Maternal mortality should be an archaic term. However, the number of women who die from pregnancy in the United States has skyrocketed, while other developed countries have experienced stable or improved maternal mortality rates. The U.S. maternal mortality rate of 17.2 deaths per 100,000 live births in 2015 is up from 7.2 deaths per 100,000 in 1987, according to the CDC.1 A global review puts the U.S. number even higher—at 26.4 deaths per 100,000—in 2015.2
The World Health Organization defines maternal mortality as death during pregnancy or within 42 days of termination of the pregnancy.3 The CDC applies a broader definition that includes deaths up to one year after delivery, meaning about 700 women per year die from pregnancy-related causes in the United States.4 The CDC considers 60% of those deaths to be preventable.4 Further, the rate of severe maternal morbidity increased almost 200% from 1993 to 2014, affecting approximately 50,000 women per year.5 This leads to short- or long-term consequences, including hysterectomy and disability.
The good news is that pregnancy-related deaths from anesthesia complications have plummeted.6 Through the American Society of Anesthesiologists (ASA), Society for Obstetric Anesthesia and Perinatology (SOAP), and other medical societies, physician anesthesiologists are working to prevent maternal deaths due to non-anesthesia factors, including cardiovascular disease, embolic disease, preeclampsia, postpartum hemorrhage and sepsis. While obstetric anesthesiologists are leading these efforts at national and state levels, physician anesthesiologists in every setting can help reduce the incidence of these catastrophic events at their institutions. As the experts in critical and emergency care, physician anesthesiologists are best equipped to seize leadership roles and help to shift the management of maternal health from being reactive to proactive by:
Most pregnant women are considered healthy, meaning signs of a developing problem often are overlooked until it’s too late. Anesthesiologists have access to a number of resources that help them lead the way, and should work closely with obstetricians and other providers to underscore the importance of vigilance, enlisting all care team members to fulfill their role in reversing the egregious U.S. maternal mortality trend.
Why Are the Numbers Increasing?
The U.S. maternal mortality rate has increased steadily for the last 30 years.1 The cause of this disturbing trend is thought to be multifactorial, although it’s unclear why the maternal mortality rate has risen in the United States while remaining steady or falling in other developed countries during the same time period.
Because women are waiting longer to have children, many turn to assisted reproduction to conceive, which increases their chance of multiple gestation, adding to the risks for developing health issues such as preeclampsia.7 Further, the increased incidence of gynecologic procedures and the cesarean delivery rate—which has steadily risen to 32.8% of all births in North America—has led to an increased risk for placenta accreta.8 Opioid use disorder, which has risen dramatically in recent years, also contributes to the risk profile.9
Racial disparities play a significant role. Maternal mortality among black women is more than three times higher than among white women, at 42 deaths versus 12 deaths per 100,000.1 Latina and Native American women also fare poorly, with twice as many pregnancy-related deaths as white women. The reasons are complex, multifaceted and incompletely understood. Black women may have less access to care, and women who do not receive prenatal care are three to four times more likely to suffer a maternal-related death.10 As is the case in a variety of health care settings, black women needing obstetric care are less likely to receive guideline-recommended medications or treatments and may be more likely to be ignored when expressing a complaint or health concern.11
Why Seemingly Healthy Women Die
We think of pregnant women as a generally healthy group. In fact, most people expect that when a woman enters the hospital for delivery, she and her baby will return home happy and healthy. But pregnancy itself is a health condition that increases the risk for morbidity and mortality. Some women are at higher risk before they become pregnant, whereas others develop problems during pregnancy or soon after giving birth despite having no known risk factors.
We don’t have all the answers yet. But we do know the common causes of U.S. maternal mortality and what increases the risk in many cases1:
Physician Anesthesiologists Are Solving the Problem
With their extensive critical care training and expertise in managing emergencies such as postpartum hemorrhage and preeclampsia, physician anesthesiologists are emerging as leaders in a multidisciplinary nationwide effort to reduce maternal mortality. The significant efforts include:
Maternal mortality review committees: Physician anesthesiologists joined the effort to pass the Preventing Maternal Deaths Act, which was signed into law Dec. 21, 2018. The law provides funding for states to establish and support state-level maternal mortality review committees and standardize the review process. To date, 36 states have formed such committees. The goal is for each state to review every maternal death to evaluate the causes and assess how it might be prevented in the future. Obstetric anesthesiologists sit on about half of the existing committees, including states taking the lead in improvement efforts, such as California, Georgia and New York, but clearly there’s a need for greater representation from the specialty.
National quality improvement initiative: Through ASA and SOAP, physician anesthesiologists have played a key role in the Alliance for Innovation on Maternal Health (AIM), a national data-driven quality improvement effort.18 Among other resources, AIM provides free access to maternal mortality safety bundles and tool kits, with the goal of improving outcomes. Each safety bundle features a collection of 10 to 13 best practices for improving safety in maternity care that have been vetted by experts, including anesthesiologists. Safety bundles include those for VTE, postpartum hemorrhage, opioid use disorder, preeclampsia and reduction of peripartum racial/ethnic disparities.19
Maternal early warning systems: AIM also provides access to maternal early warning signs criteria,20 which involve monitoring the vital signs of women in labor for early signs of distress, such as:
Additionally, these signs can be used to screen women before active labor to determine whether they are at higher risk for a negative outcome.
Levels of maternal care: In 2015, the American College of Obstetricians and Gynecologists published guidelines for Levels of Maternal Care, which determines safe and appropriate care for pregnant women according to a center’s capabilities.21 It ranges from birth centers and Level I centers (care of uncomplicated pregnancies) to Level III and IV centers for women with serious obstetric and/or medical conditions. The higher-level centers ensure that board-certified physician anesthesiologists with special training or experience in obstetrics are in charge of obstetric anesthesia services. The guidelines provide direction regarding where pregnant women should be treated based on their risk factors as well as delineate necessary resources. A newer version is in print for release soon. Both the ASA and SOAP have contributed to this updated version.
Because the document lacks guidance regarding specific characteristics that may affect the quality of anesthetic services, SOAP implemented a process to designate Centers of Excellence for obstetric anesthesia care.22 The designation is designed to “recognize institutions and programs that demonstrate excellence in obstetric anesthesia care, to set a benchmark level of expected care to improve the standards nationally, and to provide a broad surrogate quality metric of institutions providing obstetric anesthesia care.” In 2018, 39 institutions were awarded the Center of Excellence designation (Table).23
|Table. Recipients of the Society for Obstetric Anesthesia and Perinatology’s Center of Excellence Designation|
Guide to pain management: The Department of Health and Human Services recently released the “Pain Management Best Practices Inter-Agency Task Force Report.”24 Chaired by an anesthesiologist, the report details multimodal techniques that can be used to manage pain in laboring women—especially those with opioid use disorder—including nonopioid analgesics, nerve blocks and physical therapy.
What You and Your Institution Can Do
Unfortunately, our country’s health care safety and improvement efforts are not employed in a consistent manner. It is up to states and institutions to identify and implement lifesaving measures. Room for improvement exists at nearly every institution, especially those in states with particularly high maternal mortality rates, such as Georgia, Louisiana, New Jersey and Texas.25-30
Here are seven ways you can help improve maternal care at your institution:
Physician anesthesiologists are leading the charge to reduce the high rate of maternal mortality in the United States at national, state a nd local levels. But these efforts are for naught if the tools and resources that are available are not employed in every hospital and birthing center throughout the country. That’s why it’s vital that anesthesiologists across the country step up to lead the way in providing the safest and most effective care to all women receiving pregnancy, childbirth and postpartum care at their institutions.