In a recently shared Instagram post, U.S. Olympic gold medalist Tianna Madison spotlighted the sobering fact that three out of four members of the 2016 gold-winning 4x100m U.S. Olympic relay team either died or almost died due to childbirth complications. Maternal mortality, a crisis plaguing U.S. healthcare, refers to any death during pregnancy and up to a year after childbirth. Various factors, including gestational diabetes, hemorrhages, infection, and postpartum mental health disorders, can cause these deaths.
A number of factors influence maternity mortality rates, including (as the Huffington Post highlights) race, socioeconomic status, and geography, but health policy can play an important role in addressing it. While maternal mortality rates in the United States are higher than other OECD countries like Canada, Australia, and New Zealand, there are significant disparities across U.S. states. New Jersey and Louisiana have the highest rates, whereas Massachusetts and California have managed to keep their rates much closer to–and in some cases, lower than– international averages. Putting things into perspective, New Jersey has 38.1 deaths per 100,000 live births, while California has four deaths per 100,000 live births.
Congress must produce more policies using evidence-based approaches to reduce maternal mortality. Two initiatives pioneered by the Alliance for Innovation on Maternal Health (AIM) offer a good place for Congress to start this issue. The AIM protocols specifically target hemorrhages, preeclampsia, and other birth-related complications which, if not treated properly and swiftly, contribute to the maternal mortality crisis.
Hemorrhage control toolkits
The initiatives that have demonstrated the most promise in recent years include obstetricians’ adoption of hemorrhage control toolkits. These include new hemorrhage control carts and more robust guidelines to ensure fewer mistakes and complications arise.
“Crash carts” are quickly transportable carts that house materials and medications needed during a medical emergency. Hemorrhage control toolkits similarly house emergency medical equipment required during a maternal emergency and can help remedy adverse complications. These carts have tools and medications to deal with common causes of maternal mortality, like obstetric hemorrhages, preeclampsia, and thromboembolisms. The hemorrhage control toolkits reduce response time by around 11 minutes– a crucial time-saving measure when dealing with rapid blood loss and complications.
The toolkits’ guidelines also include the provision that healthcare professionals use gravimetric analysis to measure blood loss with sponges and pads rather than visually estimating blood loss. Visual blood loss estimation is a widespread practice that typically leads to blood loss underestimations. With the protocol update, healthcare professionals measure blood loss via sponges and a computerized system that calculates blood loss relative to the patient’s height and weight. This gravimetric analysis is far more accurate and leads to fewer complications. California, in particular, is a trailblazer in adopting hemorrhage control toolkits. Professionals use the methodical steps outlined in the protocols to ensure a seamless and coordinated response if a complication arises.
Officials estimate that the initiatives have cut California’s maternal mortality rate by 55%. California’s maternal mortality rate in 2019 was around 12.8 deaths per 100,000 live births compared to the national average of 20.1 deaths per 100,000 live births. Evidence also suggests that the toolkits decreased maternal morbidity (sometimes used as a measure instead of mortality because they account for near-death cases) by 21 percent. In comparison, hospitals that did not use them lowered their rate by just 1%.
Adopting this simple but life-saving measure can significantly reduce the mortality rate in other states and produce significant cost savings. Studies found that California saved approximately $9 million in health care costs due to implementing its safe birth strategies ranging from these “crash carts” to more coordinated care.
Perinatal quality collaboratives
While some states do not have hemorrhage control carts, they still use AIM patient safety bundles and packages that implement many of the hemorrhage control carts’ features. Fourty-seven states have Perinatal Quality Collaboratives (PQCs), composed of public health officials and healthcare providers, who implement quality improvement initiatives and review data regarding maternal morbidity. PQCs adopt patient safety bundles (aka, evidence-based standards for care).
Some initiatives outlined by the patient safety bundles include standardized responses for dealing with a hemorrhage, including checklists, response teams that have practiced together, and quantitative measures of blood loss– similar to the components included in California’s hemorrhage control carts. Standardized initiatives are pivotal in reducing maternal mortality by ensuring closely monitored protocols.
What happens next?
While PQCs are established in 47 states, with some being funded by the CDC, significantly fewer have adopted the AIM patient safety bundles. Even among states that have adopted the AIM bundles, many have not followed through with all the outlined initiatives. As of 2018, a mere 985 out of the 6,000 hospitals in the U.S. had adopted the AIM framework.
The CDC should help fund PQCs and require states to use the AIM patient safety bundles. These evidence-based practices have been proven to reduce maternal morbidity. The AIM patient safety bundles, akin to the hemorrhage control toolkits used in California, are the ideal protocols to improve maternal health. PQCs can help ensure that states have enough oversight to implement the protocol correctly.
While the Center for Medicaid and Medicare Services has begun to take steps by only issuing the birth-friendly hospital designation to those participating in initiatives that improve maternal health, a policy that required hospitals to adopt evidence-based solutions immediately would significantly reduce maternal morbidity and alleviate the nationwide mortality crisis.