In California, reducing maternal mortality has become a major public health goal.
That's in part because the state has 550,000 births per year, or about 1 in 8 of the births in the United States. The other factor driving action is that state mortality data seem to indicate a rise in maternal mortality in recent years.
“I think we've all been lulled to sleep by how we have done over the last 40 years,” said Dr. Elliott Main, chief of obstetrics at Sutter Health's California Pacific Medical Center in San Francisco and the principal investigator for the California Maternal Quality Care Collaborative. “It's sort of unbelievable that [maternal mortality] could go up, but I think there's real evidence that it is creeping up again.”
Dr. Main headed up the team that recently analyzed California's maternal mortality data. Although his official report is still being reviewed by the California Department of Public Health and is not yet publicly available, he said the increase in pregnancy-related deaths is “real,” not just the result of increased reporting, and that it should serve as a wake-up call for clinicians.
The raw data from the California Department of Public Health show that the overall maternal mortality rate in the state is about 16.9 deaths per 100,000 live births for 2006, up from 5.6 deaths per 100,000 live births a decade earlier.
“What I would want every obstetrician to think about is that quality improvement is very important for our specialty,” he said. “Gone is the day that everyone does their own thing.”
One of the challenges, Dr. Main said, is teasing out the exact causes. For example, there are more mothers who are over age 40 now, and they have a statistically significantly higher rate of maternal mortality than mothers in their 20s and 30s. However, there are only a small number of mothers in their 40s overall, and most of the maternal deaths that occur are among women in their 20s and 30s. Similarly, the increase in cesarean births is often cited as a possible cause of increased maternal mortality. But it's difficult to conclude that definitely, Dr. Main said, because the sicker the mother, the more likely she is to have a cesarean section.
“There are a number of associations that are hard to pin down,” he said.
So even as Dr. Main and other researchers continue to ponder the underlying causes for the uptick in maternal mortality, they are looking at practical ways to bring those numbers down. In California, they have looked closely at overlooked abnormal vital signs in the emergency department and the lack of care plans in the hospital.
The result is that Dr. Main's group, the California Maternal Quality Care Collaborative, has started working with physicians and hospitals on ways to use things like plans of care and standard protocols to reduce maternal hemorrhage, one of the diagnoses commonly associated with maternal death.
Starting in October 2009, the California Maternal Quality Care Collaborative began working with a group of 30 hospitals, most of which are located in California, on a yearlong intensive mentoring program. During the program, the hospitals work to implement hemorrhage protocols and share their experiences with one another. The 30-hospital collaborative represents about 110,000 births a year.
The hospitals are using the definition that hemorrhage occurs when a woman has a blood loss greater than 500 mL for a vaginal delivery. What they have discovered since implementing that standard definition is that many clinicians have been underestimating the amount of blood loss that should trigger clinical action, said Debra Bingham, Dr.P.H., executive director of the California Maternal Quality Care Collaborative. “It was being underrecognized and underappreciated,” she said.
The hospitals also are testing a debriefing form that allows care teams to review what went well and what went wrong during an emergency. And they are performing drills on the hemorrhage protocols. The hope is that the drills and team debriefings will have a crossover impact in how clinicians learn to respond to all obstetric emergencies. “Hemorrhage becomes the window into improving the response to all kinds of obstetric emergencies,” Dr. Bingham said.
California isn't the only place where maternal death is rising. Experts believe the trend also is occurring nationally. In a Sentinel Event Alert issued by the Joint Commission in January, the organization warned that “current trends and evidence suggest that maternal mortality rates may be increasing in the U.S., despite the rarity of the incidence of maternal death.”
The Joint Commission issued a Sentinel Event Alert after receiving several reports of maternal death to its sentinel event database, which tracks unexpected deaths. Since 1996, 84 cases of maternal death have been reported to the Joint Commission's database, with a spike in events reported in 2004, 2005, and 2006.
As of 2006, the national maternal mortality rate was 13.3 deaths per 100,000 lives births, according to the Centers for Disease Control and Prevention. That compares with a rate of 7.6 deaths per 100,000 live births in 1996.
Joint Commission officials are urging physicians, nurses, and hospitals to try to improve their recognition of the risk factors and high-risk patients. Specifically, the Joint Commission is suggesting that hospitals try to identify specific triggers for responding to change in a mother's vital signs or clinical condition and develop protocols for response.
In the case of high-risk women who have preexisting medical conditions like hypertension, diabetes, and obesity, referral may be the best option. The Joint Commission suggested that high-risk patients be referred to experienced prenatal providers who have access to a range of specialized services.
Hospitals also should make pneumatic compression devices available for patients who undergo cesarean section and are at high risk for pulmonary embolism, the Joint Commission suggested. The organization also instructed clinicians to evaluate whether patients at high risk for thromboembolism are candidates for low-molecular-weight heparin for postpartum care.
Clinicians involved in maternal and neonatal care are generally aware of these types of high-risk situations, said Ann Scott Blouin, Ph.D., executive vice president in the division of accreditation and certification operations at the Joint Commission. The bigger educational challenge is for clinicians outside the area of maternal-child medicine and nursing, such as those in emergency services who may not suspect pulmonary embolism in a woman who is coming in a day or two after what appeared to be an uncomplicated delivery, she said.
“I think it's extremely timely that the Joint Commission has put this out because it has been a concern of many of us in the obstetric community for some time,” said Dr. Mary D'Alton, chair of the department of obstetrics and gynecology at Columbia University Medical Center in New York City.
The issue, Dr. D'Alton explained, is that while maternal mortality is a very rare event in the United States, it is still higher than it should be. One area that holds significant promise for improving a mother's outcomes post partum is reducing maternal hemorrhage, she said. The good news is that most of these protocols already exist.
With a concentrated effort from organizations like the Joint Commission to push hospitals for organizational changes, there could be a decline in maternal death within 5 years, Dr. D'Alton predicted. Institutions, departments, and societies need to have the policies and procedures in place with the aim of preventing maternal death.
“I think it's just so much wider than the individual practitioner,” Dr. D'Alton said.
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