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?

Why Are Maternal Deaths on the Rise?

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
  • Obesity
  • 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:

  • Asthma
  • Hypertension
  • Diabetes
  • Obesity
  • Epilepsy
  • HIV/AIDS
  • 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?

References:

Advanced Critical Care: Evidence-Based Strategies for Maternal Stabilization and Rescue in Obstetric Hemorrhage

CDC - First Births to Older Women Continue to Rise

Office of Women's Health: Pregnancy and Pre-Existing Conditions

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14-yr RN experience, ER, ICU, pre-hospital RN, 12+ years experience Nephrology APRN. allnurses Assistant Community Manager. Please let me know how I can help make our site enjoyable.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

As an Adult Critical Care NP, we see quite a few OB admissions in our ICU since we opened a regional referral center for high risk pregnancy. The population we see are quite a set-up for peri-partum problems. We see pregnant multiparous women presenting with placenta previa/accreta, women deciding on pregnancy at an older age and at risk for pre-eclampsia, women from migrant communities with little or no prenatal care, pregnant women some from inner cities with poly-substance abuse related cardiomyopathy, etc. Some from our ICU NP group started our own database for pregnancy and childbirth related ICU admissions as a shareable compilation of our experience in treating these subset of patients.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

I developed peripartum cardiomyopathy (PPCM) when I was just over a week postpartum. Thankfully I knew what it was, and after I got over my denial, I went to my ER and told them I was in heart failure. Unfortunately I was right (dangit). Luckily my EF is fine now, but I am still on a beta blocker and an ARB as a preventive measure and I have developed very annoying palpitations. Prior to my pregnancy and c-section (breech baby), I was a daily runner in excellent cardiac health, and my cardiologist has said that my overall cardiovascular health was probably helpful in limiting my issues.

In being a member of a PPCM survivors group on Facebook, I have heard over and over and over again how so many of these women were ignored, sent home, misdiagnosed with anxiety (!!!) or bronchitis or pneumonia, etc., usually up until the point in which they went into cardiac arrest. It's sad that it took a terminal event for many of them to get help. Many of them have pacemakers, LVADs, or transplants because of PPCM. Some live, some die. I feel so lucky to have recovered as a I did without anything invasive being required, and I hope that I can come off of my meds someday too.

I am unsure why PPCM gets missed or misdiagnosed because in the ED, we diagnose people with heart failure all the time! Is it because so many of these women are younger? Because some of the symptoms are "normal" for the pregnant or recently pregnant patient? It's not hard to do an BNP or to recognize an abnormal chest xray. It's so awful, because PPCM often leaves moms with low EFs and a lifetime of cardiac issues, or even worse - mom doesn't survive and is not around to see her children grow up.

Edited to add: for those of you who work in areas where you see pregnant or postpartum patients, there is a PPCM self-test for patients. It was developed by Dr. James Fett, who has been studying PPCM for years. He is also part of the NHLBI-funded Investigations in Pregnancy Associated Cardiomyopathy (IPAC) study. More info on that at Peripartum Cardiomyopathy Network (PPCM Network) - PPCM Home Page.

Self-test for recognition of heart failure during or just after pregnancy:

Orthopnea (difficulty breathing when lying flat): (a) None - 0 points; (b) Need to elevate head - 1 point; © Need to elevate 45 degrees or more - 2 points.

Dyspnea (shortness of breath) on exertion: (a) None - 0 points; (b) Climbing 8 or more steps - 1 point; © Walking on level - 2 points.

Unexplained cough: (a) None - 0 points; (b) At night - 1 point; © Day and night - 2 points.

Swelling (pitting edema) lower extremities: (a) None - 0 points; (b) Below knee - 1 point; © Above and below knee - 2 points.

Excessive weight gain during last month of pregnancy: (a) Under 2 pounds per week - 0 points; (b) 2 to 4 pounds per week - 1 point; © Over 4 pounds per week - 2 points.

Palpitations (sensation of irregular heartbeats): (a) None - 0 points; (b) When lying down at night - 1 point; © Day and night, any position - 2 points.

ACTION: 5 or more points = see cardiologist re: plasma BNP and echocardiogram. A score of 5 or more is often associated with decreased LVEF.

Fett, J. D. (2011). Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 10(1), 44-45. doi:10.1097/HPC.0b013e31820b887b

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Specializes in Nephrology, Cardiology, ER, ICU.
As an Adult Critical Care NP, we see quite a few OB admissions in our ICU since we opened a regional referral center for high risk pregnancy. The population we see are quite a set-up for peri-partum problems. We see pregnant multiparous women presenting with placenta previa/accreta, women deciding on pregnancy at an older age and at risk for pre-eclampsia, women from migrant communities with little or no prenatal care, pregnant women some from inner cities with poly-substance abuse related cardiomyopathy, etc. Some from our ICU NP group started our own database for pregnancy and childbirth related ICU admissions as a shareable compilation of our experience in treating these subset of patients.

Totally awesome idea to develop a database about maternal complications. According to the literature I reviewed, this seems to be needed stats.

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Specializes in Nephrology, Cardiology, ER, ICU.
I developed peripartum cardiomyopathy (PPCM) when I was just over a week postpartum. Thankfully I knew what it was, and after I got over my denial, I went to my ER and told them I was in heart failure. Unfortunately I was right (dangit). Luckily my EF is fine now, but I am still on a beta blocker and an ARB as a preventive measure and I have developed very annoying palpitations. Prior to my pregnancy and c-section (breech baby), I was a daily runner in excellent cardiac health, and my cardiologist has said that my overall cardiovascular health was probably helpful in limiting my issues.

In being a member of a PPCM survivors group on Facebook, I have heard over and over and over again how so many of these women were ignored, sent home, misdiagnosed with anxiety (!!!) or bronchitis or pneumonia, etc., usually up until the point in which they went into cardiac arrest. It's sad that it took a terminal event for many of them to get help. Many of them have pacemakers, LVADs, or transplants because of PPCM. Some live, some die. I feel so lucky to have recovered as a I did without anything invasive being required, and I hope that I can come off of my meds someday too.

I am unsure why PPCM gets missed or misdiagnosed because in the ED, we diagnose people with heart failure all the time! Is it because so many of these women are younger? Because some of the symptoms are "normal" for the pregnant or recently pregnant patient? It's not hard to do an BNP or to recognize an abnormal chest xray. It's so awful, because PPCM often leaves moms with low EFs and a lifetime of cardiac issues, or even worse - mom doesn't survive and is not around to see her children grow up.

Edited to add: for those of you who work in areas where you see pregnant or postpartum patients, there is a PPCM self-test for patients. It was developed by Dr. James Fett, who has been studying PPCM for years. He is also part of the NHLBI-funded Investigations in Pregnancy Associated Cardiomyopathy (IPAC) study. More info on that at Peripartum Cardiomyopathy Network (PPCM Network) - PPCM Home Page.

Self-test for recognition of heart failure during or just after pregnancy:

Orthopnea (difficulty breathing when lying flat): (a) None - 0 points; (b) Need to elevate head - 1 point; © Need to elevate 45 degrees or more - 2 points.

Dyspnea (shortness of breath) on exertion: (a) None - 0 points; (b) Climbing 8 or more steps - 1 point; © Walking on level - 2 points.

Unexplained cough: (a) None - 0 points; (b) At night - 1 point; © Day and night - 2 points.

Swelling (pitting edema) lower extremities: (a) None - 0 points; (b) Below knee - 1 point; © Above and below knee - 2 points.

Excessive weight gain during last month of pregnancy: (a) Under 2 pounds per week - 0 points; (b) 2 to 4 pounds per week - 1 point; © Over 4 pounds per week - 2 points.

Palpitations (sensation of irregular heartbeats): (a) None - 0 points; (b) When lying down at night - 1 point; © Day and night, any position - 2 points.

ACTION: 5 or more points = see cardiologist re: plasma BNP and echocardiogram. A score of 5 or more is often associated with decreased LVEF.

Fett, J. D. (2011). Validation of a self-test for early diagnosis of heart failure in peripartum cardiomyopathy. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine, 10(1), 44-45. doi:10.1097/HPC.0b013e31820b887b

Awesome info Pixie and terrifying ordeal for you. So glad you are doing better now.

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This reminds me of a great article I read a couple of months ago about some work that is being done in this area in California. They have the data to show that their initiatives are improving outcomes and saving lives!

https://www.google.com/amp/s/www.sfchronicle.com/news/amp/How-California-learned-to-keep-pregnant-women-and-13204352.php

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Specializes in OB.
This reminds me of a great article I read a couple of months ago about some work that is being done in this area in California. They have the data to show that their initiatives are improving outcomes and saving lives!

How California learned to keep pregnant women, new moms from dying - SFChronicle.com

Yes, California is currently the only state that has really taken the reins on this. It's despicable that our nation sits by and lets this happen by refusing to actually analyze the data and figure out what the causes are and what to do about it. It's also despicable that women of color are much higher risk of death than white women. The U.S. ranks somewhere around #40 in maternal mortality among industrialized nations. Americans who consider our OB care to be of the "highest caliber" are grossly mistaken.

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I had never heard of PPCM until today. Thanks for the education.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
I had never heard of PPCM until today. Thanks for the education.

You're very welcome! Every little bit of awareness helps.

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