Health

One Death Too Many: Maternal Deaths Continue to Rise in the U.S.

Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Pregnancy silhouettePhoto by Chris Martino via Flickr (Creative Commons License)


For many women, giving birth to a child is one of the most joyful events of their lives. Yet for some, complications can lead to a special kind of heartbreak for a family — the death of the mother. While maternal mortality is often thought of as something that was a problem in the past, it remains a very current concern. Christy Turlington Burns, through her work with Every Mother Counts and two documentaries she has directed and produced, is bringing greater attention to maternal mortality. Women’s Voices for Change is honoring her today at its Champion for Change luncheon where she will be in conversation with Dr. Sharmila Makhija, department chair of obstetrics & gynecology and women’s health at the Albert Einstein College of Medicine and Montefiore Medical Center. Below, Dr. Makhija, along with research by Natalie Krumdieck, provides an update on this important issue in women’s health. —Dr. Patricia Yarberry Allen

The World Health Organization (WHO) reports a recent decrease in yearly global maternal deaths from 523,000 to 289,00. While developing countries account for more than 95 percent of cases, in the United States the maternal death rate continues to rise. Sadly, 98 percent of all maternal deaths worldwide are considered preventable.

WHO defines maternal mortality as the death of a woman from pregnancy-related causes during pregnancy, childbirth, or the 42 days after delivery. The maternal mortality ratio (MMR) is the number of maternal deaths per 100,000 live births. The U.S. Center for Disease Control (CDC) Pregnancy Mortality Surveillance System measures pregnancy-related death, a broader and arguably more complete term, as a woman who dies while pregnant or within one year of pregnancy termination, regardless of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Regardless of which indicator is used, there has been an increase in the number of U.S. maternal deaths. Since 1990, WHO noted an increase in the MMR, to 28 maternal deaths per 100,000 live births from 12. The CDC also noted an increase, to 17.8 from 7.2. African-American women have an MMR that is as much as fourfold higher than that for Caucasian women. It is difficult to assess the relationship between socioeconomic status and MMR because death certificates do not include socioeconomic data. But linking family poverty data to mortality data on a county-level basis shows that higher poverty rates are associated with a higher risk of maternal mortality. There are also dramatically different MMR in different geographic locations in the United States, ranging from a low of 4.3 in Indiana to 41.6 in Washington, D.C.

Maternal deaths due to cardiomyopathy and other medical conditions have increased, likely related to women delaying childbirth until a more advanced age and thus being more likely to have preexisting medical conditions. Preconception care is especially important for these women to optimize the health prior to undertaking pregnancy. Caesarean birth is associated with an MMR that is 8-10 times higher than that of a spontaneous vaginal delivery. However, in most cases, maternal death was related to the indication for the Caesarean birth rather than the surgery itself.

The most common cause of maternal mortality is postpartum hemorrhage (bleeding), often the result of uterine atony, or the inability of the uterus to contract. Retained placenta, or the inability of the uterus to expel the placenta is increasing as a cause of hemorrhage. Risk factors for postpartum hemorrhage include prolonged or rapid labor, hypertension, obesity, prior Caesarean birth and twins. Because hemorrhage can occur rapidly, it is vital to prepare in advance to prevent a maternal death. As a result, the American College of Obstetricians and Gynecologists, has developed clinical guidelines. These guidelines and checklists assess postpartum hemorrhage risk factors at the time of labor as well as coordinate multidisciplinary provider teams to adequately plan for and optimize the management of obstetrical hemorrhage. This is the first step in improving maternal mortality rates in the United States as one death will always be one too many.

 

Sharmila Makhija MD MBA an international expert on gynecologic cancer, currently serves as department chair of obstetrics & gynecology and women’s health, professor of gynecologic oncology and The Chella and Moise Safra Endowed Chair at the Albert Einstein College of Medicine and Montefiore Medical Center.

Natalie Krumdieck is a fourth-year medical student at Weill Cornell Medical College and is currently applying into family medicine. Her research interests include maternal and child health within the global context, most recently leading her to spend a year examining food insecurity in pregnant women of mixed HIV status in Kenya.

 

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