In September 2017, Serena Williams, the 23 time Grand Slam champion, almost died after giving birth to her daughter Olympia. Afterwards, she was open about the traumatic experience and long recovery. News outlets picked this up and ran with the story, looping in maternal death rates in the United States into their coverage. Before these headlines, I had read that in recent decades, maternal death rates in the United States have been on the rise. For instance, one study found an increase of 26.6% increase, up to 23.3 deaths per 100,000 live births in 2014 from 18.8 deaths in 2000 (MacDorman et al. 2016). Data shows that American women today are 50% more likely to die in childbirth than their mothers were (Shah, 2018) and this risk is consistently higher for women of color, in lower socioeconomic groups and in rural areas (Kozhimannil et al, 2019). Taking all this into account, it made me wonder: why does it take professional athletes and celebrities to bring attention to such a dire issue that is pervading our country?
What are mothers dying from?
There are seven underlying causes that have been identified as leading causes of maternal death, and collectively they make up approximately 71% of all maternal deaths; Hemorrhage specifically accounts for 14% of deaths (Report from Nine Maternal Mortality Review Committees, 2018). During hemorrhage, the body activates several compensatory mechanisms. When arterial blood pressure drops, baroreceptors (pressure sensors) activate the sympathetic nervous system to increase heart rate and contractility, as well as increase constriction of blood vessels to increase resistance, both of which act to rectify the lowered arterial pressure. This response has little effect on vessels that deliver blood to the brain and heart, effectively redirecting blood to the most vital organs for survival (Klabunde, 2014). Exsanguination (loss of enough blood to cause death) can occur long before a person has lost the entirety of their blood; a loss of half to two thirds can be sufficient to cause death (Mistovich and Karren, 2014).
What can healthcare providers and communities do?
Hospitals and providers can certainly step up to improve the safety of women. A report from nine Maternal Mortality Review Committees (MMRCs) indicated the following recommendations, among others, as vital to fixing this issue: improving training, increasing access to care, improving policies related to patient management, and improving policies on prevention initiatives.
States and policymakers can also have an impact. Many states were slow to adopt a pregnancy question on death certificates (which allows for more accurate data tracking) and, as of 2014, some states, including Colorado, hadn’t adopted this piece of the U.S. standard death certificate at all (Kozhimannil et al., 2019). Tracking maternal death rates are vital to understanding causes, which can help dictate prevention initiatives and the creation of relevant social programs.
Four out of five maternal deaths occur in the weeks and months leading up to and after birth (Shah, 2018). If this is the case, then what can communities do to help? First and foremost, it is incumbent upon our society to change the idea that new mothers must “do it all” and never have a bad day in the process. This stereotype is isolating and dangerous; pregnant women and mothers with a newborn must be able to ask for help and feel safe to speak up when something is wrong. If we support the new mothers in our lives by reassuring them and helping them advocate for their needs, in addition to pressuring hospitals and lawmakers to enact positive changes, then maybe we won’t need celebrities to help bring attention to this urgent and appalling issue.
References
Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs
Klabunde, R. (2014, April 28). CV Physiology | Hemorrhagic Shock. Retrieved October 14, 2019, from https://www.cvphysiology.com/Blood+Pressure/BP031
Kozhimannil, K. B., Interrante, J. D., Corbett, A., Heppner, S., Burges, J., & Henning-Smith, C. (2019). Rural Focus and Representation in State Maternal Mortality Review Committees: Review of Policy and Legislation. Women’s Health Issues, 29(5), 357–363. https://doi.org/10.1016/j.whi.2019.07.001
MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Recent Increases in the U.S. Maternal Mortality Rate. Obstetrics & Gynecology, 128(3), 447–455. https://doi.org/10.1097/AOG.0000000000001556
Mistovich, J. J., & Karren, K. J. (2014). Prehospital Emergency Care. Upper Saddle River: Pearson.
Scutti, S. (2018, January 11). After Serena Williams gave birth, “Everything went bad.” CNN. Retrieved from https://www.cnn.com/2018/01/10/health/serena-williams-birth-c-section-olympia-bn/index.html
Excellent points Alyssa. It should not take one of the best athletes in the world to bring our attention to a potential health crisis. All of my friends have babies except for me, and I was always shocked at how soon they were released from the hospital. Sometimes a day and a half after giving birth! There is a good literature review article from BMC Pregnancy and Childbirth that neither supports or discourages the release of postpartum mothers who delivered vaginally, mainly because there is a lack of clinical evidence and a lack of evidence in full economic evaluations (Benahmed, et. al., 2017). It would appear that there are a few issues in keeping up to date with these outcomes; there aren't enough clinical trials being performed, the impact on discharge research is well over ten years old and the length of duration is so variable that a short stint in the U.S. may differ from a short stint in France.
ReplyDeleteIt really makes me wonder if other women are considering these things when family planning. This notion that it is more dangerous to give birth now than 30+ years ago is not a settling feeling. I would hope that OBGYNs as well as midwives would advocate for a just system that benefits the patients they are serving and not the financial gains that the hospital puts forth on its providers. Also, educating on risks and what to look out for pre and post birth. Knowing the signs can be the difference between life and death. Why should it take the best female athlete in the world to almost die before she has reached her full legacy for this to be news? Danbjorg et al., proposed in Denmark a study to look at nursing support (via the telephone) given to parents and infants after the first seven days postnatal, since postnatal parents did not approve of the aftercare that their providers presented to them before they were discharged (Danbjorg, Wagner, Clemensen, 2014). Though I think a nurse hotline is not a bad idea, I don’t think unsure parents should be released without understanding health risks and having some of their questions answered; it’s overwhelming and traumatizing what they just went through, and I think more guidance and empathy needs to be provided before sending them home to fend for themselves.
References:
Benahmed, N., San Miguel, L., Devos, C., Fairon, N., Christiaens W. 2017. Vaginal Delivery: how does early hospital discharge affect mother and child outcomes? A systemic literature review. BMC Pregnancy and Childbirth. 17:289. doi: 10.1186/s12884-017-1465-7
Danbjorg, D.B., Wagner, L., Clenensen, J. (2014). Do families after early postnatal discharge need new ways to communicate with the hospital? A feasibility study. Midwifery. Jun; 30(6):725-32. doi: 0.1016/j.midw.2013.06.006.
Alyssa:
ReplyDeleteYour post brings to mind an old article, "Do no harm" by Sarah Kliff, which discussed the actions of Dr. Peter Pronovost of Johns Hopkins Hospital in his pursuit of preventing central line infections. While many healthcare providers were cautious in their administration of a central line (following a "gold-standard" protocol established by their facility), infections were still accepted as an infrequent but inevitable occurrence on the floor. Pronovost evaluated the CDC's dense guidelines for reducing central line infections and distilled highly effective guidelines from low-risk guidelines using review of evidence-based medicine, establishing a protocol for central line placement on his floor. Six months following implementation of the new protocol, central line infections on the surgical intensive care floor fell by 70% as providers began to adopt these new guidelines.
Prior to reading your post, I admittedly was unaware of of the growing frequency of maternal deaths postpartum, and was additionally unaware of Serena Williams' specific case. With future prospects in entering the healthcare field, I question for what other conditions/complications could risk of mortality and morbidity be reduced with reasonable intervention/changes in protocol and/or training, but are not due to our complacency.
Similarly, mortality as a result of medical error is not included on patient death certificates (Makary et al., 2016). I posit that, with respect to non-malfeasance, we as prospective healthcare professionals ought to advocate for change in how data regarding mortality is collected, as these data may offer integral insight towards necessary changes in guidelines and so-called "gold standards" that may overall improve patient outcomes. The concept of evidence-based practice is most beneficial to the patient only with sufficient evidence to draw conclusions from, and I agree with you on the absurdity of requiring a high-profile individual in order to improve tracking and patient management for postpartum deaths.
References:
Kliff, S. (2015). Do no harm. Retrieved from https://www.vox.com/2015/7/9/8905959/medical-harm-infection-prevention
Makary, M.A., Daniel, M. (2016). Medical Error-the third leading cause of death in the US. The BMJ. doi: https://doi.org/10.1136/bmj.i2139
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ReplyDeleteI didn’t realize that, in general, US maternal mortality is going up. I had previously only been aware of the overwhelming racial disparity in maternal mortality that Alyssa refers to. Thus, I am wondering if the increase in maternal mortality is mostly accounted for by non-white minorities (I could not find stats on numbers of white maternal mortality through the years to determine if it is increasing) or if there is a proportional increase across all races.
ReplyDeleteHigher African American maternal mortality rates are theorized to be due to the racism African American women experience directly during the birthing process at healthcare systems (i.e. subpar treatment from or being taken less seriously by healthcare workers) (Creanga et al., 2014), and also due to the physiological manifestations of a lifetime dealing with the stress of racism that predispose African American women to a variety of health conditions (Center for American Progress, 2018, February 1; Geronimus, Hicken, Keene, & Bound, 2006; Wallace & Harville, 2013).
I am surprised that the CNN article referenced Serena Williams in the context of maternal mortality without bringing up the fact that African American women are 3 times more likely to die during childbirth and its complications than white women. I thought the uproar around Serena Williams’ pregnancy-related complications was because this demonstrated that even a “well-off” African American woman with access to great medical care has a higher risk of maternal death. According to the US Department of Health, maternal mortality of college-educated African American women were still twice as high as white women who did not complete high school (National Public Radio Public Health, 2019, May 10; Petersen et al., 2019).
If disadvantaged populations are primarily contributing to the overall increase in US maternal death, this should direct solutions. We obviously cannot eliminate systemic racism in our society overnight to ameliorate the stress African American women experience during their lifetimes, but we can advocate for greater equity in treatment and require healthcare workers to go through more stringent racial implicit bias training.
Cited Literature
Center for American Progress. (2018, February 1). Exploring african americans’ high maternal and infant death rates. Retrieved from https://www.americanprogress.org/issues/early-childhood/reports/2018/02/01/445576/exploring-african-americans-high-maternal-infant-death-rates/
Creanga, A. A., Bateman, B. T., Mhyre, J. M., Kuklina, E., Shilkrut, A., & Callaghan, W. M. (2014). Performance of racial and ethnic minority-serving hospitals on delivery-related indicators. Am J Obstet Gynecol, 211(6), 647 e641-616. doi:10.1016/j.ajog.2014.06.006
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health, 96(5), 826-833. doi:10.2105/AJPH.2004.060749
National Public Radio Public Health. (2019, May 10). Why racial gaps in maternal mortality persist. Retrieved from https://www.npr.org/sections/health-shots/2019/05/10/722143121/why-racial-gaps-in-maternal-mortality-persist
Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., . . . Barfield, W. (2019). Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep, 68(35), 762-765. doi:10.15585/mmwr.mm6835a3
Wallace, M. E., & Harville, E. W. (2013). Allostatic load and birth outcomes among white and black women in New Orleans. Matern Child Health J, 17(6), 1025-1029. doi:10.1007/s10995-012-1083-y