It is safer to fly by plane anywhere in the world than it is to give birth in the United States. Last year, 589 people died worldwide because of an airline accident. Compare that with about 700 deaths each year among women in the U.S. as a result of pregnancy or complications during or after childbirth. Worldwide, more than 800 women die every day because of these complications.
In the United States, women of color bear the brunt of these problems. Data released last week by the Centers for Disease Control and Prevention show that black, American Indian, and Alaska Native women are significantly more likely to die because of childbirth than white women, regardless of age group, education level, and other factors.
This is inexcusable, especially since the majority of maternal deaths are preventable.
Seven years ago, my health care system, Providence St. Joseph Health, made a concerted effort to tackle this issue. Our team at the Women and Children’s Institute established a firm foundation to make childbirth safer. Our efforts have borne fruit. In the last three years, just one childbirth-associate death occurred across 51 Providence St. Joseph hospitals in seven states. Based on the current national average, the number of deaths should have been at least 32 for an organization this size.
Here are five of the top steps we took, each of which can be easily adopted by any hospital or health system that cares for women during and after pregnancy.
Focus on the major delivery complications. Excessive bleeding (hemorrhage) during and after birth, cardiovascular conditions such as high blood pressure (which can be a warning sign for preeclampsia), and sepsis are three of the leading complications that can lead to a woman’s death during or after childbirth. Providers should focus, as we did, on implementing evidence-based care for these three conditions.
Move from reaction to prevention. A proactive perspective helps prevent complications. While most hospitals have protocols to respond to an emergency, it is equally important to recognize that serious maternal issues can be avoided by identifying risk factors as early as possible. Our data specialists created the EMR Hemorrhage Risk Assessment, described recently in the New England Journal of Medicine, to help evaluate a woman’s risk for delivery complications. Upon admission to the hospital, the caregiver records responses to five key data points recommended by the California Maternal Quality Care Collaborative for postpartum hemorrhage risk assessment: past pregnancies, problems with current pregnancy, history of gestational hypertension, current vital signs, and multiple births. The tool uses an algorithm and the patient’s health history to identify her risk.
We now screen almost every patient for the risk of excessive bleeding and are getting better at identifying and treating high blood pressure, as well as preventing hospital readmissions. This is extremely important since hemorrhage after childbirth accounts for 11% of maternal deaths and cardiovascular conditions account for 15%.
Standardize protocols. Every clinician should know (or have immediate access to) all the protocols in case of postpartum hemorrhage. To make the right care easy to provide in an emergency, we built the most current care pathways into the electronic medical record so they’re readily accessible. We have also embedded all of our postpartum hemorrhage efforts into a suite of tools that work together in the electronic medical record. This suite, which we call the Maternal Early Warning Trigger Tool, provides early assessment of pregnant women to detect sepsis, cardiopulmonary dysfunction, high blood pressure and preeclampsia, and hemorrhage.
Empower the care team. One of the most important things hospitals and systems can do is become a high-reliability organization that empowers everyone — doctor, nurse, pharmacist, ward clerk, and more — to voice concerns about any potential threat. This includes specific language and tools that require everyone on a care team to stop and listen to a concern and develop an action plan for how to proceed safely. Listening to the patient is the first key to ensuring a safe delivery.
Champion prenatal and postpartum care. Mothers and children need to be safe when they are not in the hospital. In fact, according to the Centers for Medicare and Medicaid Services, some factors that contribute to maternal mortality, such as intimate partner violence or housing insecurity, occur outside of the hospital, underscoring the importance of care before, during, and after childbirth. It is important to champion expanding prenatal care, and ensuring appropriate rates of postpartum visits among pregnant women covered by Medicaid and the Children’s Health Insurance Program.
Many of our acute care hospitals provide direct maternal health-related programming to the local community, which include perinatal and prenatal care and breastfeeding education for low-income women. Although not all health system prioritize maternal and infant health as a specific need, in many cases it correlates with other necessities such as poverty, food security and nutrition, health behaviors, and adequate housing that affect maternal health.
As a nation, we still have a long way to go to ensure excellent outcomes for maternal care. Although it is shocking that maternal deaths are still an issue, they can — and must — be addressed. It is past time for all health systems to take action, so every woman in the U.S. who wants to become a mother can do so confidently and safely.
Amy Compton-Phillips, M.D., is the executive vice president and chief clinical officer at Providence St. Joseph Health, one of the nation’s largest health systems.