Maternal death became a sentinel event in 2010, signaling to hospitals that they must investigate why a woman died from pregnancy or childbirth-related complications and respond with strategies to reduce the risk of these deaths in the future.
While a critically important step, a clinical response alone will not solve this age-old tragedy. We are long overdue in bringing together healthcare providers and the public health community to look at what's happening not just inside, but also outside, the hospital so we can prevent more women in the U.S. from dying.2
The U.S. has the highest ratio of maternal mortality in the industrialized world, behind Libya, Kazakhstan and Saudi Arabia.1 And while the global ratio has declined by nearly half since 1990, the U.S. is one of only a handful of countries where the situation has not improved.1 A maternal death is just the tip of the iceberg – each year, an estimated 60,000 women nearly die from pregnancy and childbirth complications.2
Why is this happening?
One explanation is that over the past two decades pregnant women have been confronting the same health challenges as the rest of the U.S. population: the rise of chronic disease. As the country faces escalating rates of diabetes, hypertension, obesity and cardiovascular disease, not surprisingly, more and more women with chronic conditions are becoming pregnant. These conditions, which are often unmanaged, are contributing to an alarming increase in complications, exacerbating a woman's risk to her own health and the health of her baby.
Racial disparities in maternal health further compound the problem. A black woman is almost four times more likely to die from pregnancy and childbirth complications than a white woman. A recent study of the situation in New York City revealed the shocking statistic that a black woman is 12 times more likely to die than a white woman. We know that the rates of chronic disease among black women are among the highest of any reproductive-age demographic group.3
If we truly want to improve maternal health outcomes in this country, we need a more comprehensive approach to managing pregnancy. We're going to have to close the gap between what's happening in the clinic and what's happening in the community.
The good news is that pregnancy provides a unique window of opportunity to bridge the clinic/community divide. Even a woman who may not have seen a health provider since childhood will come into contact with a doctor, nurse or midwife at some point during her pregnancy. Once these providers identify pre-existing health problems, community-based services can play a critical role in helping pregnant women manage their diabetes and hypertension during pregnancy and beyond.
A "life-course" perspective to women's health will enable us to take advantage of pregnancy as an entry point into the health system. At the same time, we should view pregnancy as an ideal time to help a woman – especially one living with chronic medical conditions – pay closer attention to her own wellbeing and put a plan in place to optimize her health for the long term. Many people in her life should be involved and supportive, including family members, primary health care providers, schools, employers, payors and communities.
The challenge to ensuring good overall health for pregnant women with chronic conditions is a system that makes this kind of collaboration between the clinic and the community simple, routine and focused on a woman's needs – both social and medical.
A few encouraging steps are underway. A number of community-based organizations – including the Camden Coalition of Healthcare Providers, the Maternity Care Coalition in Philadelphia and the Northern Manhattan Perinatal Partnership in New York City – are engaging their local hospitals and clinics to determine how best to link pregnant women with chronic conditions to the care they need before and after childbirth. These projects, supported by grants from Merck through its Merck for Mothers initiative to end preventable deaths globally, take advantage of the window of pregnancy as well as new reimbursement opportunities under the Affordable Care Act.
One way that community-based organizations are establishing stronger linkages to care is through the use of community health workers (CHWs). These allied health professionals, often from the same communities as the women they serve, work with patients holistically, going beyond just a specific disease area. The CHW is part of a woman's care team and provides support outside the clinical setting to ensure she adheres to her healthcare plan by teaching her how to monitor her vital signs and empowering her to manage her health at home. As an extension of the clinical care team, a CHW helps a woman meet her health and social needs and integrates clinical care and community services to tackle the underlying social determinants of health.
More and more, the problems putting pregnant women at risk originate outside the hospital. Preexisting health conditions unmanaged before and during pregnancy are leading to worsening outcomes and degenerating maternal health statistics in this country. While we need to remain focused on continually improving the quality of maternity care in our nation's hospitals, we must also be diligent about ensuring that the relatively brief moment of childbirth is not the only time a woman gets holistic care to meet all of her clinical and social needs. We must take a population health approach to ensure that women, especially those with chronic conditions, are supported and empowered to stay healthy before, during and after childbirth.
Taking a comprehensive approach to pregnancy and childbirth in an era of skyrocketing chronic disease is essential to make sure every pregnancy is healthy and every childbirth is safe.
Dr. Priya Agrawal is the Executive Director, Merck for Mothers. Dr. Cynthia Chazotte is Professor and Vice Chair, Dept. of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Montefiore Medical Center. Dr. Seema Csukas is the Medical Director, Maternal and Child Health Section, Georgia Department of Public Health, Atlanta, GA.
References
1. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2015. http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1. Retrieved December 9, 2015.
2. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029-1036.
3. Creanga AA, Bateman BT, Mhyre JM, Kuklina E, Shilkrut A, Callaghan WM. Performance of racial and ethnic minority-serving hospitals on delivery-related indicators. Am J Obstet Gynecol 2014;211:647-16.
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