Is the US mortality rate really spiking?

A recent article raises some serious questions.

A recent article in The Washington Post titled, “U.S. maternal death rate is spiking. Here’s what’s being done to change that;” discussed how maternal mortality review panels are being formed across the country in response to America’s growing maternal mortality rate. We know that the United States is the only industrialized country where maternal deaths are on the rise, but this article left us with a few questions.

The article stated that 700 American women die every year from pregnancy-related conditions. But the CDC reports 600 women die annually and research published in The Lancet reports 800. The World Health Organization says that in 1990, 12 women died for every 100,000 live births and in 2015 the number had risen to 14.

Dr. David Goodman, senior scientist for the CDC’s Maternal and Child Health Epidemiology Program provided some insight into what the data says about the state of maternal health in the United States.

EMC: Which statistic illustrates that the US maternal mortality rate is spiking?

Dr. Goodman: I wouldn’t use the word ‘spiking.’ I think it’s trending upward in the wrong direction and has been since 1987. The CDC gets its data from the Pregnancy Mortality Surveillance System (PMSS) but so do the WHO and other international health organizations. The difference in their reports comes from how they use the data. The CDC looks at the full year after a woman’s pregnancy and international organizations look at just the first 42 days and make statistical adjustments.

EMC: Which time frame reflects maternal mortality in America most accurately?

Dr. Goodman: That depends. There was a big move in the US to look beyond just the first 42 days. That’s when we recognized a lot of deaths were being missed due to conditions like cardiomyopathy (a pregnancy-related heart condition that can cause death up to 5 months after delivery). Other causes, like hemorrhage and septicemia, occur closer to the end of pregnancy. In those cases, information from the first 42 days tells the maternal mortality story quite well.

EMC: What do maternal mortality review panels do?

Dr. Goodman: Currently, twenty-four states have fully established review panels and another 14 states have panels in the planning stages. These panels are comprised of medical experts from public health agencies and state Ob-Gyn societies to investigate every maternal death identified in their area.

Typically, they gather information from all available resources and document the story of each maternal death. They learn from that woman’s story and look for opportunities to prevent deaths of other women headed down the same storyline. Then, they take action to change the end of their stories.

EMC: Can you give us an example of how review panels could change story-endings?

Dr. Goodman: Review panels examine the circumstances that lead to mothers’ deaths layer-by-layer to see where intervention or prevention measures could have made a difference. Let’s say a woman had hypertension during pregnancy. She delivers her baby and her blood pressure seems to improve. Since most of her blood pressure readings were normal, she’s discharged from the hospital. She goes home, goes into crisis and dies. The review panel might determine she was discharged too early and in the future, recommend that hypertensive women stay in the hospital until their blood pressure is normal for a specific period of time. But that’s only one way the story could go. Let’s say the same woman was discharged with an appointment to see a specialist in two weeks. Her doctor wanted to see her sooner than at the usual six-week postpartum visit. The woman doesn’t show up at the two-week appointment though and she dies. The review panel discovers she missed her appointment because she lives in a rural area. Her partner had the car and she had no way to get to the specialist’s office an hour away, with a 2-week old and 3-year old to care for. That’s the level a review panel can get to. They look at the entire system — what’s happening on a medical level and what’s happening in a woman’s life. Then they recommend changes to prevent future deaths.

EMC: How fast can change take place?

Dr. Goodman: Sometimes change comes quickly in response to review panel recommendations, but other times, progress is slow., For example, a review in Georgia identified that too many deaths were linked to inappropriate titration (the concentration of a dose) of medications for pregnant women. Reviewers recognized that providers needed more education and Georgia’s Ob-Gyn society got that information out to providers amazingly quickly. Other issues take a long time though because they’re systemic, like lack of transportation and healthcare access.

EMC: Why are so many new panels cropping up now?

Dr. Goodman: One of the main reasons is that social and financial factors are motivating new investments in maternal health. For decades we’ve focused on the fetus, infant and child. The mother’s health hasn’t gotten the attention it needed. Infant mortality rates improved during these years but maternal mortality got worse so we shifted our attention. Maternal mortality review panels are a response to that shift.”

Improving maternal health outcomes has also become a high priority issue for some states over the past five years in part because mortality rates are rising, but also because federal funding began mandating it. Health Resources & Services Administration Title V block grants make up the largest source of funding revenue for States’ maternal and child health services.

These funds are state controlled so each state can meet their population’s unique needs. Different states face different challenges and need different programs. Every state has to meet national performance and outcome measures though and maternal mortality review panels help them measure up. I think everybody feels new energy to do something about rising maternal mortality right now. But there’s also recognition that this enthusiasm might not last and we have to do more while there’s momentum.

Every Mother Counts agrees that reducing maternal mortality overall will come from examining mothers’ individual stories and recognizing that the obstacles that prevent healthy pregnancies are universal. Tremendous inequities exist, however, in the quality and access to health care that individual women face and they’re especially challenging for low-income women of color. The more attention we pay to removing obstacles, the sooner we’ll see maternal health trends moving in the right direction.