The Increasing Mortality Rate for Pregnant Women in the U.S.

“More women die from pregnancy complications in the United States than in any other developed country,” reports the American College of Obstetricians and Gynecologists (ACOG), and the U.S. is the only industrialized country in which the maternal mortality rate is rising.

Consult QD talked with Cleveland Clinic Ob/Gyn & Women’s Health Institute’s Uma Perni, MD, about this disturbing trend.

Why is the maternal death rate increasing?

The maternal mortality rate in the United States increased by more than 25 percent between 2000 and 2014. This increasing mortality rate among pregnant women is quite alarming for Ob providers.

The problem is multifactorial. There are a number of social issues, such as drug overdoses and suicide, but chronic disease and obesity play a role too. Women with preexisting medical conditions such as diabetes and hypertension are at higher risk if they become pregnant. Preexisting cardiac conditions in pregnant women account for approximately 20 percent of maternal mortality in the U.S.

In the 1980s, when maternal mortality rates were at their lowest, certain types of chronic diseases we have today occurred at much lower rates in pregnant women — hypertension, diabetes, obesity. And many women with heart disease and other conditions did not survive to child-bearing age. In addition, women today are often delaying childbearing to a later age.

We still see deaths from long-known causes of maternal mortality such as preeclampsia, uterine hemorrhage and infection.

So there is a whole host of reasons for increasing incidence of maternal morbidity and mortality.

What about racial disparities in these statistics?

The other very shocking statistic is the racial disparity we see in maternal mortality. The fact that African-American women have a greater than three times higher rate of death than their Caucasian counterparts is shocking and distressing. There are many theories for why this occurs, including socioeconomic factors, access to care and chronic stress. However, even if we just look at white women in the U.S., maternal mortality rates are higher than other developed countries.

Cleveland and Ohio are no different and also display the shocking national trends of increasing maternal mortality and racial disparities. Ohio has established a Pregnancy-Associated Mortality Review (PAMR), a multidisciplinary group of experts to review these cases and develop initiatives to prevent future maternal deaths.

What can be done? You mentioned improving preconception counseling.

One of the things we see is women getting pregnant who are at very high risk of dying due to their underlying medical conditions. For example, women with pulmonary hypertension, cardiomyopathy and other pre-existing medical conditions are risking their lives by getting pregnant. They often become pregnant because they have not been counseled appropriately, and then it is sort of too late.

This is where we have a huge opportunity for intervention. These women — prior to becoming pregnant — need to be counseled about birth control and the real risks they will face should they become pregnant.

This is an overlooked opportunity, and something that has real potential to positively impact the maternal mortality rate.

What about optimizing prepregnancy health?

Yes, let’s optimize health for women with chronic diseases prior to them becoming pregnant. Even if women are not able to achieve an ideal weight, losing enough weight to improve diabetes or hypertension control prior to getting pregnant can impact these statistics. The preconception period is also a great time to provide education for women about their specific medical conditions and risks.

Our Ob/Gyn institute offers a weight management program specifically designed for women struggling to conceive in the face of obesity and polycystic ovarian syndrome, the Women’s Metabolic Weight Management Program. Our country needs so much more of this type of program.

What other programs address this issue at Cleveland Clinic?

We also have a Fetal Care Center, which is a multidisciplinary group that coordinates care for any pregnancy complicated by significant maternal or fetal conditions. The team includes specialists in maternal-fetal medicine (MFM), genetics, cardiology, surgeons and others.

We care for many women with significant cardiac disease, congenital particularly, so we have a combined Cardio-Obstetrics Clinic where pregnant women are seen by a cardiologist specializing in adult congenital heart disease and an MFM specialist at the same time. The clinic stresses the importance of multidisciplinary care and preconception counseling.

Each of our system hospitals conducts monthly peer reviews of maternal morbidity and mortality. The latter is rare here, fortunately. We review intensive care unit transfers, blood transfusions, hospital readmissions and other things that have potential to lead to morbidity. Vital sign warning systems on labor and delivery floors also help avoid incidents.

In the area of addiction, we are working to have our providers certified to prescribe buprenorphine, and we are developing a carepath for women with opioid-use disorders.

You talk about “putting the M back in MFM.” How will that help?

Technology, particularly ultrasound and fetal intervention, began taking off in the 1990s, and that became the focus of a lot of MFM training programs. So experts became somewhat skewed to the fetal side. The current push to include more maternal issues in fellowship training will help. Currently, fellowships require time specifically dedicated to labor and delivery, inpatient care and an ICU rotation.

I am happy to see more recognition of the increasing maternal mortality rate at the state level and how hard ACOG is working to reduce it through a variety of programs. But this remains a difficult issue that requires our continued vigilance and energy.