November 2018
Maternal Health Inequity and Rising Mortality Rates: Finding Solutions to Help Reduce the Impact
By: Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Illinois (BCBSIL)
While pregnancy should be a condition of joy, not dread, statistics are showing that there may indeed be a cause for alarm. Maternal mortality and morbidity rates in the U.S. are on the rise – in fact, maternal death rates in this country are higher than those in any other developed nation. The rate increased by 26.6 percent from 2000 to 2014, according to a 2016 analysis published by the American College of Obstetricians and Gynecologists (ACOG).1 The Centers for Disease Control and Prevention (CDC) estimates that 700 women will die each year due to pregnancy-related complications.2
Why are numbers of pregnancy-related deaths on the rise in the U.S.?
To begin to assess reasons for rising numbers and causes of maternal deaths, the CDC launched a national Pregnancy Mortality Surveillance System in 1986.* Every year, the CDC requests copies of death certificates from all 50 states, as well as New York City and Washington, DC. Information received is evaluated by medically trained epidemiologists and causes of death are categorized using a coding system developed by ACOG, together with the CDC's Maternal Mortality Study group. Reports on causes and risk factors are released periodically.3
The latest available CDC data are for the period of 2011 - 2014. Of the 7,208 deaths within a year of pregnancy that were reported to the CDC, 2,726 were determined to be pregnancy-related. Cardiovascular diseases, infection or sepsis, and hemorrhage were among the leading causes of death. The CDC data also reveal racial/ethnic disparities, with 12.4 deaths per 100,000 live births for white women, compared to 40 deaths per 100,000 black women.4
Are rising maternal death rates due to improvements in surveillance, analysis and reporting functions? Or is there an increase in chronic health conditions, such as hypertension, which may lead to stroke, hemorrhage and preeclampsia/eclampsia? In addition to racial/ethnic discrimination, what other adverse social determinants of health are presenting barriers to achieving maternal health equity? Are there differences in the quality of care, access to transportation, or health literacy for distinct segments of the population?
As discussed in our September 2018 Blue Review, the problem of inequity in health care is multifaceted and far-reaching, involving complex overlapping social structures, such as socioeconomic status (income level, education/literacy, occupation), ZIP code, housing conditions and public safety, among other social determinants of health. For mothers-to-be in some neighborhoods, educational resources on the importance of prenatal care may be limited. Some women may not have ready access to sources of healthy food to ensure proper nutrition. They may neglect going to the doctor due to lack of transportation, or concerns about health care costs.
My colleague Anita Stewart, medical director at BCBSIL, says, "Rising maternal mortality rates = Better surveillance data + social determinants of health. If that's our equation, how do we reduce the impact?”
Finding Ways to Reverse the Trend
In January 2016, the Illinois Perinatal Quality Collaborative (ILPQC) conducted an intervention targeting hypertension, which is associated with pregnancy-related complications such as hemorrhage and preeclampsia. The ILPQC’s Maternal Hypertension Initiative included 110 Illinois birthing hospitals. Participating hospital teams focused on early identification and medical management of severe hypertension, as well as enhanced patient education and follow-up. The initiative resulted in many successes, such as a 50 percent increase in the number of women receiving medication within 60 minutes for new onset severe range hypertension.5 We need to build upon these successes which improve a woman’s survival post-delivery. Continued innovation in care delivery across the community organization and provider continuum is important.
To reverse the trend, we must renew our understanding of the journey of our pregnant members and their families – before, during, and following pregnancy. This will highlight better opportunities to increase prenatal/postnatal care as well as meet other important health needs. Additionally, domestic violence remains a pernicious health problem for pregnant women and we have a collective obligation to make a difference. Across a number of factors that increase the risk of a pregnancy, strengthening case coordination and access to health resources in the community is important.
We also recognize that there are many reasons why some of our members do not travel outside of their home communities. For example, if they can’t communicate or feel they are not being heard, pregnant women with limited English proficiency may be less likely to seek care. So, we need to find a way to come to them. As Dr. Stewart says, "We have to re-envision how to support health care in new settings in the communities we serve." This might mean conducting outreach in non-traditional locations, such as churches, grocery stores, laundromats and even beauty salons.
What can providers do? Maybe a good place to start is to consider that patient-centric factors, such as language proficiency, cultural beliefs and/or socioeconomic factors may impact patient understanding, access and adherence to care plans.
All women should have access to information, care and other resources to support a healthy pregnancy, all the way through childbirth, the recovery period immediately following delivery, and beyond.
Learn more about Dr. Derek J. Robinson
*The CDC defines a pregnancy related death as the death of a woman during pregnancy or up to a year after pregnancy due to conditions caused or aggravated by the pregnancy or how it was managed.
1 Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. MacDorman, Marian F., PhD; Declercq, Eugene, PhD; Cabral, Howard, PhD; Morton, Christine, PhD. Obstetrics & Gynecology: September 2016 - Volume 128 - Issue 3 - p 447–455.
2, 3 CDC website. Reproductive Health, Pregnancy-Related Deaths. Accessed Oct. 18, 2018, at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm.
4 CDC website. Reproductive Health, Pregnancy Mortality Surveillance System. Accessed Oct. 18, 2018, at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm.
5 ILPQC Maternal Hypertension Initiative Fact Sheet. December 2017. Available at http://www.ilpqc.org/docs/onepagers/ILPQC%20HTN%20Factsheet_FINAL_2017.pdf.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.