SAN FRANCISCO (WOMENSENEWS)– Next month, the Maternal and Child Health Bureau of the Health Resources and Services Administration is scheduled to unveil a coordinated nationwide effort to reduce maternal mortality and severe maternal morbidity.
"Healthy Women, Healthy Mothers, Healthy Babies," an overarching national strategic initiative, will consist of public-private partners around the country working to improve maternal health and clinical care, increase awareness and education surrounding maternal morbidity and mortality, and improve surveillance and research, said HRSA spokesperson Samantha Miller in a recent interview. The participating organizations and government agencies all have efforts and investments at the community, state or national levels that align with one or more of the initiative’s strategic goals, Miller added.
Over the course of the 20th century the decline in childbirth-related deaths in the United States marked a near total triumph for public health, with a drop of nearly 99 percent between 1900 and 1997.
But the risks have begun rising recently and most acutely for black women. Between 2006 and 2010, the death rate among black women in the U.S. was more than three times that of white women, the Atlanta-based Centers for Disease Control and Prevention reports.
The overall U.S. maternal death rate is hard to capture since it is not tracked in a nationally consistent way and the CDC has to cobble it together based on voluntary annual reports from each state. In its most recent analysis of those data, the found that the maternal death rate in 2011 rose to 17.8 per 100,000 live births; up from 7.7 deaths in 1997.
That trend gives the U.S. the unwelcome distinction of being one of just a handful of countries to see a rise in maternal mortality over the past decade (others include Afghanistan, South Sudan and El Salvador), according to a study published last year by the Institute for Health Metrics and Evaluation at the University of Washington.
Reversing the trend is the focus of this new initiative, which includes a newly formed Alliance for Innovation on Maternal Health, or AIM, made up of public and private partners. The program will receive $4 million in funding over its first four years, Miller said.
Initially, AIM will focus on tackling several major causes of maternal death with a high degree of preventability, including obstetric hemorrhage, preeclampsia and blood clot embolisms.
"The goal is that every hospital in the country should implement maternity safety bundles; a standard set of best practices," said Dr. Elliott Main, a San Francisco Bay Area professor and OB-GYN who has helped spearhead the program.
The hemorrhage safety bundle, for instance, would include equipping each hospital labor unit with a fully stocked cart for immediate hemorrhage treatment, establishing a hospital-level emergency management protocol, conducting regular staff drills and reviewing all cases to learn from past mistakes.
It’s a strategy that has already begun in earnest in Main’s home state of California, where he also serves as medical director of the California Maternal Quality Care Collaborative, a group that seeks to end preventable morbidity, mortality and racial disparities in maternity care.
For the past five years, the collaborative has worked with four health systems that together represent more than 100 hospitals statewide, implementing hemorrhage safety bundles at each site. The ongoing multi-stakeholder project, known as the California Partnership for Maternal Safety, is funded by Merck for Mothers, a 10-year, $500 million international initiative created by the pharmaceutical giant. Under a three-year grant from Merck set to last through April 2016, the project is expanding to include all 250 California hospitals that provide maternity care. It’s the largest-scale effort of its kind, Main told Women’s eNews, though he noted that other states, including New York, are starting to implement their own programs.
Main and others acknowledge that maternal mortality rates are surprisingly difficult to measure, particularly because the majority of deaths occur days or even weeks after childbirth and at that point may not be recognized as linked to delivery.
Some believe the seeming increase in the U.S. is due not to more deaths, but to improvements in the way maternal deaths are reported, including the addition of a pregnancy checkbox to the death certificates in many states. The uptick may also be tied to increases in average maternal age and in chronic health conditions such as obesity, heart disease, hypertension and diabetes among pregnant women, all of which could lead to complications during or after delivery.
"Regardless, the rate is still much higher than in many European countries that have very accurate ways of measuring maternal mortality," Main said. "It’s debatable whether there’s been an increase [in the U.S.]; it’s not debatable that our rate is too high."
Replicating Other Programs
The national initiative is just one step toward getting to the bottom of what’s really behind the country’s maternal death rate, argues Dr. Nicholas Kassebaum, assistant professor at the Institute for Health Metrics and Evaluation and lead author of its global maternal mortality study, published last May in The Lancet.
"I do think it’s a good idea to raise awareness of types of conditions that lead to maternal death, but I’m not sure this by itself is sufficient," he said in a recent phone interview from Seattle. "What I would like to see is the U.S. undertake something more audacious and replicate something done in many other countries: a program called confidential enquiry." Such a program would seek out the root cause of every maternal death nationwide, and the various factors that played a part, in order to spot trends and systemic failures.
For the time being, confidential enquiry in the U.S. would have to take place at the state level, as the collection and analysis of vital records is a state matter, not a federal one, Main said.
California is one state already undertaking such an effort. The California Maternal Quality Care Collaborative and the state Department of Public Health began collecting data in 2002 and analyzing it in 2005, Main said.
No matter which level of government is leading the charge, something has to change, said Laura Gilkey, coordinator of The Safe Motherhood Quilt Project, a nonprofit based in Sarasota, Fla., inspired by midwifery pioneer Ina May Gaskin, that is spotlighting maternal mortality rates and honoring those who have died.
Gilkey decries what she calls the "apathy" of the U.S. when it comes to mandatory reporting and examination of maternal deaths. "How can we possibly begin to analyze the cause of our rising maternal mortality rate when we don’t even care enough to count all of the deaths?" she said in an email interview. "Today’s mothers are twice as likely to die of pregnancy- or childbirth-related causes than their mothers were. There is no reason, given our vast resources, knowledge and technology, why we should be going backwards in this area."