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Maternal deaths and serious childbirth complications in the United States are often preventable.
Dr. Elliott Main, a professor of obstetrics and gynecology at Stanford University and a founder of the California Maternal Quality Care Collaborative, has spent decades studying why mothers die or nearly die from pregnancy and childbirth — and what can be done to protect them.
Main helped pioneer the creation of what have become national “patient safety bundles” and toolkits to help hospitals and health care providers standardize their use of evidence-based best practices for identifying complications early and providing effective treatments.
In recent years, about 650 to 1,200 women across the United States have died annually from causes related to pregnancy, according to federal data. Thousands more have been at risk of dying because of severe complications, including from hemorrhaging, cardiac and blood pressure issues, and infections.
The rate of maternal deaths is far higher for Black mothers (43.3 deaths per 100,000 live births) than it is for white (13.8 deaths), Hispanic (11.1), and Asian (12.8) mothers, according to provisional data from the Centers for Disease Control and Prevention for the 12-month period ending in September.
In the context of all of the births that occur each year, maternal deaths and severe complications are relatively rare. But each statistic is a person’s life and case reviews have found that 80% of deaths could have been prevented.
“We do need to do better, and we can do better,” Main told Healthbeat as he recently provided insights on five questions about making pregnancy and childbirth safer.
This 5 From the Field interview has been edited for clarity and length.
Are we where we need to be on maternal safety?
There is lots of room for improvement.
One of the biggest struggles we see is with disparities among different races. It’s not just Black mothers. It’s other mothers, too, that may not speak English well, or who are in some ways different from their care providers.
How do you create trust between the physician and the nurses with the patients if they are from very different backgrounds? That’s a challenge. You’re in labor and things change rapidly and you’re making life and death decisions. The best physicians have developed skills to sit down and ask what the patient’s goals are, what she’s fearful of and work out ways of working together. Trust is a common issue that we’re failing at in some circumstances.
Another significant issue is support, particularly in transitions of care. One of the biggest areas of weakness in the medical system is when you transition from the hospital to home.
Why do some hospitals struggle more than others when it comes to preventing maternal deaths and serious complications?
Obstetrics is way undervalued in the current medical reimbursement system. That means there’s not much incentive to make investments in obstetric care, and that’s particularly an issue in hospitals that are less well-funded, rural hospitals, inner city hospitals. And in certain parts of the country that are poorly funded to begin with, in particular the South, that has terrible outcomes for maternity care.
Looking at public health data from my state, that has over 200 hospitals, and in other states, there is great variation that we see among hospitals. All the measures show extreme variation. And that shouldn’t really be.
In medicine we have a long tradition, unfortunately, of blaming the patient. And that’s really clear in this setting. When you control for patient conditions, the degree of hypertension or diabetes or advanced maternal age or obesity, there is still huge variation.
What I’ve seen over the years is that hospitals – if they are doing poorly on the national measure, they will first blame the patient, then blame how the data is collected, then blame the measure itself. But they should be spending the time figuring out how they can learn from others and improve their care.
You need to have leadership, both at the physician and nursing levels, for there to be meaningful change. It’s hard to change practice behaviors or the culture of a unit unless you have strong leaders involved.
Why are so many maternal deaths and severe complications preventable?
There are two driving forces. One is that, in general, maternity goes well in at least 95% to 97% of the cases. Everyone gets kind of lulled by the expectation of normality. So we tend to overlook deviations from that. You don’t want to over-call things because most of the time it goes fine.
The second issue is that many of the symptoms of significant complications are actually easily confused with the symptoms of normal pregnancy.
One of the biggest killers in the postpartum period is cardiac disease. The symptoms of heart failure are tiredness, shortness of breath, and having a hard time sleeping. And you know, most postpartum women are tired – but what degree of tiredness is abnormal?
Many postpartum women are much more focused on the care of their infant than themselves. So, things get delayed. Doctors tend to not respond to phone calls about such generalized symptoms. And so it spirals until it’s too late.
Where has standardizing maternity care made the biggest difference?
We have done better in the U.S. for hemorrhage, so it’s no longer the leading cause of death here as it is worldwide. But it is still the biggest cause of major complications for morbidity.
Essentially about 3% to 5% of women will have a significant amount of extra bleeding at birth. And that was the first thing we tackled, and we realized that every doctor had a different way of approaching it. No one had a standardized approach, or even a standardized definition of how much bleeding was too much.
So that was the genesis of a safety bundle, of having all the tools you need in a hemorrhage cart or kit that could be immediately brought into a room. You had a standardized procedure that you could teach and practice, you do drills and then assess afterwards. And then having a
standardized way of collecting the blood, so you could see exactly where you were in the process. It’s so easy to say she’s bleeding a little, but not that much, and lose count.
Those kinds of standardized approaches actually made a really big difference. And they have become now a national safety bundle, supported by bodies like the American College of OB/GYN and even the Joint Commission. CMS is now wanting every hospital in their Medicaid reporting system to document they have included it. And the WHO is supporting the bundle approach worldwide.
What still needs to be done?
We have to keep the momentum up for supporting change in the medical system. One of the things we’ve helped support is the development of perinatal quality collaboratives in every state in the country. Those can be based in or partnered with public health departments.
We now have bundles and toolkits for hemorrhage, hypertension and sepsis, cardiac disease, and mental health. But the trick is always about implementation. That’s always the hard part – how you implement that in every hospital, in every practice in your state.
That’s where you want a collaborative that includes medical leadership, organizations like the American College of OB/GYN and the maternal fetal medicine society, the nursing societies… all the providers, the payers, Medicaid and the insurance companies, and community organizations.
Data is the critical piece. This is where public health organizations can play an important role. Everybody wants to think that they’re doing well, and everyone is surprised when the data doesn’t show that. The data really does drive change.
Alison Young is Healthbeat’s senior national reporter. You can reach her at ayoung@healthbeat.org or through the messaging app Signal at alisonyoungreports.48.
