Why Are Maternal Deaths on the Rise?
There is a lot of information about fetal deaths and how to prevent them. However, did you know that maternal deaths in the US are on the rise? Why?
Maternal death rates in the US have risen 26.6% over 14 years, from 18.8 in 2000 to 23.8 in 2014, according to a recent American Association of Critical Care Nursing publication. There are many factors contributing to this including:
- Obstetric hemorrhage
- Rise in maternal age
- Pre-existing conditions
- Need for operative birth
Obstetric hemorrhage is the number one reason for maternal mortality in the US. From a recent AACN publication in the Advanced Critical Care Journal, “Obstetric hemorrhage is the leading cause of death during pregnancy throughout the world and one of the top 2 causes of severe maternal morbidity and death in the United States, tied with cardiovascular conditions at 14% of all maternal deaths each.” It’s unknown at this time exactly how many pregnant or post-partum women are admitted to the ICU with pregnancy-related complications and the reasons for this are multi-factorial: stats are not separated out by pregnancy-related causes, a critically ill pre-natal or post-partum patient may be cared for in several different settings including an adult ICU, a post-partum unit, or a telemetry unit or they might be transferred to different levels of care during the same hospitalization. Obstetric hemorrhage that occurs at the time of birth or within 24 hours of birth has the highest risk of mortality. “Postpartum hemorrhage (PPH) currently is defined as blood loss of at least 1000 mL that occurs after delivery of the fetus and placenta or any amount of blood loss accompanied by signs or symptoms of hypovolemia occurring in the first 24 hours after birth.”
Causes of maternal hemorrhage include uterine atony which accounts for 70-80% of hemorrhage. Treatment consists of pharmacologics: pitocin and methergine, bimanual uterine massage, and uterine tamponade with balloon placement per ultrasound. If surgical intervention is needed, uterine curettage is sometimes performed, embolization of pelvic arteries with interventional radiology can be needed, and possibly exploratory laparotomy. Occasionally, hysterectomy is indicated.
Complications from maternal hemorrhage include disseminated intravascular coagulopathy (DIC). “The causes of DIC specific to pregnancy are most likely related to activation of the hemostatic system; hemostatic abnormalities, including placental abruption, PPH or hypovolemia preeclampsia or HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome; acute fatty liver; sepsis; and amniotic fluid embolism syndrome. Disseminated intravascular clotting is more likely to occur after delivery of the infant, following disruption of the placental attachment sites or after uterine rupture.”
As our technology has grown in the area of pregnancy, so have the risks. The Centers for Disease Control (CDC) states that from 2000-2012, first birth rates for women 35-39 years rose 24% and 35% for women aged 40-44. With increased maternal age comes the increased risk of complications including maternal hemorrhage which is the leading cause of maternal deaths in the US. First births for women under the age of 20 have declined over the past decade.
Some pre-existing chronic conditions negated the possibility of pregnancy just a few years ago. However, now it is possible for women who have heart disease, lung disease, who are status post-transplant, women who have had cancer, hypertension, diabetes – all can and do become pregnant. Some women will be considered to have a high-risk pregnancy which can result in both maternal and fetal complications. However, it is possible to mitigate these risk factors with careful, consistent and expert prenatal care. The Office on Women’s Health offers many tips for patient education about pre-existing conditions:
- Thyroid disease
Obesity also increases maternal mortality due to hypertension during pregnancy and increased risk of gestational diabetes as well as the need for operative birth. Losing weight prior to becoming pregnant is preferable over attempting to lose weight during pregnancy. Careful monitoring of weight gain in the obese is very important.
Americans have always considered our prenatal and birthing experiences to be of the highest caliber. Maybe we need to look at how we care for our birthing and post-partum Moms in order to reduce mortality risks.
What is your hospital doing to decrease maternal mortality?