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October 8, 2019

Maternal mortality in America, in 3 charts

Daily Briefing

    Black women and American Indian/Alaskan native women experienced significantly more pregnancy-related deaths than white women between 2007 and 2016, even among states with the lowest maternal mortality rates, according to a recent CDC report.

    How the US maternal mortality crisis is rooted in inequality (and 4 ways to combat it)

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    For the report, researchers used CDC data and U.S. natality files to determine rates of maternal mortality in the United States by race and cause of death.

    The data showed significant difference in maternal mortality among different races. Compared with white women, black women were three times more likely to die from a pregnancy-related complication, while American Indian/Alaskan native women were more than twice as likely to die from pregnancy-related complications.

    According to the researchers, these racial disparities were consistent across age groups and present even in states with the lowest maternal mortality rates in the country. They also persisted regardless of level of education.

    The researchers also found that, in general, pregnancy-related deaths have increased since 2007, from 15 deaths per 100,000 live births, to 17 per 100,000 live births in 2016. While each race saw fluctuations in pregnancy-related deaths between 2007 and 2016, all races saw net increases except for American Indian/Alaskan native women.

    The most common causes of pregnancy-related deaths were cardiovascular conditions, like congenital heart disease, ischemic heart disease, cardiac valvular disease, hypertensive heart disease, and congestive heart failure, which accounted for 15.3% of all pregnancy-related deaths. Causes of death were similarly split among races.

    Why do we see these racial disparities?

    The researchers suggested a number of potential reasons for the significant racial disparities present in maternal mortality rates.

    For instance, they noted that several chronic diseases associated with higher risk for pregnancy-related deaths, like hypertension, are more prevalent among black women. The researchers also suggested that systemic factors, like gaps in access to health care and preventive care; a lack of care coordination and social services; and community factors like inadequate housing or transportation could also be contributors to the racial disparities.

    Quality of care could also play a role in the racial disparities, the researchers wrote, citing studies that have found black women are more likely to receive obstetric care in hospitals with lower quality ratings than white women. To address this, hospitals can "implement standardized protocols and training in quality improvement initiatives, ensuring implementation in facilities that serve disproportionately affected communities," the researchers wrote.

    The researchers also noted the role of stress in the community as a possible factor behind the disparities. They suggested the "weathering" hypothesis could play a role in care disparities. The hypothesis states that black women "experience earlier deterioration of health because of the cumulative impact of exposure to psychosocial, economic, and environmental stressors."

    There is also implicit racial bias to consider in the health care system specifically. "Implicit racial bias has been reported in the health care system and can affect patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient outcomes," they wrote.

    Identifying and addressing racial bias within the structure of a health care settings, alongside supporting community-based programs to build social support and resiliency, "would likely improve patient-provider interactions, health communication, and health outcomes," the researchers wrote.

    How providers and states are addressing the problem

    There's been a growing acknowledgement nationwide that care practices need to be standardized to prevent maternal deaths.

    For example, the American College of Obstetricians and Gynecologists, the American College of Nurse-Midwives, and the American Academy of Family Physicians, developed the AIM Program to formalize safety practices demonstrated to decrease maternal injuries.

    According to USA Today, 985 hospitals, representing about 40% of U.S. birthing hospitals, are participating in the AIM program, and many have seen a measureable impact.  

    The University of Utah Hospital is one of those hospitals. Hospital officials adopted best practices from the AIM program, as well as those of other experts, after data revealed 12% of its pregnant patients suffered hemorrhages in 2013—three times the national rate.

    According to officials at the hospital, the program led their hemorrhaging rates to drop by one-third.

    Meanwhile, some states are enacting legislation to lower maternal mortality rates, according to USA Today. For example, Massachusetts officials have a maternal death review panel that in 2014, recommended every hospital set guidelines for treating maternal hemorrhage. The state now has the second lowest rate of maternal mortality in the country.

    Similarly, California implemented its California Maternal Quality Care Collaborative (CMQCC) over a decade ago to reduce mortality and racial disparities in obstetric care.

    This effort included the creation of toolkits to help doctors and nurses respond to obstetric emergencies. For example, one kit aimed at preventing obstetric bleeding provides materials related to creating "hemorrhage carts" to hold medications and supplies, crisis protocols for major transfusion, and regular drills and training.

    The hospitals that adopted the protocols in the toolkit saw near-deaths from maternal bleeding drop 21% the following year. Several years after, maternal deaths in California had dropped to 7 per 100,000—a rate comparable to Canada and the Netherlands.

    Want to learn more about what your organization can do to fight maternal mortality? View our blog post outlining four steps you can take to overcome inequality now.

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    Then, read about why OB hospitalists are crucial to perinatal care quality, and four contracting models you can use to hire them.

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