What can be done to reduce the high Maternal Mortality Rate in this location?

Reducing Maternal Mortality: Evidence-Based Strategies

To reduce maternal mortality, implement standardized maternal safety bundles addressing the leading causes of death (cardiovascular conditions, hemorrhage, hypertensive disorders, and infection), extend postpartum care and Medicaid coverage to 12 months, establish robust maternal mortality review committees, and prioritize interventions for high-risk populations including Black and American Indian/Alaska Native women and rural residents. 1, 2, 3

Understanding the Problem

The maternal mortality crisis is characterized by preventable deaths, with two-thirds of pregnancy-related deaths being avoidable through evidence-based interventions. 1 The leading causes of maternal death from 2007-2016 were cardiovascular conditions, non-cardiovascular medical conditions, and infection, with over half of deaths occurring after birth and nearly 12% occurring 43-365 days postpartum. 1

Critical Disparities

• Non-Hispanic Black women have 3.2 times higher mortality compared to non-Hispanic White women 1, 2, 3
• American Indian/Alaska Native women have 2.3 times higher mortality than non-Hispanic White women 1, 2
• Rural residents have 9% higher severe maternal morbidity during delivery hospitalizations and nearly 2 times higher mortality compared to urban residents 3, 4

Priority Interventions to Implement

1. Maternal Safety Bundles and Clinical Protocols

Implement standardized maternal safety bundles through programs like the Alliance for Innovation on Maternal Health (AIM), which provides evidence-based practices for obstetric hemorrhage, severe hypertension/preeclampsia, venous thromboembolism, and obstetric sepsis. 2, 3 These bundles standardize responses to the direct causes of maternal death and have demonstrated effectiveness in reducing preventable mortality. 3

2. Extended Postpartum Care

Extend Medicaid coverage to 12 months postpartum rather than the traditional 6 weeks, as more than half of pregnancy-related deaths occur after birth. 1, 2, 3 Implement "fourth trimester" care with multiple personalized postpartum visits to address complications including hemorrhage, hypertensive disorders, depression, anxiety, and other morbidities that emerge after 6 weeks. 3

3. Maternal Mortality Review Committees

Establish or strengthen state-level Maternal Mortality Review Committees (MMRCs) to systematically review all pregnancy-related deaths, identify preventable factors at patient, provider, and system levels, and implement targeted interventions. 1 These committees have been instrumental in documenting that two-thirds of deaths are preventable. 1

4. Enhanced Surveillance and Data Systems

Improve maternal mortality surveillance through accurate data collection systems that track deaths during pregnancy and up to one year postpartum. 1 This includes proper use of pregnancy checkbox questions on death certificates and linking vital statistics with hospital discharge data to capture severe maternal morbidity cases. 1

5. Address Rural Healthcare Access

Expand telemedicine services for rural areas to provide access to maternal-fetal medicine specialists and emergency obstetric consultation. 2, 3 Given that rural residents face nearly double the mortality risk, telehealth can bridge geographic gaps in specialized care. 4

6. Comprehensive Risk Assessment

Initiate continuous risk evaluation starting in the preconception period and continuing throughout pregnancy and the full year postpartum. 3 Early identification of women at higher risk—including those with obesity, chronic diseases, cardiovascular conditions, or previous cesarean delivery—allows for timely intervention. 3

7. Clinical Workforce Training

Implement mandatory implicit bias training for all healthcare providers involved in maternity care to address the stark racial disparities in maternal outcomes. 2 Combine this with culturally responsive care practices and training in recognition and management of obstetric emergencies. 1, 2

8. Pregnancy Medical Home Models

Adopt comprehensive care coordination models like North Carolina's Pregnancy Medical Home program, which includes nurse/social work care managers, milestone-based payments, and enhanced physician reimbursement to incentivize high-quality prenatal care. 2 This model has demonstrated success in reducing cesarean delivery rates and low birthweight babies. 2

Addressing Leading Clinical Causes

Obstetric Hemorrhage

Standardize protocols for hemorrhage management including quantitative blood loss measurement, staged response algorithms, and immediate availability of blood products and uterotonics. 3 Postpartum hemorrhage prevention is crucial and requires institutional protocols. 3

Hypertensive Disorders

Implement severe hypertension bundles with clear blood pressure thresholds for treatment (≥160 systolic or ≥110 diastolic), standardized antihypertensive protocols, and postpartum blood pressure monitoring extending beyond hospital discharge. 3

Cardiovascular Conditions

Given that cardiovascular disease is now the leading cause of pregnancy-related death, establish protocols for cardiac screening in high-risk patients and ensure access to cardiology consultation during pregnancy and postpartum. 1

Critical Implementation Considerations

Common pitfall: Focusing only on the immediate peripartum period when over half of deaths occur after hospital discharge. 1 The solution is extending surveillance and care through the full year postpartum. 2, 3

System-level barriers: Delays in seeking care, reaching healthcare facilities, and receiving appropriate treatment once at facilities contribute significantly to preventable deaths. 3 Address these through community education, improved emergency transport systems, and ensuring all facilities have capacity for emergency obstetric care or rapid transfer protocols. 3

Resource allocation: Prioritize interventions for populations at highest risk—Black women, American Indian/Alaska Native women, and rural residents—rather than applying uniform approaches that may not address underlying disparities. 1, 2, 4