The anesthesiologist’s role in reducing maternal mortality and morbidity

It could be a headline straight out of the pioneer days, when maternal mortality rates were abysmal. Yet in 2019, news headlines about maternal morbidity and mortality remain modern-day health care problems. Many recent studies have reported increasing rates in both. This fact provides anesthesiologists with the opportunity to step in and make a positive difference.

Rachel M. Kacmar, M.D.

During Monday’s session “Maternal Morbidity and Mortality? An Anesthesiologist’s Role and Perspective,” Rachel M. Kacmar, M.D., an Associate Professor of Anesthesiology at the University of Colorado School of Medicine and Chair of Patient Safety for SOAP, offered a detailed snapshot of the current status of maternal morbidity and mortality, recent trends and the factors that contribute to the problem, and the role anesthesiologists play in preventing it.

“Maternal morbidity and mortality is a major worldwide health issue, and both seem to be increasing in the United States,” Dr. Kacmar said. “Patient, provider and systems issues contribute to these trends, and all are areas that need immediate attention.”

Maternal morbidity and mortality is defined as unintended outcomes or complications of pregnancy, labor and/or delivery with significant maternal health consequences within the first year of pregnancy. In the U.S., 900 women die each year during pregnancy and the postpartum period.

So why are American women still dying after childbirth in this day and age? According to Dr. Kacmar, the most common causes of maternal morbidity in the U.S. are hemorrhage, preeclampsia, sepsis and thromboembolic disease, while the most common cause of maternal mortality is cardiovascular disease. It currently accounts for about 25% of maternal deaths in the U.S. Not surprisingly, pregnant women have not been untouched by the opioid epidemic, she said. Opioid use and abuse during pregnancy is rising and is the most common substance identified following maternal death due to overdose

“This means we need to extend our opioid attention to labor and delivery and post-partum patients as well,” she said.

Significant racial and ethnic disparities are apparent within this topic, Dr. Kacmar said, as black, non-Hispanic women have an approximate three-fold increased rate of maternal mortality compared to white, non-Hispanic women, and a significantly higher risk of nearly all causes of maternal morbidity.

Recognizing women at risk for maternal morbidity and mortality through analysis of existing co-morbidities and risk factors or via resources such as the Maternal Early Warning System is critical, she said. In addition, Dr. Kacmar underscored the importance of implementing maternal safety bundles on labor and delivery units, which is an important national and multidisciplinary initiative under way by the Council on Patient Safety in Women’s Health Care. In making evidence-based recommendations for maternal safety resources and pathways, state-wide maternal mortality review committees have a crucial role in dissecting what contributed to maternal deaths and when data is compiled. Finally, multiple legislative efforts related to maternal morbidity and mortality are currently in the works, including the Preventing Maternal Deaths Act that was passed in December 2018.

Anesthesiologists can and should take the lead in reducing maternal morbidity and mortality rates, Dr. Kacmar said, particularly in community hospitals.

“Anesthesiologists fly under the radar in so many ways. We have the ability, expertise and opportunity to help, and we need to be involved in promoting maternal safety and positive outcomes,” she said. “Our training sets us up to move to the front lines of taking care of these women.”

Still, despite urging anesthesiologists to move to the front lines of care, Dr. Kacmar said the subspecialty has been integrally involved in much of the research, multidisciplinary work and on-the-ground implementation efforts related to maternal morbidity and mortality.

Dr. Kacmar urged attendees to use their acute and critical care backgrounds when working in labor and delivery to help provide the best culture and environment of safety. In particular, anesthesiologists must be readily available in Level 2 and present in Levels 3 and 4 hospitals, as defined by the American College of Obstetricians and Gynecologists, she added.

“Maternal morbidity and mortality is a crisis, and we should be a key part of the solution – not just in academic centers, but in community hospitals and low-volume centers. Maternal morbidity and maternal deaths occur in these settings,” she said. “This involvement, which leverages our medical and critical care expertise as well as presence on labor and delivery, can help decrease the rates of maternal morbidity and mortality.”

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