The United States is the only first-world country where maternal mortality rates are rising. The number of maternal deaths in the United States has risen from 674 in 1990 to 1063 in 2015, and the maternal mortality ratio, the number of maternal deaths per 100,000 live births, has increased from 16.9 to 26.4 in the same years. This trend is disproportionately affecting black and Hispanic women, with increased rates for both maternal mortality and severe maternal morbidity compared to white women.
The severity of the situation has been publicized in the media and grabbed the attention of elected officials in Washington, who last year passed the Preventing Maternal Deaths Act.
On December 21, 2018, this act was signed into law to establish a federal infrastructure to collect data on every maternal death in every state to carefully review each of the contributing factors leading up to the death and all the data on it to establish strategies and best practices for prevention. But questions remain, and the topic is bound to arise during the upcoming elections.
The Preventing Maternal Deaths Act allocated federal funds and directed the U.S. Department of Health and Human Services to establish a program that directs the funds to five crucial tasks:
- Review all maternal deaths
- Establish and sustain a Maternal Mortality Review Committee (MMRC) in every state
- Develop for every state a plan for ongoing health care provider education to improve the quality of maternal care, the dissemination of findings, and the implementation of recommendations
- Distribute Maternal Mortality Review Information Applications (MMRIA) to every state MMRC
- Provide public disclosure of information found in these review committees in the form of state reports
The passage of this act occurred due to the increasing rate of maternal deaths, their high preventability, and a shortage of reliable data. The goal of the new law is to standardize how each state handles maternal deaths in order to collect the best data available to establish recommendations and policies to prevent maternal death.
Anna Kheyfets is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai.
An example of standardization is the creation of the Maternal Mortality Review Information Application (MMRIA) by the Centers for Disease Control and Prevention (CDC). Many states already have review committees, but there is great variability across states, resulting in data that is missing or not comprehensive. Not all states use the same definitions of maternal death or the contributing factors, nor do they have a common source of contributing factors or causes of death available for selection in their reviews.
While contributing factors can range from comorbidities to delay in treatment on the part of the provider, the very definition of what classifies a maternal death is still up for debate. Some review committees, along with the general MMRIA form itself that has been implemented by 33 states thus far, divide these deaths into “pregnancy-related” and “pregnancy-associated.”
If a woman was pregnant at the time of her death, or died up to one year after the termination of the pregnancy, this would fall into the umbrella category of pregnancy-associated. (The duration post-partum that is considered pregnancy-associated is another contested factor across varied definitions of maternal death.)
If the death occurs from a direct pregnancy complication or a sequence of events that occurs from pregnancy, such as the aggravation of an unrelated condition by the physiologic effects of pregnancy, then this death is pregnancy-related. If the death is not related to her pregnancy, then it is still pregnancy-associated but not related.
However, there is variation as to how maternal deaths are classified as pregnancy-related or not. Due to the lack of standardization, opportunities for prevention are difficult to identify, though we know they exist. With the MMRIA and the federal infrastructure behind the MMRCs, the CDC can identify solutions to improve health care quality and outcomes for mothers.
Several 2020 Democratic presidential candidates have already spoken out on policies that could reduce maternal mortality. There will be much more on this topic to look out for during these primaries.
Anna Kheyfets is a Clinical Research Coordinator in the Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai. Her work focuses on hospital quality and racism and discrimination in maternal and child health care.