Maternal Morbidity and Mortality in the US

[Campanella]

It seems like now is as good as time as ever to reflect on major medical news of 2017, and one story that I have noticed being repeated in several different forms this year is maternal morbidity and mortality in the United States. We've known for several years that the we have the highest rates of maternal mortality among industrialized nations for years, but there have been several stories this year that have explored this grim statistic in detail. Some of them are below:

U.S. Has The Worst Rate Of Maternal Deaths In The Developed World

Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S.

How Hospitals Are Failing Black Mothers — ProPublica

The problem is multifactorial, with rising rates of morbidity in the general population and varying access to health care playing large roles. However, even after taking those factors into account, the sobering reality is that our unacceptably high. Have you all noticed any practices that your hospital or health system is using to reduce maternal morbidity and mortality rates in the community? What can we as individual ob/gyns do differently to lower rates in the patient populations we serve?

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[anonperson]

The US lags behind many of these countries due to a variety of reasons. Countries like Finland and Denmark have extremely homogenous patient populations. They cannot even begin to compare to the wide variety of ethnicities/races that are in various parts of the United States. The United States has a higher number of black women who unfortunately are at higher risk for preterm delivery, chronic hypertension, and pre eclampsia. That alone will skew our numbers for the worse.

Let's not forget that the patient population we are dealing with is fatter/older/sicker than that of other countries regardless of race. I may have read the links too quickly but I don't think they stated that even after controlling for all of these confounding factors we are still the worst. To try to compare us to Findland/Netherlands/Sweden is a joke.

There is a huge segment of the population as well who are non compliant with their care . I know because I see it on a fairly regular basis.

Some recent examples:

Fetal demise at 30+ weeks of a mom who has been using amphetamines during pregnancy. Non compliant with her care and has missed several appointments.

Ended up transfusing a different patient a few units due to post op (post c section) hypotension. Her risks: BMI ~40, GDMA2-Non compliant with care, C/D X 3. Her abdomen was a mess but she came in as a ticking time bomb with all of these co morbidities and it was no surprise that this happened. Probably bled from some adhesion. She did fine but it was a close call.

Patients who are young, only in the early to mid twenties with BMIs in the upper 40s and low 50s. We know that this increases all sorts of pregnancy complications and also increases the risk of cesarean delivery but what can an OB GYN even do when a patients comes into the office pregnant at 20 weeks who already weights 290lbs. Not much other than tell them to not gain weight but that is easier said than done. So it's no surprise they have issues peri partum. We can only do so much.

Add in the older patients getting pregnant either spontaneously or through the assistance of REI who already have a host of other problems like chronic HTN, diabetes, kidney disease and you have a set up for disasters.

Where I'm at, medicaid/medical is available but you still see a steady stream of patients roll in at ~40 weeks in labor with absolutely no prenatal care. Sometimes they do fine but we've had a couple come in seizing with evidence of PRES on imaging.

What has been helpful in reducing mortality is making protocols for acute HTN and hemorrhage. These have worked well at the hospital I am at. They are not perfect but it speeds up the management of common obstetric emergencies with minimal delay in patient care while waiting for a physician order. This should be more widespread in general.