The burden of maternal mortality in the United States (U.S.) has recently garnered a great deal of media attention and is now supported by new data from the Building U.S. Capacity to Review and Prevent Maternal Deaths project team. Released earlier this year, their Report from Nine Maternal Mortality Review Committees (MMRCs) provides an evidence-based analysis of why preventable maternal deaths continue to take place in the U.S. Incorporating data from nine states—Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina and Utah—as well as lessons learned from surveying maternal mortality in a total of 20 state and local MMRCs, the report investigates causes, contributors and next steps related to addressing maternal mortality.
According to David Goodman, PhD, team lead, Maternal Health Team in the U.S. Centers for Disease Control and Prevention (CDC) Division of Reproductive Health,
“While maternal deaths are relatively rare in the United States, each one is tragic. We have an opportunity to build on current momentum to turn the tide. A tangible step in that direction is new data and insight we published earlier this year in Report from Nine Maternal Mortality Review Committees. In the report, we confirmed that the majority of these deaths are preventable, provided in-depth insight into causes of death and racial disparities, and highlighted actionable prevention recommendations made by the Nine Committees. Each maternal death is a tear in the community fabric—a child without a mother, parents without a daughter, and partners without their other half. CDC is committed to reducing maternal mortality in the U.S., and welcome additional collaboration as we work together to end preventable deaths.”
Over 60% of pregnancy-related deaths in the U.S. were preventable. The report estimates that 63% of pregnancy-related deaths were preventable while 68% of cardiovascular and coronary deaths and 70% of hemorrhage deaths were preventable.
Both direct and underlying causes led to maternal death—and varied by race. Nearly half of pregnancy-related deaths were caused by hemorrhage, cardiovascular and coronary conditions, cardiomyopathy or infection. Underlying causes such as preeclampsia and eclampsia and embolism were identified as leading causes of death among non-Hispanic black women, while mental health conditions comprised an important cause of maternal deaths, especially among white women.
Patient/family and provider factors were considered largest contributors to maternal death. An average of four contributing factors were identified for every one pregnancy-related death, with the greatest proportion of factors contributing to pregnancy-related death linked to patient/family factors, such as lack of knowledge on warning signs and the need to seek care. This was followed by provider and systems of care factors, including misdiagnosis/ineffective treatment and poorly-coordinated care, respectively. Facility and community factors were not commonly associated with maternal death. However, the authors caution readers not to “assume that the absence of ‘community-level’ factors in our last report is evidence that community-level factors do not contribute to pregnancy-related death.”
Equity key to improving maternal health outcomes. Given that non-Hispanic black women in the U.S. die from pregnancy-related causes at a rate three to four times that of non-Hispanic white women, the report stresses the impact of social determinants of health on maternal death. The report introduces an equity framework, a tool that addresses disparities and “encourages MMRCs to consider the contributions of patient/family, provider, facility, health system and community-level factors as part of the broader context of each death.”
The following were the most common themes emerging from Nine Committees’ recommendations:
- Improve training
- Enforce policies and procedures
- Adopt levels of maternal care/ensure appropriate level of care determination*
- Improve access to care
- Improve patient/provider communication
- Improve patient management for mental health conditions
- Improve procedures related to communication and coordination between providers
- Improve standards regarding assessment, diagnosis and treatment decisions
- Improve policies related to patient management, communication and coordination between providers and language translation
- Improve policies regarding prevention initiatives, including screening procedures and substance use prevention or treatment programs
*For more information on levels of maternal care, refer to the ACOG and SMFM Obstetric Care Consensus Statement.