Seven Steps to End Maternal Mortality in the United States

Despite spending the most on healthcare per person, the United States consistently has poor health outcomes compared to similarly wealthy countries. One area where this is evident is in examining maternal mortality. Among wealthy countries, the US has the highest maternal mortality rate, and in recent years, the rate has increased instead of decreased. Maternal mortality is defined as a pregnancy that results in the mother's death during pregnancy or due to pregnancy-related complications occurring within 42 days after birth. The rate of maternal mortality in the US is 17.4 per 100,000 pregnancies. In 2018, approximately 660 women in the US died due to maternal mortality.

There are steps that healthcare providers in the US can take to address the alarming rate of maternal mortality. Below are seven areas of focus that the US and healthcare providers can take to keep mothers safe during and after childbirth. Maternal mortality can be significantly decreased in the US, and it is every healthcare provider's responsibility to take necessary steps to eliminate maternal mortality.

1. Put a greater focus on cardiovascular conditions during pregnancy

The leading cause of maternal mortality is cardiovascular conditions. Cardiovascular conditions contribute to 33 percent of all maternal deaths. Most of these deaths stem from cardiovascular conditions that develop during pregnancy. Therefore, healthcare providers should systematically monitor pregnant women for symptoms associated with cardiovascular conditions, including heart disease and stroke. These symptoms include shortness of breath, chest pain, heart palpitations, and fluid retention. Additionally, regardless of a woman's symptoms or health history, special attention and monitoring of the heart should be standardized during pregnancy and delivery.

Healthcare providers can also address complications related to cardiovascular conditions and other pregnancy-related complications by creating protocols for how quickly they have to respond to women expressing pregnancy-related concerns. While protocols exist for deciding the timing and delivery of severe conditions, pregnancy-related complications are not held to similar protocols. Therefore, when a pregnant woman expresses concerns, they must be guaranteed to be addressed within an adequate time frame. Minutes and even seconds can be the difference between life and death.

2. Tackle two leading causes of maternal mortality: hemorrhaging and eclampsia?

Obstetric hemorrhaging (excessive bleeding) and eclampsia, the onset of seizures due to high blood pressure, together make up the second leading cause of maternal mortality in the US. While both conditions can occur anytime during pregnancy, they are most likely to occur during childbirth and postpartum. Eclampsia is especially prevalent in the US due to the high prevalence of two common risk factors: hypertension and obesity, however they can occur without these risk factors.?

Obstetric hemorrhaging and eclampsia can be identified and minimized by careful monitoring from healthcare professionals. To address hemorrhaging, blood loss during Cesarean and vaginal deliveries must be carefully monitored via devices such as pads and sponges, which are then weighed instead of by sight. Delivery units must also be stocked with blood should transfusions be needed, and healthcare providers must be equipped to quickly identify signs that obstetric hemorrhage has occurred, including low blood pressure, nausea, and dizziness. To prevent eclampsia, pregnant mothers should be monitored for signs of hypertension, and healthcare teams should be equipped with emergency hypertension medication. Blood pressure must also be carefully monitored during pregnancy and labor.

Healthcare providers should be prepared for obstetric hemorrhaging and eclampsia to occur during any pregnancy. Every healthcare delivery team should be ready to address hemorrhaging and eclampsia should they occur. All delivery team members should be educated on risk factors, warning signs, and their role during emergency response protocols. A program implemented across California introduced check-lists and crash-carts with all of the medical equipment necessary to treat obstetric hemorrhaging and eclampsia. This program resulted in maternal mortality decreasing by 55 percent in the state from 2006 to 2013.

3. Create a plan to care for mothers during obstructed labor

Obstructed labor is another leading cause of maternal mortality, which occurs when an infant is blocked from exiting the womb and is one of the leading issues that result in obstetric hemorrhaging and eclampsia. While healthcare providers are often equipped to address infant survival during obstructed labor, little education and training focus on maternal health. In addition to education and training regarding maternal health during obstructed labor, women who experience obstructed labor must receive adequate follow-up care and referrals to address lasting health concerns that may occur due to obstructed labor.?

4. Address the reliance on Cesarean births within the US

In the US, 31.7 percent of all births occur via Cesarean delivery. The US has one of the highest Cesarean delivery rates among high-income countries and the highest maternal mortality rate. Many Cesareans that occur in the US are not medically necessary; therefore, they are avoidable. The hospital a woman gives birth at is the best predictor of whether or not she will deliver via Cesarean. Healthcare providers must carefully determine whether or not a Cesarean delivery is genuinely in every woman's best interest as she prepares to give birth and should be informed of and inform women of the risks associated with Cesarean delivery, particularly in elective cases.

Cesarean deliveries require a more extended and more complex postpartum recovery period for women who have recently given birth. The Cesarean procedure itself can also increase the risk of surgical complications. Women who deliver via Cesarean are more likely to have complications including infection, sepsis, bleeding, blood clots, and ultimately death than women who deliver vaginally. Any decrease in unnecessary Cesareans can help to reduce these complications. Lastly, Cesareans cost more than vaginal deliveries. Every dollar counts when it comes to public health interventions and maternal mortality. By reducing the reliance on Cesareans, substantial healthcare funding can address additional factors of maternal mortality and other pressing public health issues.

5. Address opioid treatment among pregnant women and new mothers

While there is an ever-increasing focus on the opioid epidemic in the US, the magnitude of the impact between opioid use disorder and maternal mortality is still being uncovered. However, the increase in opioid use disorder has increased maternal mortality. Opioid use increases the risk of maternal mortality and preterm birth and complications for infants, including low birth weight, feeding problems, and breathing problems. The US must address the opioid epidemic on a larger scale, particularly among pregnant and postpartum women.

To address opioid addiction among pregnant women, healthcare providers need to be cognizant as they prescribe opioids to women who may become pregnant and should increase efforts to monitor opioid prescriptions. In addition, pregnant and postpartum women with opioid use disorder should be provided with drug addiction treatment, including medication-assisted treatment, post-birth drug treatment-related care, and relapse-prevention program. Finally, increased surveillance and studies need to be conducted to fully understand the magnitude of the opioid epidemic and maternal mortality.

6. Advocate for the expansion of Medicaid for women who have recently given birth

Currently, certain low-income pregnant women are eligible for health insurance via Medicaid during their pregnancy and up to 60 days after delivering their child. However, in many states, these women lose their Medicaid coverage after 60 days. While maternal mortality typically only includes maternal deaths during pregnancy or within 42 days after birth, pregnancy-related deaths also occur at high rates from 60 days to one year after birth. Extending Medicaid coverage to all recent mothers for at least one year after birth can help to ensure that women who have recently given birth are not struggling with or dying from pregnancy-related complications. In states that have expanded Medicaid, maternal mortality has decreased by 7.01 maternal deaths per 100,000 live births. Additionally, by keeping women healthy in between births, they are more likely to have a healthy delivery. Therefore, healthcare providers must be on the frontline advocating for the expansion of Medicaid for all women up to one-year post-birth.

7. Address racism in the medical field

None of the steps listed above to address maternal mortality can be adequately implemented without addressing the systemic and structural racism and bias within the medical field. In the United States, race is one of the most significant predictors of maternal mortality, with Black and Indigenous women being two to three times more likely than white women to die during or shortly after childbirth. Alarmingly, Black women with a college degree are five times more likely than white women with a college degree to die from a pregnancy-related cause. Until systemic racism is addressed, there will be disparities among women dying from pregnancy-related causes in the US. While this cannot be solved or fully addressed by a single healthcare provider or hospital, providers should begin by addressing their biases, examining how their delivery protocols may differ for women based on factors such as insurance status, and advocating for equity in healthcare.

The future fight against maternal mortality

While there are countless interventions to decrease maternal mortality, the above seven steps are critical in addressing the unique factors contributing to maternal mortality in the US. Other countries and even some states, such as California, have shown that these interventions can significantly decrease maternal mortality in the long term. Women deserve the right to survive to see their children, and healthcare providers and institutions must be equipped to fight for their survival.

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