The headlines are screaming it, your patients are asking about it, and your national organization is warning you about it: America has one of the highest maternal mortality rates in the developed world, and it is continuing to escalate. In 2018, USA Today released an article that dropped like a bomb: American mothers are dying. The number varies but hovers around 700 a year. This number includes women who died during pregnancy, as well as women who died during labor and the postpartum period.
Each year, approximately 4 million babies are born in the U.S., making the mortality rate, 0.0175%, seem very low at first glance. However, every maternal death is one too many, and we have set our bar at zero.
In the months since the internet blew up with opinion, fact, action, and inaction, a lot of confusion and finger-pointing ensued. Consumers blamed hospitals. Doctors blamed an increasing obesity rate, older first time mothers, a deteriorating health network, nurse staffing ratios, noncompliance, and opioid addiction. Hospitals dug into their outcome data. Celebrities who had near misses highlighted that this is not an uncommon occurrence, and for every death there are hundreds of women who came close. Recently, a finger was pointed by CBS at Nurse-Midwives as possible contributors to adverse outcomes, an accusation unfounded in evidence, that made the flames rise higher and drove a wedge in the already precarious collaborative care model in the U.S. Without delving into the ample data readily available online and in the literature, take it from me that there is a real problem, and we are not in agreement on how to resolve it. We aren’t even on the same page. What we all agree on is that we want it to go away, immediately.
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Maternal Mortality: The Issues
Everyone can be outraged about maternal mortality, making it the one topic that is blurring political lines. In the aftermath of the initial awareness, there were those who emerged into the spotlight to fuel their own platforms, drawing attention away from the underbelly of issues that remain largely unexplored in the media but beg a closer look. Among those issues is the way women experience childbirth and how their care is reimbursed in comparison to care received by men. Childbirth, often a surgical procedure, is reimbursed at low rates compared to prostate surgeries. Alarming stories surfaced out of busy academic centers with residents caring for patients, calling for a closer look at our residency programs and who is watching over women.
Another issue that jumped out is the stark geographical difference in outcome data: What is happening in Louisiana, Georgia, and Arkansas to have astronomical mortality rates compared to California, Connecticut, and Colorado, who rank among the lowest in the U.S.?
Obstetricians are focused on the prevention of catastrophic outcomes, but sometimes do so at the cost of the principles of shared decision making and informed consent.
Women are increasingly reporting that they felt mistreated during their hospital stay and were pushed into interventions for themselves and their babies they did not want. Obstetricians are focused on the prevention of catastrophic outcomes, but sometimes do so at the cost of the principles of shared decision making and informed consent. The growing cesarean rate underscores that more than 1 out of 3 women in America give birth surgically for a multitude of reasons ranging from scheduling births for convenience to a fear of litigation. In response to maternal mortality awareness, intervention appears to have increased. Women present their obstetricians with the information they pull from social media, afraid to become a statistic, with a response of increased vigilance and less patience to let the process of labor unfold naturally, eliminating risk of giving birth remote from the hospital or during absence of the physician.
In response to the fear of dying and the strong push for intervention, a number of families are turning to homebirth and unattended birth, or ‘freebirth’, out of a conviction that hospitals are where laboring women go to die and that home is safer. In response, obstetricians are more concerned than ever about birth remote from a hospital. Common in other Western nations, homebirth in the U.S. is still stigmatized as alternative and perceived as fraught with risk. Out-of-hospital birth is overwhelmingly safe with appropriate patient and provider selection, has far lower cesarean and episiotomy rates than hospital birth, and is certainly legal, yet women experience tremendous bias from healthcare providers when they present in labor from a home or birth center birth. Deterrents to immediate emergency care put women and infants at risk. Few hospitals and EMS providers have open, non-punitive community transfer policies.
Obstetric Violence, which remains undefined in tort law in the U.S., is becoming more clearly defined as it pertains to birth in the U.S.
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Maternal Mortality and Near-Miss Events
Women took to social media to share their near-miss stories, and a current of anger sprinkled with words like ‘abuse,’ ‘assault,’ ‘negligence,’ ‘racism,’ and ‘coercion’ put nurses, hospitals, and physicians on the defensive. Birth advocacy organizations like ImprovingBirth, who have worked for years to rally women to speak up against an over-medicalized and broken maternity system, found a foothold in the confusion and chaos as the proverbial chips landed. Stories poured in from everywhere in the nation that highlighted negative birth experiences from the view of those who personally experienced unwelcome and, at times, unconsented intervention.
The stories empowered more women to speak up, resulting in an additional level of urgency. Obstetric Violence, which remains undefined in tort law in the U.S., is becoming more clearly defined as it pertains to birth in the U.S. The terms ‘respectful maternity care’, ‘tokophobia’, and ‘D&A’ (disrespect and abuse) are now fast becoming familiar to those who follow birth activism on social media.
Where it left us was in a place of mutual distrust, putting birthing people in an impossible climate of uncertainty and overwhelmed by conflicting information. Out of the chaos, some important catalysts are emerging as we work towards a solution. Racism and implicit bias were identified as significant factors, as were reliance on Medicaid and the growing awareness of the impact of untreated mental health diagnoses. There are far more African American fatalities than other races, which has given voice to women and birth workers of color and other under-represented at-risk populations with unique needs, such as Native Americans, who often feel unheard and invisible.
ACOG took a strong lead in the discussion, focusing a portion of their recent annual conference on the topic, and presenting victims as speakers. ACNM, long a proponent of collaborative MD-CNM/CM collaborative care with exemplary maternal and neonatal outcome data among its members, got resounding support from the World Health Organization, which identified that midwives play a role in mortality prevention and are an optimal way to address access to care and a global physician shortage. The two organizations released a new joint statement in 2018 that underscores that shortages and maldistribution of maternity care clinicians cause serious public health concerns for women, children, and families, and that ob-gyns and CNMs/CMs work together to optimize women’s health care. There is a robust discussion around hospital design and the impact optimally designed birth spaces may have on outcomes. States with Medicaid expansion and robust social services and states that tie outcomes to reimbursement fared far better in maternal health outcomes than states with tight control on taxpayer healthcare subsidies, and states that did not have perinatal quality and maternal mortality review boards are now creating them.
Data collection is being scrutinized. There are two national data sources for measuring maternal mortality in the U.S., the CDC’s National Vital Statistics System (NVSS) and the Pregnancy Mortality Surveillance System (PMSS). The data collection is incomplete and inconsistent, a concern that now has a renewed focus. The opioid crisis, which affects women and children in large numbers, is a significant contributor to maternal mortality. States are rallying to collect prevalence data and ramp up state resources.
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Maternal Mortality: What’s Next
For hospitals, the discussion needs to be transparent around how women are safeguarded in the system while preserving a “your birth, your way” philosophy. A non-punitive environment for healthcare workers, including physicians, supports open dialogue and process improvement. Nurses who are empowered to have a strong voice and advocacy for women in their care are significant contributors to positive outcomes. One of the factors identified by various maternal mortality boards is that women reported concerns that were at times ignored or dismissed by nurses and providers. A strong “I am listening” message is encouraged, with sensitivity training for staff to address bias, which prompted ACOG to provide large buttons for obstetricians to wear that spell out, “I’m listening. Every mom. Every time.”
A non-punitive environment for healthcare workers, including physicians, supports open dialogue and process improvement.
Staffing ratios in labor and delivery have a critical impact on outcomes. Due to the complexity and acuity of obstetrics and the tremendous impact when an adverse event occurs, this is one of the most critical areas in the hospital to focus on optimal staffing efforts. Emergencies in labor and delivery can unfold in minutes without any warning and require an immediate response.
As the nation begins to address the crisis and best practice recommendations emerge, it is important that we put our collective biases and long-standing beliefs aside and respond to the emerging evidence with a commitment to rapid improvement. Birth philosophies are a touchy subject with everyone believing their way is best. Early indicators point fingers at an obstetric model with high induction and cesarean rates that has moved away from spontaneous labor and tincture of time as the safest way to have a baby. Much of obstetric management has primarily been focused on prevention of stillbirth. As one obstetrician said, “We let the cat out of the proverbial bag with inductions and quick surgical births, and now it is hard to go back.” Once the recommendations for care become more clear, we can add those to the collective discussion. The sooner we identify best practices that prevent maternal deaths, the better. Now is the time to bridge our differences and put mothers and babies first.
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- HRSA Maternality Mortality Summit: Promising Global Practices to Improve Maternal Health Outcomes – Technical Report February 15, 2019
- ACNM College Statement of Policy – Joint Statement of Practice Relations Between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives
- USA Today: Deadly Deliveries
- Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009
- The Lancet: Midwifery Series
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About the Author
Amber Price, DNP CNM RN, is a hospital administrator and Certified Nurse-Midwife. She received her Executive Doctorate in Nursing from The Johns Hopkins University, with a research focus on Respectful Maternity Care (RMC), particularly the intrapartum monitoring of obese patients, and improving maternal-fetal outcomes in that population. She served as state President of the American College of Nurse-Midwives, and currently serves on several state executive boards, including the Maternal Mortality Review board, and the Perinatal Quality board. She was nominated for Birth Advocate of the Year in 2015, and was the recipient of the Monarch award for Innovation in Nursing in 2017. Amber leads several important innovative change initiatives that impact on a national level, including hospitalist effect on NTSV cesarean rates, implementation of collaborative MD/CNM hospitalist programs, and adopting an RMC platform in hospitals. In 2018, she published a chapter on women’s voice in maternal healthcare in “Nobody Told Me about That”, a guide to the first six weeks postpartum. She is the author of numerous articles and a speaker on consent practices and clinical innovation.