Maternal Mortality and Morbidity - Position Statement
I. ASTHO Supports the Reduction of Maternal Morbidity and Mortality
The Association of State and Territorial Health Officials (ASTHO) affirms that the reduction of preventable maternal morbidity and mortality will improve health outcomes for both mothers and infants, and is critical to the promotion of health across the lifespan. ASTHO believes that preventing maternal mortality and morbidity can only be accomplished if the social, economic and healthcare issues that impact women’s health are addressed at multiple levels. This includes influencing federal, state, and local healthcare policy, systems, and environmental levers which will improve maternal health in communities with limited resources and engage populations who experience disparities in health and healthcare.
Integrating targeted public health interventions with healthcare delivery efforts to achieve accessible, affordable, culturally appropriate and high quality reproductive health services is a step in the right direction. This integration includes preconception, prenatal, postpartum, and interconception care. Because of the increasing contribution of chronic disease to maternal morbidity and mortality, an important aspect of prevention is promoting women’s health and identifying and managing chronic disease prior to pregnancy. ASTHO believes that perinatal and maternal quality collaboratives and maternal mortality reviews are key tools that allow states and territories to characterize and intervene in maternal death and morbidity. These interventions must also connect with efforts to identify upstream root causes of morbidity, including social determinants of health (SDOH), to effectively develop and implement prioritized strategies for primary, secondary, and tertiary prevention. ASTHO also recognizes the right of pregnant women to make fully informed medical decisions about their options for care providers and birth setting.
II. ASTHO Recommendations for State and Territorial Health Agencies:
- Collaborate with partners in healthcare delivery to achieve the triple aim by improving patient experience and population health, and reducing per capita healthcare costs related to maternal outcomes.
- Proactively reduce health inequities by incorporating a health-in-all-policies lens into upstream and mid-stream strategies within the design of maternal interventions.
- Invest and sustain partnerships with community-based organizations, government, and businesses to address SDOH which influence maternal mortality and morbidity.
- Strengthen links between primary care and reproductive health providers to ensure that vulnerable populations have access to the full range of recommended preventive primary, reproductive, and obstetric healthcare services which contribute to the elimination of health inequities.
- Facilitate strategies to promote effective preconception health and reproductive life planning within existing family planning, healthcare, and public health settings, and maximize the use of voluntary long-acting reversible contraception.
- Partner with clinical providers to promote meaningful use of health information technology to improve the identification and management of chronic diseases in women of childbearing age and promote optimal control of these conditions prior to pregnancy in order to decrease their impact on maternal and infant health outcomes.
- Provide public education that is evidence-based, medically accurate, and culturally and linguistically appropriate for women of childbearing age regarding the importance of preventing and managing their chronic conditions before and during pregnancies.
- Coordinate and leverage all available funding sources, including but not limited to the Title V Maternal and Child Health Services Block Grant, Home Visiting funds National Breast and Cervical Cancer Early Detection Program, Medicaid, Patient Protection and Affordable Care Act provisions, and other public health programs to support this work.
- In addition to working independently on maternal health outcomes, establish or participate in perinatal quality collaboratives that are linked to systemic multidisciplinary maternal mortality review team efforts. The collaboratives have the ability to address racial and ethnic disparities in maternal mortality and morbidity directly by prioritizing the engagement of community and civic organizations in at-risk communities. The combined initiatives have the benefit of integrating efforts in data collection and analysis and expert review of factors contributing to poor maternal health outcomes, and the capacity to alter the organization and delivery of both preventive primary care and obstetric and gynecologic care.
○ Perinatal quality collaboratives and multidisciplinary maternal mortality review teams should include a diverse set of key stakeholders with the ability to change healthcare delivery.
○ Review data collection efforts to assure alignment with HHS’s Office of Minority Health Data Collection Standards for Race, Ethnicity, Sex Primary Language and Disability Status.
○ Engage all key collaborative stakeholders at the state level to understand the context, obtain and analyze data, and institute changes in healthcare delivery and public health prevention approaches (e.g. improving maternal obstetric outcomes through implementing maternal safety bundles on obstetric hemorrhage, severe hypertension in pregnancy, and venous thromboembolism in hospitals).
○ Ensure that state health agency vital records systems are able to link infant birth and maternal death records with hospital discharge data to promote complete case ascertainment and comprehensive data analysis.
○ Maximize the use of geographic information system technology to convert vital birth and death records into information to identify specific census geographies with persistent poor maternal outcomes to target interventions.
○ Invest in integrated data management systems that document and track interventions to facilitate program asset mapping and evaluate impact.
○ Ensure that perinatal quality collaboratives and maternal mortality review teams utilize available best practices in surveillance, data gathering and abstraction, review, analysis, and formulating recommendations and action plans.
○ Promote translating recommendations into system changes in policies, clinical care protocols in primary care, and pregnancy care clinical sites and birth hospitals.
○ Include categorization of preventability of maternal deaths and morbidity in data analysis and reports to target efforts for preventing specific cause of maternal deaths.
- Work closely through perinatal collaboratives and with the OB/GYN and neonatology providers to prevent and manage substance abuse during pregnancy.
- Promote a screen-intervene-treat-referral approach to community resources for women with perinatal mental health issues, such as perinatal mood and anxiety disorders.
- Work closely through perinatal collaboratives and with the OB/GYN, midwifery and nursing communities to increase immunizations, particularly influenza and pertussis vaccines, during preconception and postnatal periods.
- Support policies that improve women’s health prior to pregnancy, encouraging lifestyle choices that are free from substance abuse and lead to healthy weight, and smoking cessation.
ASTHO Recommendations for the Federal Government:
- Develop flexible policies and funding mechanisms that allow states to use federal funding to support state perinatal quality collaboratives, maternal mortality reviews, and other maternal mortality and morbidity prevention efforts.
- Develop flexible policies and funding mechanisms that allow states to use federal funding to support state women’s health quality collaboratives.
- Develop policies to ensure adequate obstetric and midwifery workforce and woman-centered midwifery care.
- Support the establishment of a maternity workforce shortage designation, so that providers can be incentivized to work in vulnerable communities that do not have access to maternity care.
- Ensure that the Title V block grant performance measures related to maternal health are aligned with effective maternal mortality and morbidity prevention practices.
- Provide adequate funding to support quality, accessible, and culturally and linguistically appropriate preconception and interconception healthcare for women, especially those in populations with a disproportionate share of preventable pregnancy related deaths.
- Promote public education campaigns related to maternal and newborn outcomes in different birth settings, including hospitals, birthing centers, and at home.
- Enhance and expand the work of CDC’s Pregnancy Mortality Surveillance System, including fostering use of consistent definitions by states to aid in the comparability of data for surveillance and quality improvement efforts.
- Provide technical assistance and support to develop or enhance maternal mortality review teams in all states.
- Address barriers related to women’s access of long active reversible contraceptives (LARC) including limits to number of LARC per year, and provider stocking and supply costs.
- Encourage the effective integration of perinatal quality collaboratives, maternal mortality review initiatives with state public health department initiatives to identify primary drivers of state, and local patterns of maternal morbidity and mortality so prevention efforts can be prioritized.
○ Encourage states to increase linkages of vital records for infant birth and maternal death files.
○ Identify best practices in abstraction, review, and recommendation processes that could serve as a model for state perinatal quality collaboratives and maternal mortality review teams.
○ Gather, track, and provide resources to support states in complete ascertainment of pregnancy related deaths.
○ Support the documentation, dissemination, and implementation of effective action plans developed by integrated perinatal quality collaboratives and maternal mortality review initiatives to address preventable maternal mortality and morbidity.
III. Background: Reducing Maternal Mortality and Improving Birth Outcomes
Maternal mortality is a relatively rare event. During the 20th century, the U.S. maternal mortality rate decreased by an impressive 99 percent from a peak of 800 per 100,000 live births at the turn of the century.1 However, data suggests that pregnancy-related mortality has increased since the institution of the Pregnancy Mortality Surveillance System, perhaps due to improved case identification. The most recent overall pregnancy-related mortality ratio is 17.8 per 100,000 live births, resulting in approximately 500-600 deaths per year in 2011.2 The rates for black women are even higher at 42.8 per 100,000 live births, a huge disparity compared to the 12.5 deaths per 100,000 live births for white women.3 Over the past several decades, there has been a change in the rank order of the most common causes of this adverse pregnancy outcome, although the top ten causes remain the same. The most recent national data indicates that the top causes of pregnancy-related mortality are hypertensive disorders of pregnancy, cardiovascular conditions, hemorrhage, and non-cardiovascular medical conditions.4,5 Hemorrhage shifted to the leading cause of pregnancy-related deaths in the period 1987-1990, causing almost 30 percent of the deaths, however, from 1998-2005 hemorrhage related deaths dropped to only 12 percent of deaths.6,7,8 This important change in the incidence of postpartum hemorrhage has been attributed to significant improvements in obstetric care and the ability to recognize and manage this potentially fatal complication, although there is a suggestion that postpartum hemorrhage due to uterine atony may be increasing.9,10 The impact of chronic medical conditions has also increased, possibly due to a shift in older maternal age and an increase in maternal obesity, with its associated adverse health effects. This shift in the epidemiology of the causes of maternal mortality requires new ways of measuring and monitoring the health of women of reproductive age at the population level and acting on opportunities to implement primary, secondary, and tertiary prevention when women of reproductive age are not pregnant.
There are several technical barriers for addressing the maternal mortality issue, including incomplete ascertainment due to differing birth and death certificate fields and varying approaches to defining which deaths are attributed to pregnancy. For example, American Congress of Obstetricians and Gynecologists and CDC include any death related to or aggravated by pregnancy, or its management, within 100 days of the termination of pregnancy, whereas WHO defines maternal mortality using a shorter period of 42 days after the termination of pregnancy.11,12,13 The incomplete case finding and differing definitions make comparing data among countries, states, or different time periods challenging.
Although experts disagree on the exact percentage, there is strong consensus that a substantial proportion of maternal deaths are preventable – up to 30-40 percent.14 Importantly, the racial and ethnic disparities are evident in maternal mortality overall and are exacerbated with a higher proportion of black maternal deaths, 46 percent, being defined as preventable, compared to 33 percent of those of white women.15 Furthermore, although the specific areas for improvement vary by the causes of death, reviews of pregnancy-related deaths have highlighted the importance of quality of clinical care and lack of preconception care as important drivers of preventable deaths.16 This understanding of the preventability of these deaths provides an excellent opportunity to operationalize the functional integration of public health and clinical care delivery systems. Maternal mortality review teams should be staffed with experts from various disciplines and organizations to ensure that both medical and non-medical causes of death are examined. Review team membership may include professionals from medical specialties, nursing and midwifery, state medical societies, public health departments, social services programs for women, social work, nutrition, medical examiners, hospitals, managed care organizations, education boards, clergy and other religious leaders.17 Integrating perinatal quality collaboratives with maternal mortality review initiatives will improve the ability of states and their partners to develop and implement effective strategies to reduce pregnancy-related deaths.18 Currently, 27 states have a perinatal quality collaborative and three additional states are developing them.
ASTHO position statements relate to specific issues that are time sensitive, narrowly defined, or are a future development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Board of Directors. Position statements are not voted on by the full ASTHO membership.
Access Policy Committee review and approval: May 2015
Board of Directors review and approval: June 2015
Policy expires: June 2018
For ASTHO policies and additional publications related to the Position Statement, www.astho.org/Policy-and-Position-Statements.
Related ASTHO Documents
- Access to Care Policy Statement
- Health Equity Policy Statement
- Prevention Policy Statement
- A Transformed Health System in the 21st Century Position Statement
- Improving Birth Outcomes Position Statement
- Preventing Unintentional Injuries and Violence Position Statement
- Access to Reproductive Health Services Position Statement
- CDC. “Achievements in Public Health, 1900-1999: Healthier Mothers and Babies.” Morbidity and Mortality Weekly Report, October 1, 1999, 1999:48(38);849-858. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4838a2.htm. Accessed 3-24-2014
- CDC. “Pregnancy Mortality Surveillance System.” Available at http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html. Accessed 3-19-2015.
- Berg CJ, Callaghan WM, Syverson C, and Henderson Z. “Pregnancy-Related Mortality in the United States, 1998 to 2005.” Obstetrics & Gynecology. 2010. 116:1302-1309. Available at http://www.ncbi.nlm.nih.gov/pubmed/21099595. Accessed 12-8-2014.
- Creanga AA, Berg CJ, Syverson C, et al. “Race, Ethnicity and Nativity Differentials in Pregnancy-Related Mortality in the United States: 1993-2006.” Obstetrics & Gynecology. 2012. 120:261-268. Available at http://journals.lww.com/greenjournal/Abstract/2012/08000/Race,_Ethnicity,_and_Nativity_Differentials_in.11.aspx. Accessed 12-8-2014.
- Clark SL, Belfort MA, Dildy GA, et al. “Maternal death in the 21st century: causes, prevention and relationship to cesarean delivery.” American Journal of Obstetrics and Gynecology. 2008.199:36.e1-36.e5. Available at http://www.ncbi.nlm.nih.gov/pubmed/18455140. Accessed 12-8-2014.
- Berg CJ, 1998, op cit.
- Callaghan WM, Kuklina EV, and Berg CJ. “Trends in postpartum hemorrhage: United States, 1994-2006.” American Journal of Obstetrics and Gynecology. 2010.202:353.e1-6. Available at http://www.ajog.org/article/S0002-9378%2810%2900022-0/abstract. Accessed 12-8-2014.
- Berg CJ, Harper MA, Atkinson SM, et al. “Preventability of Pregnancy-Related Deaths: Results of a State-wide Review”. Obstetrics & Gynecology. 2005.106:1228-1234. Available at http://www.ncbi.nlm.nih.gov/pubmed/16319245. Accessed 12-8-2014.
- Callaghan WM, 2010, op cit.
- American Congress of Obstetricians and Gynecologists. “Did you know? Data comparisons.” Available at https://www.acog.org/~/media/Departments/Government%20Relations%20and%20Outreach/momsDidYouKnowDC.pdf?dmc=1&ts=20140403T1328256083. Accessed 3-25-2014.
- CDC. “Pregnancy-Related Deaths.” Available at http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm. Accessed 3-19-2014.
- World Health Organization. “Maternal mortality ration (per 100,000 live births).” Available at http://www.who.int/healthinfo/statistics/indmaternalmortality/en/. Accessed 3-25-2014.
- The Joint Commission. “Sentinel event alert: preventing maternal death.” Available http://www.jointcommission.org/assets/1/18/sea_44.pdf. Accessed 3-25-2014.
- Berg C. Danel I. Atrash H, Zane S, and Bartlett L (Editors). “Strategies to reduce pregnancy-related deaths: from identification and review to action.” Available at http://www.cdc.gov/reproductivehealth/ProductsPubs/PDFs/Strategies_taged.pdf. Accessed 1-5-2015.
- Berg C. Danel I. Atrash H, Zane S, and Bartlett L (Editors). “Strategies to reduce pregnancy-related deaths: from identification and review to action. Available at http://www.cdc.gov/reproductivehealth/ProductsPubs/PDFs/Strategies_taged.pdf. Accessed 12-8-2014.