Global efforts aim to end preventable maternal death

Rachel M. Kacmar, MD

Rachel M. Kacmar, MD

Protecting maternal health is a priority of health care providers worldwide. Despite that, maternal morbidity and mortality rates are on the rise, even in the United States.

Rachel M. Kacmar, MD, Associate Professor of Anesthesiology at the University of Colorado School of Medicine in Aurora, will address this health crisis during Monday’s session “Maternal Morbidity and Mortality: An Anesthesiologist’s Role and Perspective.”

Here, Dr. Kacmar offers insight into the topics she will explore during the session, including why new statistical measures may partially be responsible for the inflated numbers on maternal morbidity and mortality and how anesthesiologists can join the multidisciplinary effort to promote maternal safety.

Q: What is the status of maternal morbidity and mortality worldwide and in the United States?

A: Decreasing the rate of maternal morbidity and mortality is a worldwide goal, and over the past 30 years some improvement has been seen. Unfortunately, both maternal morbidity and mortality rates in the U.S. seem to be rising, and our performance compared to other high-resource countries is especially poor.

Maternal Morbidity and Mortality: An Anesthesiologist’s Role and Perspective

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Q: Why is it so high in a developed country like the United States?

A: There are many factors that contribute to the high rates of maternal morbidity and mortality in the U.S. On average, our pregnant patients are getting older and have more co-morbidities like obesity, diabetes, hypertension, and cardiac disease. Lack of access to both primary and prenatal care as well as the prevalence of Medicaid and uninsured patients also increase risk for morbidity and mortality. Racial and ethnic disparities also exist across most of the causes of both maternal morbidity and mortality. Finally, delays in appropriate patient assessment, diagnosis, and treatment are commonly cited as contributing factors in cases of maternal morbidity and mortality in the U.S.

Q: Why is it increasing?

A: When we compare data across time points, there seems to be a swift rise in the mortality rate from the late 1990s and early 2000s to present day. Two of the main factors that have influenced that data are the implementation of the pregnancy checkbox on death certificates and the change from ICD-9 to ICD-10 medical coding system. As more states added the pregnancy checkbox to death certificates and added the additional codes for pregnancy-related death included with ICD-10, the accuracy of reporting increased. Now, we can better appreciate if a woman was pregnant anytime within the past year prior to death and whether that pregnancy was in any way related or causative to the death. It seems that the drastic increase in maternal mortality may not be the exact right interpretation; instead, the conclusion may be closer to accepting that we were very inaccurate before, leading to significant underestimation of the maternal mortality numbers. This is not to say that we are not experiencing increased maternal mortality rates – especially compared to other high-resource countries – but, instead, that it might not be quite as significant as feared.

Q: What is being done to decrease these numbers on a local, state, and national level?

A: Stakeholders are working to address maternal morbidity and mortality on many levels. Locally, individual hospitals and health systems are implementing components of maternal safety bundles for things like peripartum hemorrhage and the hypertensive disorders of pregnancy. Multidisciplinary review of cases help identify contributing factors at the patient, provider, and system levels that could potentially be addressed to avoid similar outcomes in the future. At the state level, Maternal Mortality Review Committees (MMRCs) and Perinatal Quality Care Collaboratives work to improve the integrity of maternal mortality data as well as propose and disseminate evidence-based maternal safety interventions. Nationally, there are groups working on coordinating efforts of individual state MMRCs for more powerful insight into causative factors that can be addressed. Multiple bills are also currently in Congress that take aim at various aspects of maternal morbidity and mortality.

Q: How can anesthesiologists help?

A: We can help with all of the above initiatives! As anesthesiologists, our background in critical care as well as acute treatment of things like hemorrhage and hemodynamic instability in the perioperative environment provides crucial perspective on obstetric units. We have to be part of the multidisciplinary efforts for maternal safety in our own hospitals and institutions as well as the broader work in addressing the disparities and community level socioeconomic factors that contribute to maternal morbidity and mortality. Anesthesiologists can also join MMRC efforts and even work with their representatives in Congress to support the legislation currently under review. Just as we strive to be leaders in patient safety in the operating room, we have to be leaders in maternal safety as well.

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