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Maternal  Mortality  :Closing  the  

Disparity  Gap

Haywood  L.  Brown,  MD
Professor  Obstetrics  Gynecology
Duke  University
President  ACOG  2017-­‐2018
Maternal  Mortality  Rate:  Rising  in  the  U.S.

Source:  MacDorman.  Recent  Increases  in  US  Maternal  Mortality.  
Obstetrics  and  Gynecology.  2016
Pregnancy  Related  Maternal  Mortality  Ratio

Year # All white black other
1987-­‐90        1453         9.1 6.2 22.9 9.8

1991-­‐97        3201 11.5 7.9 29.6 11.1

1998-­‐05        4693 14.5 10.2 37.5 13.4

**  Risk  3-­‐4  fold  higher  for  black  women
Callaghan.  Sem Perinatol 2012;36:2-­‐6
Maternal  Mortality  Among  Black  Women  

Source:  Centers  for  Disease  Control  and  Prevention
Graphic:  Tiffany  Farrant-­‐Gonzalez,  Scientific  American
Cesarean  Delivery  
Morbidity/Mortality
• Deneaux-­‐Tharaux et  al  Obstet  Gynecol
• Risk  of  postpartum  maternal  death  was  3.6  times  higher  after  
cesarean  than  vaginal  delivery  (odds  ratio  2.64,   2.15-­‐6.19)
• Complications  of  anesthesia,    puerperal  infection,  
thromoboembolism as  leading  causes  of  death.
• Canadian  Institute  for  Health  Information’s  
Discharge  Abstract  Database   compared  46,766  
women  with  planned  cesarean  to  2,292,420  
women  with  planned  vaginal  birth  
• overall  severe  morbidity  of  27.3/1000  compared  to  9.0/1000  for  
cesarean  vs.  vaginal  delivery,  respectively.  
• Planned  cesarean  delivery  had  increased  risk  for  postpartum  cardiac  
arrest  (OR  5.1,  95%  CI  4.1-­‐6.3  
Cesarean  delivery  morbidity
• Lydon-­‐Rochelle  et  al  JAMA,  2000;283:2411-­‐2416)  
• women  with  cesarean  delivery   RR  of  1.8 (95%  CI,  1.6-­‐1.9)  
for  re-­‐hospitalization  within  60  days  after  adjusting  for  
maternal  age  
• Reasons  for  readmission  included  
• uterine  infection
• obstetrical  surgical  wound  complications,
• cardiopulmonary  
• thromboembolic  conditions.  
Understanding  Racial  Disparities:
The  Big  Picture

Source:  Elisabeth  Howell,  MD,  MPP.  Reduction  of  
Peripartum  Disparities  Bundle.  2017.
Severe  Maternal  Morbidity:  “Near  Misses”
ü For  every  maternal  death,  over  100  women  experience  
severe  maternal  morbidity:
• The  physical  and  psychological  conditions  that  result  
from,  or  are  aggravated  by,  pregnancy  and  have  an  
adverse  effect  on  the  health  of  a  woman.
• Affects  60,000  women  annually  in  the  U.S.

ü Rates  are  rising:  nearly  doubled  over  the  last  decade.

ü Racial  and  Ethnic  disparities  exist.
Alliance  for  Innovation  on  Maternal  Health  
(AIM)
ü National  alliance  of  clinicians,  public  health  
officials,  hospital  administration,  patient  
safety  organizations,  and  advocates  
working  to:
• Reduce  maternal  mortality  by  1,000  
deaths  by  2018
• Reduce  severe  maternal  morbidity  
ü Offers  assistance  to  states  and  hospitals  to  assess  culture  
of  safety  in  maternity  care  and  employ  resources  to  
improve  outcomes.  

ü Creates  condition-­‐specific  “bundles”  – evidence  based  
action  steps  endorsed  by  major  maternity  care  provider  
organizations        to  guide  the  best  care.  
Michigan  AIM  
Alliance  for  Innovation  on  Maternal  
Health  (AIM)

OB  Safety  Bundles
Severe  Hypertension
Reducing  Disparities  in  Maternity  Care
in  Pregnancy

Maternal  Mental  Health Safe  Reduction  of  Primary  Cesarean  Births

Patient,  Family  and  Staff  Support Obstetric  Hemorrhage
Reducing  Peripartum  Racial  Disparities  
“Bundle”
ü Consider  racial/ethnic  disparities  broadly

ü Acknowledge  complex  causes:  social  determinants,  behaviors,  
quality  of  care

ü Focus  on  quality  of  care,  modifiable  factors

ü Important  attributes  of  the  bundle:
• Actionable
• Evidence-­‐based
• Feasible
• Impactful
U.S.  Maternal  and  Infant  Mortality
U.S.  has  higher  maternal  and  infant  
mortality  rates  than  other  developed  
countries:

• Ranks  25th in  infant  mortality
• Ranks  >  21th in  maternal  mortality
Maternal  Mortality  Historical  Interventions
®Between  1930-­‐1950  maternal  mortality  decreased  from  600/100,000  to  
40/100,000  in  US
®1930  – ABOG  incorporated
® 1951,  ACOG  founded
®1938-­‐1948,  shift  from  home  to  hospital  deliveries
• Hospital  deliveries  increased  from  55%  to  90%
• Shift  slower  in  rural  areas  and  the  South
• Maternal  mortality  decreased  by  71%

®Legalized  abortion  in  1960”s  contributed  to  89%  decline  in  death  from  septic  
illegal  abortions  during  1950-­‐1973

® 1988  CDC  began  Maternal  Mortality    Surveillance
Maternal  Mortality  Callaghan  (O&G  2010)
Maternal  Mortality

• Overall  global  maternal  mortality  is  430  
per  100,000  live  births
• North  America:  11  per  100,000
• West  Africa:    1,020  per  100,000
Causes  of  Maternal  Mortality  in  US
2001  (Clark  et  al)
• Causes  of  Death %
Complications  of  preeclampsia 15
Amniotic  Fluid  Embolism 14
Obstetric  hemorrhage 11
Pulmonary  embolism 11
Cardiac  disease 11
Nonobstetric infection 7
accident/suicide 7
Obstetric  infection 7
Medication  Error  or  reaction 5
Ectopic 1
Other 11
Postpartum  Hemorrhage
Recent  US  Data  on  PPH  
(based  on  ICD9  codes  from  nationwide  inpatient  sample)
• PPH  implicated  in  2.9%  all  deliveries
• Uterine  atony  present  in  79%  of  cases
• PPH  associated  with  19.1%  all  in-­‐hospital  deaths  after  
delivery
• Overall  rate  of  PPH  ↑  27.5%  from  1995-­‐2004  due  to  ↑  
incidence  atony  

Bateman  et  al  Anesth  Analg  2010;;  110:1368-­73
22
Postpartum  Hemorrhage

Management
Treatment  of  Obstetrical  Bleeding
• Evacuation  of  the  uterus
• Delivery  the  placenta,  or
• Removal  of  the  placenta  manually
• Stimulation  of  the  uterus  to  contract  (uterotonics,  
massage)  →
• myometrial  compression  of  the  vasculature
• Balloon  tamponade  or  compression  sutures  if  
necessary  
• If  uterus  is  unresponsive,  devascularization  
• Finally…  hysterectomy
Active  Versus  Expectant  
Management
Management  of  Third   Blood  Loss  * Blood  loss  *
Stage  of  Labor >  500  mls >  1000  mls

Expectant  (n=3126) 13.6% 2.6%

Active  (n=3158)** 5.2% 1.7%

*  Clinical  estimation  generally  thought **Oxytocin,  ergometrine  
to  be  underestimates  by  about  34-­50% or  both  IM/IV    

Prendiville,  Elbourne,  McDonald,    The  Cochrane  Library  issue  3,  2003  
Obstetric  Emergencies
Preeclampsia/Eclampsia
Management  of  Preeclampsia  
with  Severe  Features
• ≥  34  wk or  <23  wk
• Delivery
• <  34  wk
• Individualize
<  34  wk
Individualize
Counsel

Fetal  /
Maternal Newborn
Risk Benefit
Postpartum HTN-Preeclampsia
Recommendations
ØAll  women  with  hypertensive  disorders

• BP  check  at  3  days  (  hospital,  office  or  home)
• BP check again at 5-7 days
• Daily  Sxs.  of  preeclampsia
• No non-steroidal anti-inflammatory agents
• Impacts platelet function

ØAll women

• Education  about  signs  / symptoms
• Symptoms  to  report
• Office  and  L&D    phone  #
Maternal  Morality  in  the  US
• HCA  examination  of  Maternal  Death  among  1.5  million  
birth  in  124  hospitals  over  6  years    (Clark  SL  et  al.  Am  J  
Obstet Gynecol 2008)
• Most  common  preventable  errors
• Failure  to  adequately  control  BP  in  hypertensive  women
• Failure  to  adequately  diagnose  and  treat  pulmonary  edema  in  
women  with  preclampsia
• Failure  to  pay  attention  of  vital  signs  following  cesarean
• Hemorrhage  following  cesarean  delivery
Rates  of  VTE  (DVT  +  PE)
4,000
Per  100,000  woman-­‐years

3,000 DVTor PE

2,000

1,000

0
1st 2nd 3rd Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6
Trim Trim Trim PP PP PP PP PP PP

*  Heit et  al,    Ann  Intern  Med,  2005
Obstetric  emergencies

Sepsis
Sepsis  Bundle
Obstetric  Morbidity
Pregnancy  in  Women  >  45    
Rural  vs  Urban  Care  and  Maternal  
Morbidity
• Lisonkova et  al.  CMAJ  2016
• Results
• British  Columbia,  Canada  comparing  mortality  and  severe  
morbidity
• death  and  severe  maternal  morbidity  (  OR-­‐1.15,  Ci  1.03-­‐1.28)  in  
rural  vs  urban
• Rural  had  Higher rate  of  eclampsia  (OR-­‐2.70,  Ci  1.79-­‐4.08),  
embolism  (OR-­‐2.16,  CI  1.14-­‐4.07),  uterine  rupture  (OR-­‐1.96,  CI  
1.42-­‐2.72)  than  urban  women
• Infant  in  rural  more  likely  to  have  severe  neonatal  morbidity  (OR-­‐
1.14,  CI  1.10-­‐1.19
• Conclusions
• Providers  in  rural  areas  need  to  be  aware  of  potential  morbidities  
and  mortality  risk.
A  collaboration  between
The  American  Congress  of  
Obstetricians  and  
Gynecologists,  Society  for  
Maternal-­‐Fetal  Medicine,  
Centers  for  Disease  Control,  
Arizona  Perinatal  Trust,  and  
Prevention,  and  National  
Perinatal  Information  Center.
Levels  of  Maternal  Care  Program  
Objectives  for  2016-­‐2017

1. Facilities  understand  their  maternal  care  capabilities  
consistent  with  ACOG/SMFM  Levels  of  Maternal  Care  
guidelines.
2. Translation  of  risk  appropriate  care  policies  that  are  
consistent  with  ACOG/SMFM  Levels  of  Maternal  Care.
3. Formalized  system  support  where  women  deliver  at  
facilities  appropriate  for  their  risk.
Levels  of  Maternal  Care  Objectives  
for  2016-­‐2017
How  will  we  accomplish  these  objectives?  (continued)

2.        Pilot  studies
§ CDC  has  been  testing  LOCATe since  2012
§ On  Site  verification  assessments  (target:  3  states,  12  
facilities)
3.        Validate  Assessment  Instruments  
§ CDC  – LOCATe (facility  self-­‐assessment)
§ ACOG/SMFM  On-­‐Site  Assessment
4.        Test  and  finalize  site  review  and  verification  process
5.        Use  formative  assessment  process  to  improve  program  
ACOG  Presidential  Initiatives
Avera  Health  e-­‐Care
• E-­‐ emergency
• E-­‐ ICU
• E  -­‐ Obstetrics
Psychiatry/Mental  Health
Telehealth
• Periscope  Program  (Milwaukee,  WI)
• Resource  information
• Support
• Psychotherapy
• 22  year  old  with  anxiety/depression  stops  taking  
medication  when  she  learns  of  pregnancy  now  with  
increasing  anxiety  seen  by  midwife  in  public  health  
clinic
• Next  step  (tele  consult)
Maternal  Mortality

Opiate  overdose
Maternal  Mortality  NC
Presidential  Initiatives
Pregnancy  and  Long  Term  Health
Pregnancy  and  Long  Term  Health
Cardiovascular risk reduction should be addressed annually through blood pressure
monitoring, body mass index calculation, and lifestyle modification involving exercise and
dietary instruction. Lipid and glucose measurements should be measured every five years
PARITY
• For women with more than five pregnancies, the CVD increases by 60%

BIRTHWEIGHT
• Low birthweight doubles the risk of cardiovascular disease

PRETERM DELIVERY
• Preterm delivery doubles the risk of cardiovascular disease

OBESITY
• Two fold risk of cardiovascular disease

GESTATIONAL DIABETES
• Seven-fold risk of diabetes later in life and seventy percent increased risk of cardiovascular disease
• Recommend: Repeat screening for diabetes, at a minimum interval of every three years and more
frequently if pregnancy is considered

HYPERTENSION
• Twice the risk of cardiovascular disease
• Recommend: yearly assessment of blood pressure, lipids, blood glucose, and body mass index.
Medications to consider while breastfeeding: Methydopa, Labetalol, captopril and calcium channel
blocker
In  South  Asia
22%  of  world’s  population
50%  of  all  maternal  deaths
Maternal  Mortality  Rates  in  South  Asia
Heart  Disease 32
Respiratory  Disease 22
Medical  other 10
Hypertensive  Disorders 10
Obstetric  Haemorrhage 9
Amniotic  fluid  embolism 9
Liver  disease 5
Suicide 4
Sepsis  -­‐ Reproductive 4
Septic  Abortion 3
Anaesthesia  Complications 3
Other 2
DVT 2
*  Number  of  deaths Anaphylaxis 2
Surgical  Mishap 1
Sepsis  -­‐ other 1
0 5 10 15 20 25 30 35

Cause  of  Death  -­‐ 2013
Almost  25%  of  maternal  deaths  are  due  to  un  met  
need  for  contraception

Main  barriers  facing  promotion  of  FP  services
• Certain  religious  groups  not  practicing  FP  methods  
instill  fear  into  other  ethnic  groups  with  regard  to  a  
possible  ethnic  imbalance  in  the  future
• Lack  of  facilities  in  government  institutions  for  
sterilizations
• Resistance  to  introduction  of  newer  contraceptive  
methods  such  as  PPIUD
Maternal  Mortality  Review  Committees  
(MMRCs)
ü State  MMRCs  are  a  key  piece  of  the  puzzle:
• Interdisciplinary  groups  of  local  ob-­‐gyns,  nurses,  social  
workers,  and  other  health  care  professionals  to  review  
individual  maternal  deaths  and  recommend  solutions  to  
prevent  these  tragic  events  in  the  future.    

ü Every  state  should  have  an  MMRC.  

ü 17  states  have  not  yet  established  an  MMRC.  
ü In  order  for  a  state  to  join  the  AIM  program,  it  must  have  or  be  
in  the  process  of  developing  an  MMRC.  
Cosponsor  H.R.  1318,  Preventing  
Maternal  Deaths  Act!
Sponsors:
ü Representatives  John  Conyers  (D-­‐MI),  Jaime  Herrera  Beutler (R-­‐WA),  
Diana  DeGette  (D-­‐CO),  and  Ryan  Costello  (R-­‐PA).  
What  the  bill  does:
ü Authorizes  the  CDC  to  assist  states  to  create  or  expand  MMRCs.
• Collect  consistent  data  to  help  our  Nation  understand  what  causes  
maternal  mortality.  
• Recommend  locally  relevant  strategies  for  State  Departments  of  
Public  Health  to  prevent  pregnancy  deaths  and  reduce  disparities.  
• Report  to  Congress  on  maternal  mortality  data  to  track  successes  
and  setbacks.  
ü HHS  to  research  disparities  in  maternal  health  outcomes.
ü Senate  Companion  Bill:  S.  1112,  the  Maternal  Health  
Accountability  Act,  sponsored  by  Senators  Heidi  Heitkamp  (D-­‐
ND)  and  Shelley  Moore  Capito  (R-­‐WV).
CDC  Maternal  Mortality  
Review  Action  Cycle
Identification  of  
cases

Data  Collection
Evaluation

Data  Review  
Action and  analysis
Global  Maternal  Mortality