first book, Obstetric Myths Versus Research Realities, was a valued resource for childbirth professionals. Its successor, Optimal Care in Childbirth: The Case for a Physiologic Approach, won the American College of Nurse-Midwives "Best Book of the Year" award. Goer has also written The Thinking Woman's Guide to a Better Birth, which gives pregnant women access to the research evidence, as well as consumer education pamphlets and articles for trade, consumer, and academic periodicals; and she posts regularly on Lamaze International's Science & Sensibility. Goer is founder and director of Childbirth U, a website offering narrated slide lectures at modest cost to help pregnant women make informed decisions and obtain optimal care for themselves and their babies.

References

Moaddab, A., Dildy, G. A., Brown, H. L., Bateni, Z. H., Belfort, M. A., Sangi-Haghpeykar, H., & Clark, S. L. (2016). Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014. Obstetrics and Gynecology.

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