Maternal Mortality: Reducing Disparities

In the United States, there are significant racial disparities in pregnancy-related mortality (i.e., the death of a woman while pregnant or within one year of the end of pregnancy), according to 2016 data collected in the Centers for Disease Control’s Pregnancy Mortality Surveillance System. Black, non-Hispanic women were 3.2 times more likely to die from pregnancy-related death than white women, with a pregnancy related mortality rate (PRMR) of 42.4 and 13.0 per 100,000 live births among the black, non-Hispanic and white, non-Hispanic populations, respectively.

PRMR was also significantly higher for women living in metropolitan or rural counties, those who are unmarried and those over the age of 30. Leading causes of death include hemorrhage, cardiomyopathy, infection, other cardiovascular conditions, as well as other, non-cardiovascular related medical conditions.

Social determinants of health

“It’s very important to recognize that these disparities are related to social determinants of health along with purely biological factors,” states Jeff Chapa, MD, a maternal fetal medicine specialist. “We’re addressing these issues in a number of ways. We are improving access with at different locations throughout the community, including Cleveland Clinic’s Stephanie Tubbs Jones Health Center, Lakewood Family Health Center and Marymount Hospital, and we now offer high-risk maternal fetal medicine services at Cleveland Clinic main campus. We have also implemented earlier postpartum checks, at one week postpartum for patients at high risk and at two weeks postpartum for others. Patients are also educated to watch for symptoms and come in earlier if they have concerns. We are partnering with public health programs, such as CenteringPregnancy® and First Year Cleveland.”

Optimizing management of obstetric emergencies

Additional efforts underway to decrease preventable maternal morbidity and mortality, says maternal-fetal medicine specialist Kathleen Berkowtiz, MD, include the implementation of order sets and protocols to optimize the management of the three causes of obstetrics emergencies: obstetric hemorrhage, preeclampsia and hypertensive disorders, and deep vein thrombosis (DVT).

“With nearly 10,000 deliveries per year in Cleveland Clinic hospitals, obstetric hemorrhage is a near daily occurrence,” Dr. Berkowitz says. “Everyone who will be involved in care on either the antepartum, labor and delivery, or postpartum floors, is involved in obstetric hemorrhage simulations. In 2019, we also built automatic order sets for the de-escalation of high blood pressure. The order is triggered when a patient hits a threshold for high blood pressure, and calls for medication administration within 60 minutes or less. Finally, we have DVT-related protocols that ensure all of our patients are treated with either mechanical or chemical prophylaxis according to individual patient risk factors.”

“As a healthcare system, we are doing everything possible to develop solutions to maternal morbidity and mortality. Once we have successfully scaled these initiatives, we intend to partner with the greater Cleveland community, and hope to serve as a model for other Cuyahoga county-area hospitals. We want to do more than just prevent maternal deaths locally; we want to see PRMR decrease throughout the state of Ohio,” Dr. Berkowitz notes.