How state reduced maternal mortality
As deaths of new and expectant moms multiplied in the United States, the picture in California and the rest of the developed world has veered in the opposite direction.
Beginning in 2006, health leaders in the state managed to reduce pregnancy-related deaths by more than half. Six years after their efforts began, a woman was 3 times more likely to die from having a baby in the U.S. as a whole compared with her chances in California.
A study out Tuesday in the journal Health Affairs, by the Stanford University medical team that started the initiative, seeks to explain why.
Elliott Main, a professor of obstetrics and gynecology at the university and one of the study’s authors, said California’s success in reducing maternal mortality — the death of a woman during or up to six weeks after a pregnancy — comes down to four factors, each of which encompasses numerous actions.
“It’s all of the above — that’s what it takes to move the dial at the population level,” he said. “You can’t just have one approach. You have to whack-amole all at once.”
The four-pronged plan of attack combined analyzing public health data, convening an array of public and private health groups, creating a data system for hospitals to measure their progress, and developing health interventions for use across the state.
“What’s unusual is to get everyone working together at the same time,” Main said. “The medical system isn’t much of a system in the U.S. It’s a lot of people following their own interests. … This was an opportunity to work together.”
But while California reduced pregnancy-related deaths across all racial and ethnic groups, disparities remain, notably for black mothers, whose maternal mortality rate is 2 to 3 times higher than that of white mothers.
Main is medical director of Stanford’s California Maternal Quality Care Collaborative, the project that spearheaded the state’s turnaround. He said simply reviewing pregnancyrelated death cases in a committee — which hadn’t been done since the 1940s — revealed alarming trends.
It turned out that many women were dying from obstetric hemorrhage, or bleeding out during childbirth; and from preeclampsia, characterized by high blood pressure and problems with organ function. Deaths from the two conditions are preventable.
The collaborative developed a task force for each that resulted in “tool kits,” or step-by-step guides and training information, for hospitals. To prevent women from bleeding to death in labor, for instance, Main’s team created a “hemorrhage cart” for maternity wards, stocked with every instrument that doctors and nurses could need for such an event.
“When you’re in the midst of a crisis, you’re very focused on the patient and the emergency, and having a checklist there that someone can read to you is a very important tool,” said Malini Nijagal, an obstetrician and gynecologist at UCSF. “If not, critical things can be missed.”
Nijagal, who led the hemorrhage protocol implementation when she worked as a physician for Marin County and is now director of San Francisco’s Joint Perinatal Health Equity Project, said any maternal mortality is a “catastrophic event.” Even one for a hospital in a given year is hugely consequential, she said.
Despite the relative infrequency of maternal deaths, Main said, tracking the rate in a state or country is important because it’s an indicator of how a society treats women overall.
The Stanford project built a real-time data system that automatically links health information from birth certificates and maternal and newborn discharge files. The web application allows hospitals to visualize their own data, see how they compare to others and track their progress over time. They get alerts when their metrics start to slip.
The initiative is now focused on encouraging vaginal birth and reducing cesarean deliveries for single babies at full term that are positioned correctly. The rate of C-section births for that low-risk subgroup varies wildly across California hospitals, from 1 in 10 in some to 7 in 10 in others.
“C-sections can be life-saving, and there are settings where they are very appropriate to be done, but there is a sizable gray zone,” Main said. “The variation really was the key to see there was a lot of stuff going on that didn’t need to happen.”
In addition to the work of the collaborative — which consists of hospitals, patient groups, health providers and payers, professional organizations, state agencies, and consumer unions — California’s embrace of the Affordable Care Act likely played a role in the maternal mortality rate reduction, according to the study. The law helped the state’s rural hospitals stay afloat and kept more women insured between pregnancies.
The result was that by 2013, the latest year for which numbers are available, California saw 7 pregnancy-related deaths for every 100,000 live births — or a total of about 35. That was down from 17 per 100,000 in 2006 and put the state on par with Western Europe.
The United States, on the other hand, saw 22 mothers die per 100,000 in 2013.
“We have to remember that pregnancy is not a disease,” Nijagal said. “When our rates are so significantly higher than those in equally high-wealth countries in the world, that’s really concerning.”
But as rosy as the picture may be in California, there’s one glaring shortcoming, Main said. Black women who are pregnant or new mothers are still much more likely to die than their white counterparts.
In California, while maternal mortality rates for black and white moms both dropped by 40 to 50 percent, the gap between the two did not close, the study said.
Even after accounting for socioeconomic status, age and obesity and other conditions, the racial disparity remains. A college-educated black woman is more than 2 times as likely to have serious complications from pregnancy as a collegeeducated white woman, after adjusting for other variables, Main said.
He said the issue will be the next area of focus for the collaborative.
Nijagal said part of the issue comes down to racism, both structurally and person to person.
“The care that we provide, even here in San Francisco, is not respectful or responsive to low-income women, and it’s even worse for low-income black women,” she said. “To tackle the racial disparities we’re seeing in maternal mortality and other birth outcomes, we have to focus on how we treat women and how we structure our care systems in a way that’s respectful to every individual and responsive to every woman’s needs and preferences.”