Reducing maternal deaths

EKG monitor

Earlier in the week I criticized the ProPublica/NPR piece on maternal mortality (What ProPublica didn’t explain and possibly didn’t even know about maternal mortality).

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We must create regional centers for maternal intensive care just as we have done for newborn intensive care.[/pullquote]

Because ProPublica failed to explain changes in reporting of maternal mortality, failed to explain the changing causes , failed to explain the outsize contribution of race and failed to explain the inherent deadliness of childbirth, they presented a fundamentally misleading picture of the issue. But there is disturbing fact that they got absolutely right: 60% of maternal deaths are potentially preventable.

In order to understand how these deaths could be prevented, we need to understand what causes them.


The chart above shows the leading causes of pregnancy related deaths. These causes can be roughly divided into three groups, pre-existing medical issues, complications of pregnancy, complications of hospitalization.

Let’s start with the easiest group first, complications of hospitalization. Deaths due to infection and thrombotic pulmonary embolism make up the bulk of these deaths. They aren’t strictly due to hospitalization; they have always been leading causes of death because childbirth puts women at risk of infection and pregnancy puts women at increased risk of blood clots. But there are easy to implement methods that can dramatically reduce both, including checklists and proper aseptic technique to reduce infection and low dose heparin and compression boots to reduce blood clot formation. A lower C-section rate could contribute to a reducing both complications as well. This is the low hanging fruit of the maternal mortality problem, easy to grasp and easy to correct. We will never be able to abolish all infection and blood clots in pregnancy, but we can do a lot better.

The second group is complications of pregnancy like hemorrhage and hypertensive disease (pre-eclampsia and eclampsia) as well as strokes resulting from high blood pressure. Both hemorrhage and hypertensive disease are endemic to pregnancy. Neither can be entirely or even mostly prevented (at least not yet); they must be treated. And before they can be treated, they must be diagnosed.

We know that a certain percentage of women will hemorrhage after childbirth just like we know that a certain percentage of women will developed hypertensive diseases of pregnancy. Diagnosing those problems as early as possible requires an high index of suspicion, careful monitoring, and the immediate application of technology. This is where algorithms, drills and tool kits come into play. No one should assume that a woman won’t develop childbirth complications; everyone should be alert to the a fact that they are both common and inevitable. Algorithms can help providers make an early diagnosis.

Hemorrhage and pre-eclampsia are often full blown emergencies where minutes count. Tool kits allow providers to have all relevant diagnostic and treatment technology at hand. Drills help providers utilize that technology expeditiously. They are often the difference between life and death.

Cardiomyopathy is also a complication of pregnancy but not nearly so common as hemorrhage and pre-eclampsia. It is relatively rare and therefore most providers may have never seen it. Nonetheless it is one of the fastest growing causes of maternal death. Unfortunately:

Early, rapid diagnosis of peripartum cardiomyopathy is not the norm. It took 7 or more days to establish the diagnosis in 48% of women, and half of those had major adverse events before the diagnosis was made…

In this situation the most important elements are high index of suspicion when women complain of shortness of breath or chest pain and rapid consultation with cardiologists and other specialists.

The final group is pre-existing medical conditions. Childbirth is now more common than ever in women who are older, heavier and suffering from a greater number and range of pre-existing medical conditions. In many cases, such as heart disease and kidney disease, pregnancy and childbirth can put tremendous strain on already weakened organs. Specialized intensive care is the key to preventing maternal deaths.

We long ago recognized the value of specialized intensive care in saving the lives of critically ill newborns. That’s what led to the creation of neonatal intensive care units (labeled Level I, II or III based on the type of technology available), neonatologists, and routine regional transfer of newborns to higher level NICUs. A premature or critically ill newborn will be transferred to a Level III nursery if born at a hospital that only has a Level I or II nursery.

It’s hardly surprising that we addressed the intensive care issue in newborns first. Death rates for newborns are approximately 100X higher than for new mothers. It is surprising that we have never addressed the issue of maternal intensive care units, maternal intensivists and routine regional transfer of critically ill mothers at all. Mothers are dying as a result.

Only the rare obstetrician is trained in intensive care. No obstetrician should be trying to manage pregnant women with pre-existing medical conditions on his or her own. The appropriate specialists should always be involved hopefully before complications develop and certainly after.

Most intensivists trained in the care of adults are typically unfamiliar with the specific issues that arise in conjunction with pregnancy. We should create regional centers for maternal intensive care just as we have done for newborn intensive care. We should rank them by available technology and we should routinely transfer women to higher level centers to deliver there preferentially or when they develop complications after birth.

We’ve all read countless articles in the mainstream press about efforts to reduce pregnancy interventions, but there is precious little effort being made to reduce maternal deaths. New mothers will continue to die until we develop the will and deploy the technology to prevent these eminently preventable maternal deaths. Let’s stop wringing our hands, and start working.