Are more American women dying during or shortly after giving birth due to high blood pressure, diabetes and obesity – a growing epidemic in this country? There’s some debate about the causes of maternal death and The Joint Commission, the CDC, and others recognize this as an issue that needs attention. Why? Because even the conservative estimates about maternal death rates show that too many women are dying from preventable causes. We invite your feedback on this issue, and on the recommendations The Joint Commission has issued to try to improve safety. We invite you to use this blog as a forum for sharing experiences, data, and improvement strategies.
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Could there be a correlation between the deaths and the nurse-to-patient ratio? Over the past few years more and more facilities have increased the nurse-to-patient ratio for post partum patients and more and more units are combining GYN patients with post partum patients. I do not think the published perinatal standards take into consideration the health factors for post partum patients. The published standard is 1:8 for couplet care, but it does not indicate is that 4 vaginal delivery patients with NO health issues.
Hello,
As a 22 year veteran of L&D nursing and having worked at 3 different “progressive” NYS birthcenters, I think that in order to sufficiently attempt to solve this problem of increased maternal deaths in OB that the concominant problem of increased nurses workloads in OB needs to be sufficiently addressed. Often times nurses are being placed in situations where their workloads are unmanageable, which directly threatens patient safety. Reasons for this trend include higher acuity patients (comorbidities like HTN, obesity, and diabetes), and cost cutting. Hospital administrators need to stop cutting nursing costs, and organizations like The Joint Commision need to look at regulating / mandating birthcenters to staff sufficiently. Yes, we have a problem, and some women’s health and safety will continue to be jeopardized. We need to address the issue of increased nurses workloads in OB threatening patient safety ! ! ! Thanks for reading this.
There is no prevention for amniotic fluid embolism and it has a 50% mortality rate. PE with a known history has a limited prevention plan of treatment and also carries a high mortality rate. Efforts for prevention needs to be directed at those treatable comorbidities. Knowlegede of the s/s for early intervention of both types of embolism is key.
Could the increase in the number of c-sections and elective inductions be a potential cause of this increase in maternal death?
It seems that what the CDC needs to look at is the what measures can be taken to reduce complications, rather than focusing on those to identify and treat the problems. With a national C/S rate of 31%, a huge epidural rate, and an increasing number of women being induced, early discharge with minimal support, we are causing some of these problems!!
I have been a midwife for more than 35 years and have over the last decade gathered the names of 300 women who have died in the US since 1982 (the year of our lowest reported maternal death rate). Most of these 300 deaths happened since 2000.
Many of the women’s names come to us from local news articles and obituaries and some from friends or relatives of the deceased women. In most cases, the story of the cause of the woman’s death is known. Judging by this sample of 300, the previous comments about the understaffing of nurses is directly relevant in several of the maternal deaths. Understaffing contributes to medication errors, to failure to notice poor vital signs, cumulative blood loss, or other potentially life-threatening lapses in practice or judgment. It also contributes to not being able to respond in cases when two crisis situations happen simultaneously. Hospitals should be hiring, not firing nurses, according to many of the stories of this group of 300 women.
Not all postpartum cesarean mothers seem to be getting the help from nurses to get out of bed each day after surgery (understaffing?) or being informed about the signs of clotting complications that could develop after hospital discharge. Some pulmonary embolisms can be prevented. Reducing the primary cesarean rate is another obvious way of doing this.
Healthy women who ended up with cesarean complications, induced labors or had multiple gestations are all well-represented in the 300.
Many studies show that close to 50% of maternal deaths from amniotic fluid embolism are associated with induction of labor. This group of 300 includes about 15 such cases.
It is known that the risk for placenta previa, and various degrees of accreta also rise after abdominal surgery. The 300 names provide examples of all of these expected complications following a cesarean or in pregnancies following a previous cesarean.
The US is still the only industrialized country that doesn’t routinely provide for postpartum home visits. There are several cases of single mothers with no friends or family able to help them, who died for lack of appropriate postpartum care. Do nurses have time to tell mothers ready to be discharged and family members about danger signs? What plans are there to prevent this kind of death? It is not just single mothers, though, who require postpartum home visits to prevent serious complications from developing.
Stepping back from the problems already mentioned is the inescapable fact that we still have to guess why the maternal death rate is rising in the US. We have to guess because there is currently no way to systematically and accurately collect the information about each birth that most other industrialized countries collect to make up their annual statistic—the all-important feedback system that any health care system requires to maintain high quality care. In some of our maternal death reports from recent years, there was no way to distinguish between deaths caused by amniotic fluid embolism or pulmonary embolism, despite the fact that the two complications are unrelated as to cause.
There is another problem with our data. When we publish our official statistics, we mostly depend upon death certificate information when it comes to maternal death. This provides very little information of rather poor quality. Since it is not mandatory for the states to use the U. S. Standard Death Certificate, the data gathered is far less helpful in figuring out the major causes of maternal death than it should be. The CDC has been saying this for years. It is time that we do something about it.
For more on these issues, please see: http://www.rememberthemothers.org
Ina May Gaskin, PhD(Hon.), CPM, Curator
The Safe Motherhood Quilt Project
Founding Member of the White Ribbon Alliance for Safe Motherhood
http://www.whiteribbonalliance.org
I’d like to take this chance to say I was almost a Sentinel Event. 6 years ago, 32 weeks pregnant with twins, my OB/GYN called me to the hospital to just “recheck some labs” and that I might want to pack a bag. Turns out I had HELLP Syndrome and everything was shutting down quickly on me. My only perseptive symptoms were really horrible heartburn and fluid retention. Because my wonderful doctor and her staff paid excellent attention to my labwork, I am convinced my life and my two beautiful children were saved.
I am in hospital support and administration now. We always review the JC Sentinel Alerts, but this one really caught my eye. I cannot stress to you how important the role of not just the hospital staff is in recognizing signs and symptoms, but also the patient’s OB/GYN, associated lab work, and the value of adhering to your critical test results protocol. I am living testimony.
Thank you for all of your work.
As a maternal-child health nurse for 16 years and now a patient safety advocate, I have been writing letters and trying to draw attention to the over-medicalization of childbirth for years.
It is so disheartening to see the fall-out;
CDC data and graphs clearly show an increase in mortality as our cesarean rate began climbing in 1995.
Providers ‘blame’ women who demand inductions and cesareans but these women are largely uninformed of the risks associated with surgery; and especially of the exponential increase in risk with each successive cesarean. Induction rates of 40-75%, c/s rates of 30-50% & epidural rates of 50-80% are bound to lead to increased morbidity and mortality and yet hospitals across the country have allowed this to go on; not holding docs accountable to evidence-based care.
We tell women not to take even over-the-counter medication all during pregnancy but then flood them with routine medical interventions and drugs when they check in for labor. They are tethered to beds by IV’s, EFM, IFM, Pitocin, IUPC’s, etc, and the cascade of interventions that follow. (Cytotec is still being used off-label to ripen the cervix without FDA approval. How many hemorrhages are associated with the use of this drug? How many birth defects?)
We are losing respect for pregnancy & birth and for the fact that ALL drugs and invasive procedures carry risks to both mom and baby. In so doing, we are headed in the direction of causing more unnecessary & preventable harm.
What ever happened to the answer I remember many older OB’s giving when a women tried to cajole him/her into an induction or C/Section: “I can’t do that unless it’s medically necessary—that would be malpractice”?
Requiring all hospitals (& states) to publicly report their induction/cesarean/epidural/infant & maternal mortality rates would at least give patients/consumers outcome data that they could compare hospitals with, and it would drive urgent improvements inside the system. Putting more RN’s/Dhoulas/Labor Support Professionals at the side of laboring women & in the home after discharge would also go along way in improving outcomes.
Thank you for posting this as an AE Alert; now it should be followed up with actionable steps toward improvement with accountability. One maternal death is too much.
I am pleased to see that maternal deaths are being tackled. I am surprised that sickle cell disease is not highlighted as a major risk factor in view of the associated multi-system pathology.
This is a huge step in the right direction. However, two of the four main preventable causes of maternal death result from cesarean sections. In light of research showing the correlation of elective cesareans to increased maternal death, what seems glaringly missing from the Joint Commission’s suggested course of action is a campaign to educate patients (and physicians!) on the risks of elective cesarean section surgery. Instead of education, the Joint Commission suggests the universal use of pneumatic compression devices and prophylactic embolism prevention for women who undergo c-section surgery.
Dr. Steven Clark, medical director for women and newborn services for HCA, says in the Alert that “the only cause of maternal death amendable to nationwide systematic prevention efforts is pulmonary embolism.” I urge Dr. Clark to take this statement further. Any maternal death that resulted from an unnecessary intervention or surgery was preventable. Proper nationwide systematic prevention efforts MUST include universal prenatal education about risks of and treatment following obstetric interventions.
I am a certified Doula and have been at hospital births, home births ( one unplanned) and hospital births for the last 6 years. I am also Executive Director of the Tatia Oden French Memorial Foundation ( http://www.tatia.org). My daughter and granddaughter BOTH died due to a Cytotec Induction. Both were perfectly healthy. The underreporting of maternal deaths in the US is dispicable. The high rate of maternal deaths, even with the underreporting ( per CDC) is in many, many cases, like my daughters due to unnecessary interventions for the convience of the doctor, and totally preventable. EVERY maternal death needs to be looked into very throughly. In order to do that it must be mandated that EVERY state have a box on the death certificate that designates whether or not the woman was pregnant at the time of death, or died within 9months preceeding, or 12 months following a birth. It must be federallly mandated that all those deaths be investigated. Only then will be able to truellly document the causes of maternal death and reduce the maternal mortality rate in the US.
Ms. Oden brings up many good points about the failures of state death certificates. Sadly, this is the case with maternal as well as other deaths with iatrogenic causes or contributing factors; they are sorely under-documented (infections, medication and/or medical errors; source: The CDC).
Our state (New Hampshire) has a bill working its way through the legislature right now that would allow the formation of a maternity mortality review panel. Although I whole-heartedly support these panels, I requested an amendment be made to require that a family interview be a component of every investigation. Families are an extension of the healthcare team, and they often hold a ‘bigger picture’ view of what went wrong. Failing to include them will assuredly result in less than optimal investigations from which to learn and prevent the next maternal death. Providing compassionate care shouldn’t end when someone is harmed or dies; we owe it to families to ask: “Is there anything you would like to tell us?” and “How can we do better?”
It may be the first & only opportunity a family has to ‘tell their story.’
ACOG has issued a white paper supporting family interviews for both infant and maternal death review panels:
http://www.acog.org/departments/dept_notice.cfm?recno=10&bulletin=2353
“Patient Safety” means putting the patient at the center of not only care, but also solutions toward prevention.
It is my understanding that one of the leading causes of maternal death (not mentioned in this sentinel event at all) is domestic violence. The issues of standardized death certificate information has particular importance in capturing this data to clarify particular times of risk to pregnant women. Is the initial knowledge of the pregnancy a trigger for violence, or is there more risk as the fetus becomes more of a person (threat?) in the mind of the abuser. The prevention of these deaths is also more problematic in the setting of the hospital, but certainly could be amenable to better screening for safety. My personal observations have been that “safety” questions are done perfunctorily, if at all when women are admitted to the ER or to other areas of the hospital. Better information can be a key and I believe that better screening should be part of nation wide prevention of maternal death along with the issues already mentioned in the Sentinel Event and these comments.
This important alert omits use of the words “nurse”, “nurse-patient ratio”, “nurse anesthetist”, or “anesthesiologist”.
Who are we to suppose is taking care of these patients?
There is, for example, a known correlation between nurse:patient ratios and ICU death rate.
This Alert suggests (but does not say) that “Failure to adequately control blood pressure in hypertensive women” is a preventable error that is causative of maternal death yet, as a conclusion, this assertion is not supported by the sited study which found that “most maternal deaths are not preventable”. These “preventable errors” are the exception and the causative nature of these errors is simply expert opinion and should be viewed as speculative.
For example,as an anesthesiologist with ten years experience in a high risk obstetrical unit of a tertiary care hospital and thirty years experience in obstetrical anesthesia, I can recall many patients with blood pressures that were very difficult or impossible to control and yet they delivered healthy babies and survived intact. The two most recent maternal deaths with which I am familiar both had good control of blood pressure before they died. Both deaths were due to cardio-pulmonary failure associated with pre-eclampsia but layered on top of chronic hypertension, diabetes, morbid obesity, occult coronary insufficiency, and insufficient or no pre-natal care.
It is this last descriptor that is the most important and so long as women cannot or do not get comprehensive healthcare before, during, and after pregnancy maternal mortality will continue to rise no matter how attentive and alert the providers are.
In southern California we have clinics in every street corner and in between. Our patient get very poor prenatal care in those money making clinics. They use staff that is not trained and pay minimun wages. They get to see an OB at 30 or 32 weeks once every 2 weeks. They dont know when their high risk problem started and sometimes they are treated too late. High blood pressue, diabetes, bleeding problems are detected way tool late to control or fix.
And we wonder why do we still see maternal deaths at this time and age?
We have to look at the whole picture on what is happening to our society.
Is it true that, “United States places 41st on the World Health Organization’s list of safest countries for childbirth.”, as I read in the original article by Kate Drummond on AOL news? If so, we have many sources to evaluate what may work better. What do we know about perinatal practice in countries with lower maternal death rates? Is this information compiled and available to all interested parties?
It is certainly the correct way to look at changes in practice and environmental factors to explain the rise in maternal mortality in this country. However, in addition to the rise in obesity and in C/S rates I believe that attention should be given to the following:
Lower quality of obstetrical skills by the end of residency.
As an obstetrician myself, I can say that training level as compared to 2 decades ago changed dramatically. There are 2 main causes for that change. One is the fear of litigation which prevents residents from performing the very basic procedures. These are now done by their attendings. Instead, most of their time on the labor floor is spent on “charts appearance” making them expert in writing, writing and more writing. On top of that is the significant reduction in training time as a result of the “80 hours working week rule” which include night calls and weekend calls. This is down from over 120 hours a week 10 years ago. Considering the increase in knowledge and required rotations over the years (ultrasound, minimally invasive surgery, genetics etc)the available time for obstetrics is even less. As most labor floors are covered by young attendings that just came out of residencies, this must be one of the causes to the rise in mortality that has to be investigated.
yes, it is true, that we ( USA) are 41st in the world in maternal deaths. I totally agree the US should look at the countries who rank in the single digits… you will note that those countries have medical care that covers everyone…. and the emphasis is on life and the individual…. not on money and liability.
While attempting to validate a JC complaint, my research lead to many theories and outcome results to our current obstetric issues. The result lead to some more questions that need to be answered by JC and CMS.
1. Reviewing multiple medical records indicated poor quality of documentation by physicians and nurses as to purpose for certain intervention as necessary and if questioned, the peer review done internally was hindered by physicians unwilling to have courage to address issues of a peer. The facility should have all reviews done by outside consultant who has no relationship to a facility or physician to assure an unbias opinion is assured.
2. Nurses have grown professionally in skills and critical thinking but continues to be hindered to intervene in the best interest of the patient for fear of retaliation by administrations who place revenues first then the risk of a law suit. Malpractice insurances are less costly for the the organization then taking the courage to set standards higher for physicians and assure patient safety.
3. The current economical environment in healthcare has encouraged the abuse of revenue seeking needs for physicians and hospitals. JC and CMS should have the courage to stop reimbursements for incomplete documentation from hospitals and physician for CPT and ICD codes. 25% review of all claims for primary cesarean birth should provide the following misuse of government funds and private insurer’s loss:
any code identified as a valid issue should have the documentation for the code to be considered valid. Many women are being subjected to unnecessary surgery to assure the physician and hospital are reimbursed at the highest level. Women are told at 20 weeks gestation, they will need a cesarean deliver for small pelvis or large baby and the physician and facility accept this diagnosis without validation and there is no criteria to assure this is an appropriate diagnosis.
4. Obstetrics and Newborn care are not a priority to assure patient safety and even JC and CMS does not require facilities to report since it is considered voluntary. There is more emphazisis on MI, CHF, etc then the lowest reimbursement for women and newborns.
5. Healthcare is walking a tight rope, if our government asgencies can not take this beast and corral it we will continue to have a government that allows physicians and hospitals to abuse a system that does not place our patients in first consideration, we will continue to have cost that destroying American women.