Maternal mortality in New York--Looking back, looking forward

Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly..

Two decades of interventions in New York State to reduce maternal mortality: a systematic review

Objective: To perform a systematic review of interventions to reduce maternal mortality in New York.Study design: We conducted a systematic review of literature published between 2000 and January 2019 reporting interventions to reduce maternal mortality in New York using PubMed and search terms: pregnancy-related death or maternal mortality OR maternal death AND New York. Eight hundred and ninety-three articles were reviewed by title, content, and focus on New York interventions or policies. Ten met inclusion criteria. A second review of the Safe Motherhood Initiative (SMI) identified an additional six articles.Results: Nine articles described hospital-based initiatives; one described a community-based initiative. No prospective randomized controlled trials in a nonsimulated setting were identified. Several articles described SMI bundles; one tested simulated checklist implementation. Three presented results of bundle implementation but did not significantly impact measured maternal mortality and/or morbidity. The single community-based initiative provided doulas to low-income women, yielding significantly lower rates of preterm birth and low birthweight, but no difference in cesarean deliveries compared to other women in the community.Conclusion: Current hospital-based interventions have not reduced maternal mortality in New York. The single community-based intervention identified reduced adverse birth outcomes. Continued concern about maternal mortality in New York suggests community-based approaches should be considered to affect change in conjunction with longer term hospital-based interventions.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma

OBJECTIVE

To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations.

METHODS

We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed.

RESULTS

Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01).

CONCLUSION

There may be an opportunity to reduce use of β-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Opportunities for hospitals, hospital systems and leadership to improve VTE prophylaxis

A sustained increase in the maternal death rate in the U.S. remains one of the most challenging issues of the twenty-first century. Ten years ago, we investigated the major conditions contributing to the maternal death rate between the years 2000 and 2006. The leading causes of death in the U.S. at that time were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Venous thromboembolism accounted for 9% of all maternal death, and an overall pregnancy-related mortality risk of 0.9 maternal deaths per 100,000 live births. VTE was the most common preventable cause of maternal death noted during that time period. In this paper, we will review and summarize changes in obstetric health care over the last ten years implemented to prevent VTE and its related morbidity. We will then examine opportunities for hospitals and hospital systems to improve VTE prophylaxis.

Safe Motherhood Initiative: Early Impact of Severe Hypertension in Pregnancy Bundle Implementation

Objective  To describe the implementation and early results of the American College of Obstetricians and Gynecologists District II Safe Motherhood Initiative's Severe Hypertension in Pregnancy bundle on the timely treatment of severe hypertension in New York State obstetric hospitals. Methods  This is a retrospective comparative study of two time periods during voluntary implementation of the Severe Hypertension in Pregnancy bundle in New York State's obstetric hospitals. The main outcome measure was the administration of an appropriate antihypertensive agent within 1 hour of the second elevated value for all pregnant or postpartum patients with severe hypertension. Results  Of the 117 obstetric hospitals participating in the Safe Motherhood Initiative, 111 (94.9%) submitted data included in this analysis. During the study period, 80 of the 111 (72.0%) hospitals reported implementing the hypertension bundle. Overall, 2.4% of pregnant women were diagnosed with severe hypertension, and 60 to 65% of patients were treated within an hour of the second elevated value. Although not statistically significant, a greater numbers of patients were treated within an hour of the second elevated value in the second time period compared with the first in most obstetric hospitals (overall 64.8 vs. 60.8%; p  = 0.33). Conclusion  There were increasing numbers of patients receiving timely treatment of severe hypertension during early implementation of a Severe Hypertension in Pregnancy bundle in New York State obstetric hospitals. However, bundle implementation requires significant financial and human resources and the long-term impact on maternal morbidity and mortality in our state remains uncertain. Precis There was a tendency toward more timely treatment of severe hypertension following implementation of a Severe Hypertension in Pregnancy bundle in New York obstetric hospitals.