What are the factors contributing to high fetal and maternal mortality rates in North Carolina?

Factors Contributing to High Fetal and Maternal Mortality Rates in North Carolina

North Carolina's high fetal and maternal mortality rates are driven by multiple interconnected factors including racial disparities, rural healthcare access limitations, and gaps in standardized emergency obstetric care.

Racial and Ethnic Disparities

• Non-Hispanic Black women and American Indian/Alaska Native women have the highest pregnancy-related mortality ratios in the United States, with rates 3.2 and 2.3 times higher than non-Hispanic White women, respectively 1
• In North Carolina specifically, 46% of deaths among African-American women were potentially preventable, compared with 33% of deaths among white women 2
• Systemic racism and discrimination contribute to these disparities through chronic stress and inadequate healthcare responses to expressed concerns 1

Geographic and Access Barriers

• Rural residents have a 9% higher probability of severe maternal morbidity (SMM) and mortality during childbirth hospitalizations compared to urban residents 1
• The closure of obstetric units has resulted in the loss of obstetric services in more than 50% of U.S. rural counties, affecting access to specialized care 1
• North Carolina faces challenges with inadequate transportation options and limited access to clinical care, particularly in rural areas 1

Healthcare System Factors

• Lack of standardized approaches to emergency obstetric care contributes to poor maternal health outcomes 1
• Gaps in responding to obstetric emergencies such as hemorrhage are significant contributors to preventable deaths 1
• Inadequate attention to women's health during the postpartum period is problematic, as more than half of all pregnancy-related deaths occur after birth, including nearly 12% occurring 43-365 days postpartum 1

Medical Risk Factors

• Increasing prevalence of obesity and chronic conditions among pregnant women plays a role in high rates of pregnancy-related mortality 1
• Advanced maternal age increases risk; nearly one-third of all pregnancy-related deaths in the United States occur in women aged 35 years or older 3
• Substance use disorders significantly increase mortality risk; deliveries associated with maternal opioid abuse or dependence have more than 4 times the odds of maternal death compared to deliveries without such issues 1

Prevention Initiatives in North Carolina

• North Carolina has implemented the Pregnancy Medical Home (PMH) program for the Medicaid population, targeting reduced primary cesarean delivery rates and decreased rates of low-birthweight babies 1
• The PMH program involves over 1,600 providers and includes nurse/social work care managers providing case management services to high-risk patients 1
• Despite these efforts, a comprehensive review of pregnancy-related deaths in North Carolina found that 40% of these deaths were potentially preventable, primarily through improved quality of medical care 2

Effective Interventions

• Maternity care coordination services in North Carolina have shown positive impacts - women on Medicaid who received these services had 21% lower low birth weight rates, 62% lower very low birth weight rates, and 23% lower infant mortality rates 4
• For each $1.00 spent on maternity care coordination in North Carolina, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age 4
• Women receiving maternity care coordination for 3 or more months had better outcomes than those receiving it for less than 3 months 4

Additional Contributing Factors

• Homicide and injury-related deaths are significant contributors to maternal mortality in North Carolina, accounting for 37% of maternal deaths in one study, with homicide being the most common cause of injury-related death (35.5%) 5
• The relative risk of injury-related maternal death for nonwhites compared to whites was 1.7 in North Carolina 5
• Counseling regarding injury prevention, domestic violence, and depression should be integrated into both prenatal and postpartum care 5

Recommendations for Improvement

• Implementation of maternal safety bundles and standardized protocols for obstetric emergencies such as hemorrhage, severe hypertension, and venous thromboembolism 1
• Expansion of telehealth services to increase access to care for high-risk pregnant women, especially in rural and medically underserved areas 1
• Enhanced surveillance and data collection systems to better identify contributory factors to maternal mortality and inform targeted interventions 1
• Addressing racial disparities through provider education on implicit bias and structural racism 1
• Extending comprehensive care beyond delivery through the "fourth trimester" with multiple customized postpartum visits 1