“I just don’t want to die.”
“I’ve heard about women dying in childbirth, is that going to happen to me today?”
“What are you going to do to make sure I won’t die after my baby is born?”
Familiar with comments like these? These and similar statements seem to have increased especially after the recent NPR story of the neonatal nurse who died from a serious (and treatable) complication during her labor and delivery. If you missed the article, you can read it here:
http://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger. There are many reasons that contribute to the rising US maternal mortality rate in a time when most developed nations are curbing and decreasing their mortality rates. Adding up the complexity of the health care system with poorer overall population health, potential lack of standard facility protocols, staff training, emergency drill practice, provider skill and experience and it’s no wonder that American women are having worse outcomes.
Georgia has been ranked for years at the bottom of maternal and fetal health outcomes- cesarean section rates, preterm delivery, low birth weight infants, maternal chronic disease and maternal mortality. So what exactly is going on in our state?
HOW DATA IS COLLECTED AND REPORTED:
Maternal Mortality Rate or Ratio (MMR) is defined as the number of maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy and/or management of pregnancy- this generally excludes accidental death causes.
– Pregnancy- related deaths occur by conditions related directly to pregnancy or management of pregnancy (i.e. hemorrhage, hypertensive disorders or complications).
– Pregnancy- associated deaths occur by any other method (i.e. accidents, suicide, heart disease)
When the maternal death occurs and whether it is included in the MMR is dependent on the organization reporting:
- The World Health Organization (WHO) defines pregnancy-related deaths as maternal deaths that occur during pregnancy or within the first 42 days after pregnancy is over.
- The Centers for Disease Control (CDC) with the American College of Obstetricians and Gynecologists (ACOG) developed a system in 1986 that is still used in CDC reports of MMR: pregnancy-related deaths occur during pregnancy or within 1 year after pregnancy is over.
HOW DEATH IS REPORTED IN THE US
In general, maternal death data is collected from ICD codes recorded on death certificates. In 1979 with the implementation of ICD-9, US maternal death rates increased by ~ 10% due to improved ICD coding definitions. There was another general increase in maternal deaths in the early 2000s due to more detailed questions regarding pregnancy on death certificates. However not all states used the same death certificates so this increase in maternal death rates was observed in states using updated death certificate documentation (Hoyart, 2007). Comparing maternal death rates between states becomes complicated when recorded data is often incomplete (despite improvements in ICD coding) or individual states are not asking the same questions on death certificates regarding maternal death in relation to pregnancy.
WHAT GEORGIA REPORTS
Georgia implemented the updated death certificate in 2008- which includes questions regarding pregnancy within 1 year of death (HMHBC, 2016). However the Georgia reporting system – the Online Analytical Statistical Information System (OASIS) only includes deaths occurring during pregnancy or less than 42 days of death- presumably because most pregnancy-related deaths occur during this time period. The OASIS system excludes any maternal deaths caused by external causes such as homicide or injury.
MOST RECENT GEORGIA DATA:
According to the OASIS reporting system, Georgia MMR for previous years is as follows:
2015 – 59.4 deaths/100,000 live births
2014 – 68.8 deaths/100,000 live births
2013 – 43.6 deaths/100,000 live births (national MMR as reported from the CDC was 17.4 in 2013)
2012 – 17.7 deaths/100,000 live births
The Georgia Maternal Mortality Review Committee (MMRC) is a collaboration between the Georgia Department of Public Health, CDC and the Georgia OBGYN Society consisting of ~ 45 members. It was established in order to review maternal deaths in Georgia and identify areas for improvement and intervention. In 2015, the MMRC published its first report with a review of all maternal deaths occurring in 2012. Below are the major findings of their review:
Total deaths in 2012: 123
26- pregnancy-related deaths (Of note, OASIS report generates 23 deaths)
60- pregnancy-associated deaths
37 – not actual cases – the death certificates were marked that pregnancy had occurred within 1 year of death but no actual evidence of pregnancy was available- this may be caused by data entry error, documentation of spontaneous or therapeutic abortions
Major causes of pregnancy-related death in Georgia include:
1- Hemorrhage – related to abruption, ectopic
2- Hypertension – delay in medication, lack of early response teams
3- Cardiac causes– women unaware of risks, providers failing to screen, educate or refer
4- Embolism – obesity and lack of prophylaxis
5- Suicide – one death related to pregnancy, the patient stopped her medication.
Major causes of pregnancy-associated death in Georgia include:
1- Motor vehicle accidents
4- Heart disease
6- Drug toxicity
Number of deaths were significantly higher in African American, non-Hispanic women. Data was missing in almost 50% of cases regarding pre-pregnanacy BMI, initiation of prenatal care, adequacy of prenatal care so report findings have to be considered with some bit of caution. Concluding the report are suggestions offered by the committee to address the common causes of maternal death and it is expected that with review of additional years (currently undergoing) these data will become more specific.
Contributing to poorer outcomes in Georgia is the lack of providers in rural areas (only 80 of Georgia’s 159 counties have an OBGYN present, data on CNM/NP coverage in not currently available) as well as the closing down of labor and delivery units across the state. In the last 21 years, 31 L&D units have closed making it harder for women living in rural areas to receive timely obstetric care in emergent conditions.
WHAT YOU CAN DO
- Stay up to date on common pregnancy complications, risk factors, evaluations, treatments, pharmacology as well as patient education and warning signs to report.
- Review facility protocols for obstetric emergencies and if there aren’t any (or if they haven’t been updated recently) start working on them! The Council on Patient Safety in Women’s Healthcare has excellent resources available here:
- Encourage staff training and emergency drill practice.
- Use electronic records to your advantage- insert “dot phrases” or reminders in electronic notes to prompt referrals for patients with pre-existing diseases or morbid obesity.
- Get involved in your state ACNM Affiliate- connect with other midwives, participate in continuing education sessions, get involved in legislative efforts!
Healthy Mothers, Healthy Babies Coalition of Georgia. (2016, August 12). State of the state of maternal & infant health in Georgia; where we have been, where we are now, and what we can do. Retrieved from https://drive.google.com/file/d/0BxndQpkPFFfySm5aNmdkYXZYQm8/view.
Hoyert, D. (2007). Maternal mortality and related concepts. National Center for Health Statistics. Vital Health Stat 3(33).
Martin, N. (2017, May 12). Focus on infants during childbirth leaves U.S. moms in danger. National Public Radio. Retrieved from http://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger.
Maternal Mortality Case Review 2012. (2015, June). Department of Public Health. Retrieved from https://dph.georgia.gov/sites/dph.georgia.gov/files/MCH/MMR_2012_Case_Review_June2015_final.pdf
OASIS reporting system: https://oasis.state.ga.us/oasis/oasis/qryMCH.aspx