What are the epidemiology and interventions for fetal and maternal mortality in North Carolina?

Epidemiology and Interventions for Fetal and Maternal Mortality in North Carolina

North Carolina faces significant challenges with maternal and fetal mortality, with racial disparities and geographic barriers being major contributing factors to these preventable deaths. The Pregnancy Medical Home (PMH) program has been implemented across North Carolina with over 1,600 providers participating to reduce primary cesarean delivery rates and decrease very-low-birthweight and low-birthweight babies.

Epidemiology of Maternal and Fetal Mortality in North Carolina

• Pregnancy-related death occurs in approximately 700 women each year in the United States, with the U.S. maternal mortality rate at 17.4 per 100,000 live births in 2018 1
• Non-Hispanic Black women and American Indian/Alaska Native women have the highest pregnancy-related mortality ratios, with rates 3.2 and 2.3 times higher than non-Hispanic White women, respectively 2
• Rural residents in North Carolina have approximately 9% higher probability of severe maternal morbidity during childbirth hospitalizations compared to urban residents 2
• For every pregnancy-related death, there are approximately 70 cases of severe maternal morbidity (SMM), with more than 50,000 women affected by SMM in 2014 1
• According to a report from 14 state Maternal Mortality Review Committees, two-thirds of pregnancy-related deaths were preventable 1

Contributing Factors to Maternal and Fetal Mortality

• 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 in North Carolina 2
• Inadequate transportation options and limited access to clinical care, particularly in rural areas of North Carolina, contribute to poor outcomes 2
• Lack of standardized approaches to emergency obstetric care and gaps in responding to obstetric emergencies such as hemorrhage are significant contributors to preventable deaths 2
• Increasing prevalence of obesity and chronic conditions among pregnant women plays a role in high rates of pregnancy-related mortality 2
• Advanced maternal age and substance use disorders significantly increase mortality risk 2

Interventions Implemented in North Carolina

Pregnancy Medical Home (PMH) Program

• North Carolina Division of Public Health developed the PMH program for the pregnant Medicaid population with targeted outcomes to reduce primary cesarean delivery rates and decrease the rate of very-low-birthweight and low-birthweight babies 1
• Key features include:
  • Nurse/social work care managers providing case management services to high-risk patients 1
  • Payments to providers at multiple milestones (after risk screening and postpartum visit completion) 1
  • Higher physician reimbursement rates 1
  • Extensive reach with more than 1,600 providers participating across the state 1, 2

Addressing Racial and Geographic Disparities

• Implementation of implicit bias training for healthcare providers and culturally responsive care practices are essential to reduce disparities 3
• Extending Medicaid coverage to 12 months postpartum can improve maternal health outcomes and reduce fetal mortality 3
• Expansion of telehealth services to increase access to care for high-risk pregnant women, especially in rural and medically underserved areas 2

Standardized Protocols and Safety Measures

• The Alliance for Innovation on Maternal Health (AIM) program assists state-based teams in implementing maternal safety bundles, which are evidence-based practices for maternity care 3
• Standardized protocols for obstetric emergencies such as hemorrhage, severe hypertension, and venous thromboembolism are being implemented 2
• Continual reassessment of patient risk status using validated tools and prompt addressing of any changes can prevent adverse outcomes 3

Early Risk Identification and Management

• Identifying women at greatest risk and initiating appropriate interventions early in the reproductive life course is crucial 3
• Risk factors requiring attention include pre-existing health conditions, socioeconomic factors, and history of previous pregnancy complications 3
• Enhanced surveillance and data collection systems to better identify contributory factors to maternal mortality and inform targeted interventions 2

Comprehensive Postpartum Care

• Extending comprehensive care beyond delivery through the "fourth trimester" with multiple customized postpartum visits 2
• Improved care transition communication between providers is essential for continuity of care 3
• Connecting patients in need of safe and affordable housing, transportation, and food with appropriate social services can improve outcomes 3

Challenges and Future Directions

• Despite implementation of the North Carolina Maternal Mortality Review Committee, maternal mortality remains a challenge to families, health systems, and communities 4
• The maternal death rate after 20 weeks' gestation is almost 10 times that associated with pregnancy interruptions, highlighting the need for focused interventions during later pregnancy stages 5
• Collaborative models are needed to improve the referral process for women in rural areas who need more specialized care during childbirth 1