October 26, 2017

How many women die from pregnancy in the US? Nobody really knows, ProPublica finds

Daily Briefing

    The United States does not have an accurate count of how many U.S. women die annually from complications related to pregnancy or childbirth, according to a ProPublica investigation published Monday.

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    Investigation details

    For the investigation, ProPublica reviewed how the Unites States investigates and identifies U.S. maternal deaths. Specifically, ProPublica examined the:

    • Accuracy of U.S. maternal death statistics;
    • Factors contributing to incomplete and unreliable statistics;
    • Efforts at the national and state level to improve the quality of statistics; ; and
    • Recommendations from researchers on how to improve U.S. statistics.

     Unreliable data

    According to ProPublica, the United States rigorously tracks cancer trends, infant mortality, teen pregnancy, and even the performance of transplant centers, but it does not have a rigorous system in place to monitor maternal deaths.

    According to ProPublica, most agree that in the United States about 700 to 900 women die annually for reasons related to pregnancy and that many of these deaths are preventable. But the United States' current process for tracking maternal deaths is so "perennially short on funding and scientific attention" that those numbers are often deemed "incomplete and untrustworthy," ProPublica reports.

    According to ProPublica, "[d]oubts about U.S. data on maternal deaths are so profound that some experts have questioned if the rise in U.S. rates over the last 25 years is a mirage, reflecting noise in the numbers rather than a real increase in fatalities."

    One reason why the data are unreliable is because the United States for more than a century has largely relied on death certificates to track maternal deaths. Death certificates typically identify the immediate cause of death, the intermediate cause of death, and the underlying cause of death, according to ProPublica—but CDC typically relies on the underlying cause of health to compile its mortality statistics. Experts say that data set will not always show a link to childbirth or pregnancy, particularly if the death occurred several weeks after delivery.

    Further, CDC officials say death certificates are prone to error, especially when they are filled out by individuals who are not trained to recognize a link between a death and pregnancy.

    For example, William Callaghan, who heads CDC's maternal and infant health branch, said an emergency department physician might have a female patient who dies of a pulmonary embolism, which expectant and new mothers are at greater risk of having—but the physician might be unaware that patient gave birth a week earlier and so fail to note the pregnancy on the death certificate. 

    Death certificate codes present another problem, Callaghan said. "There are death certificates I stare at all day long and I wouldn't be able to tell you what the real cause of death was," he said.  

    The National Center for Health Statistics in 2003 sought to address some of those issues by revising and standardizing U.S. death certificates to include a checkbox for questions on whether the patient who died was pregnant or had been pregnant within a year before their death.

    However, researchers have found the checkboxes could result in false positives, with certain deaths incorrectly being categorized as being related to pregnancy or childbirth. For example, a recent report on Colorado, Delaware, Georgia, and Ohio showed there was no evidence of pregnancy for about 15 percent of women whose death certificates linked the cause of death to pregnancy or childbirth via the checkbox.

    Ways to improve

    In the United Kingdom, which Callaghan said has set the "gold standard for maternal health data," health care practitioners review medical records and other sources to identify pregnancy or childbirth-related deaths and to determine how such deaths could have been prevented, ProPublica reports.

    But in the United States, only about half of states have a maternal mortality review committee that has operated for longer than a year to review maternal death cases in depth—and many of the existing committees suffer from a lack of resources.

    Researchers have suggested the United States should rely on information from such state review committees to build on the data from death certificates, because review committees draw from several sources in addition to vital records, such as social media and obituaries. According to ProPublica, the most active review committees have prompted the development of toolkits and safety bundles to prevent maternal deaths.

    For example, Stacie Geller, a member of the Illinois Maternal Mortality Review Committee, said after the committee found that the No. 1 cause of preventable maternal death in Illinois was obstetrical hemorrhage, the state invested $1 million to retrain hospitals on how to address the problem. Geller said the state saw improvements in clinical practice within a couple years.

    Other research has suggested the United States could improve the quality of data by training individuals who complete death certificates and re-evaluating death certificates for certain women had truly been pregnant to determine whether they were pregnant.

    First steps

    David Goodman, who manages CDC's maternal health efforts, said CDC and the Association of Maternal & Child Health Programs are taking steps to improve the quality of maternal mortality data.

    For instance, he said they have created a tool to collect and analyze data from review committees, called the Maternal Mortality Review Information Application. According to ProPublica, the application is the first tool designed to pool national information on maternal mortality, and so far nearly a dozen states are providing information.

    Goodman said CDC has also designed a web portal to help states and local jurisdictions improve their reviews of maternal mortality. Merck for Mothers completely funded the project, donating $2.3 million so far, ProPublica reports.

    Goodman said, "Every little step you take is a little step forward and you're keeping the conversation alive for when that opportunity does come up, and I think it’s now that the timing seems to be right" (Fields/Sexton, ProPublica, 10/23; Baker, "Vitals," Axios, 10/24).

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