What is maternal mortality and how can it be prevented?

Maternal Mortality: Definition, Implications, and Prevention Strategies

Maternal mortality is a critical health issue defined as deaths during pregnancy or within 1 year of the end of pregnancy from causes related to pregnancy or its management, with approximately 700 women dying each year in the United States alone, and two-thirds of these deaths being preventable through improved surveillance, standardized protocols, and targeted interventions. 1, 2

Definition and Epidemiology

Maternal mortality encompasses:

• Deaths during pregnancy or within 1 year of pregnancy end from pregnancy-related causes
• Deaths within 42 days after pregnancy end from pregnancy-related causes (narrower definition)
• The U.S. maternal mortality rate was 17.4 per 100,000 live births in 2018 1
• Severe maternal morbidity (SMM) affects approximately 50,000 women annually 1
• For every maternal death, approximately 70 cases of SMM occur 1

Leading Causes of Maternal Mortality

1. Cardiovascular conditions - leading cause of pregnancy-related deaths 1, 3
2. Non-cardiovascular medical conditions 1
3. Infection 1
4. Hemorrhage - major cause requiring prompt intervention 3
5. Cardiomyopathy 3

Risk Factors and Disparities

• Racial/ethnic disparities:

  • Non-Hispanic Black women have 3.2x higher mortality rates than non-Hispanic White women 2, 3
  • American Indian/Alaska Native women have 2.3x higher mortality rates than non-Hispanic White women 2

• Other risk factors:

  • Advanced maternal age (≥35 years) 2
  • Pre-pregnancy obesity 2
  • Chronic medical conditions 2
  • Substance use disorders (4x increased risk) 2
  • Rural residence (9% higher probability of severe maternal morbidity) 2

Prevention Strategies

1. Risk Assessment and Early Identification

• Conduct comprehensive risk assessment at first prenatal visit with continuous reassessment throughout pregnancy 2
• Ensure all women of childbearing age receive pregnancy-related health risk assessments 2
• Identify and treat pre-existing conditions before conception 2
• Utilize maternal early warning criteria (MEWC) to identify women at risk for deterioration 2

2. Standardized Protocols and Safety Bundles

• Implement maternal safety bundles through the Alliance for Innovation on Maternal Health (AIM) program 2
• Develop standardized protocols for common obstetric emergencies, including:
  • Severe hypertension management
  • Venous thromboembolism prevention
  • Hemorrhage management 2

3. Enhanced Postpartum Care

• Shift from a single postpartum visit to comprehensive care customized to women's needs 2
• Extend care beyond the traditional 6-week postpartum period 2
• Monitor for complications in the postpartum period, when more than half of all pregnancy-related deaths occur 2
• Implement postpartum telehealth monitoring with home blood pressure monitors for high-risk women 2

4. Healthcare System Improvements

• Establish a complete and integrated system of perinatal regionalization with risk-appropriate maternal care levels (I-IV) 2
• Implement regionalized maternal care with appropriate transfer protocols for high-risk cases 2
• Decrease variation in care across facilities providing obstetric services 2
• Expand insurance coverage before, during, and after pregnancy 2
• Address rural healthcare disparities 2

5. Provider Training and Education

• Expand provider training in obstetric emergencies 2
• Improve communication within care teams 2
• Train providers to recognize early warning signs of the leading causes of maternal mortality 2
• Combat implicit bias and structural racism at provider and healthcare system levels 2

6. Surveillance and Review

• Establish maternal mortality review committees (MMRCs) to analyze deaths and inform prevention strategies 2, 4
• Utilize the Maternal Mortality Review Information Application (MMRIA) data system for standardized review 2
• Implement the ERASE MM Program to identify and review maternal deaths 2

7. Targeted Interventions for Vulnerable Populations

• Implement peer education programs and group prenatal care models 2
• Utilize remote monitoring technologies for rural and medically underserved areas 2
• Support the State Maternal Health Innovation Program to address maternal health disparities 2
• Implement the Rural Maternity and Obstetrics Management Strategies program to improve access in rural communities 2
• Support the Healthy Start Initiative to reduce racial/ethnic differences in maternal outcomes 2

Pitfalls and Caveats

1. Avoid focusing solely on acute obstetric emergencies while neglecting medium and long-term complications 2
2. Be aware of medication interactions - severe hypertension can occur when oxytocin is given after vasoconstrictors 5
3. Monitor for water intoxication with continuous oxytocin infusion, which can lead to convulsions and coma 5
4. Recognize the impact of social determinants of health on maternal outcomes 2
5. Don't overlook postpartum period - nearly 12% of deaths occur 43-365 days postpartum 1
6. Ensure accurate data collection - standardized methods for identifying maternal deaths are essential 3

By implementing these evidence-based strategies and addressing the multifaceted factors contributing to maternal mortality, healthcare systems can work toward reducing preventable maternal deaths and improving maternal health outcomes.