Maternal Mortality

Reducing maternal deaths from haemorrhage: Seeking the low-hanging fruit

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INTRODUCTION

In an attempt to reignite the reduction in maternal deaths that has stalled since 2015,1 WHO has recently published a postpartum haemorrhage (PPH) roadmap following wide consultation.2 The roadmap seeks to reduce mortality through progress in four areas: research, standards, advocacy and implementation. But some have argued that global maternal deaths are primarily a result of poverty and global inequity, and that there will be little improvement until that fundamental problem is addressed. So how much can really be achieved, and are there practical interventions that can be made despite limited resources?

2 CAUSES OF MATERNAL DEATHS

Although rates of clinical PPH are much higher in high-resource settings and are increasing with time, death from PPH is closely associated with poverty, both on an individual and health system level. As a result, of the estimated 80 000 PPH deaths annually, nearly 90% occur in countries with low- and low/middle socio-demographic indexes.3 India, Pakistan, DRC, Ethiopia and Nigeria together have nearly 30 000 haemorrhage deaths annually, accounting for 37% of the global total. The same inequity is seen within countries as well, with maternal deaths occurring largely within the poorest in the society.4

The classic PPH is an atonic bleed after a spontaneous vaginal birth but most of these women can be relatively easily cured with uterotonics and so account for few deaths where healthcare is provided. Confidential enquiries show how PPH deaths come largely from two groups, representing the well-recognised split of ‘too little, too late’ and ‘too much, too soon’.5, 6 The former group comprises those who frequently give birth outside of the health system for reasons of distrust, poverty, ignorance or lack of transport. They are typically anaemic, malnourished and have infectious disease comorbidities. They present in a moribund state after tortuous journeys with untreated atonic uterus, ruptured uterus, genital tears or retained placenta, and the local health system cannot rescue them. Tragically, sometimes this group includes some women who have given birth in facilities and who have relatively minor, easily treatable complications, but whose care has been delayed and inadequate. Death results from delays, a lack of adequately trained staff, and shortages of blood, drugs and consumables.7 The latter group is those whose PPHs occur after current or prior intervention: those undergoing emergency caesarean sections (CSs) or who have placenta praevia/accreta or rupture following previous CSs. With intervention rates spiralling worldwide in an attempt to protect mothers and babies, this is becoming a critical group worldwide.

3 IMPLEMENTATION PRIORITIES

What can be done to address this terrible toll? Without doubt, the long-term solution is country-wide economic growth, unhindered by conflict, with free services provided for those who are do not have the means to obtain them privately. Economic growth allows governments to lift the poorest out of poverty and to improve their provision of maternal healthcare, education and transport. All countries who currently enjoy low maternal mortality rates (e.g. Sweden, UK, Poland) have used this method to progress through the process of obstetric transition,8 thereby reducing their MMR from the levels seen in much of sub-Saharan Africa today. But this is not easy, and neither is it in the hands of health workers. And so, as politicians work to eradicate world poverty and uplift services, there is a need to identify high-impact interventions that provide the very best care for the available money. They also need to be able to reach the women who need them most.

Given these broad principles, there are five broad areas that are likely to provide the best value for money in PPH care and that would make a real change.

  1. High-quality intrapartum care by midwives supported by doctors. Care during labour and birth is the front-line of the battle against PPH. In some settings, this is primarily the role of doctors. But not only is this unnecessary for healthy women having normal births, repeated studies have shown that scaling up midwifery is a cost-effective way of reducing maternal and perinatal mortality.9 It also has the effect of reducing intervention rates which themselve cause PPH. However, a midwifery-led system requires an extensive support system around it. Well-trained medical staff are critical to deal with high-risk women and complications of labour, and to provide interventions when necessary. Their clinical skills are needed to identify correctly those women who need a caesarean and then carry it out rapidly and safely, as well safely assisting vaginal births with forceps or ventouse. Ongoing multi-disciplinary training of this maternity team in emergency obstetric care is required along with clear-sighted, compassionate leadership to teach and conduct ongoing audit and review. Managers are needed to ensure that staff, medicines and consumables are readily available when needed. This all needs to be wrapped in respectful care for staff and pregnant women as, without it, women (and staff) will stay away.
  2. Antenatal anaemia treatment. Antenatal anaemia is very common worldwide and is one of the mechanisms by which PPH mortality is linked to poverty. Anaemia not only makes atonic PPH more likely, it also makes women more vulnerable to death when bleeding does occur. Thankfully, the detection and treatment of anaemia in antenatal clinics is a low-cost midwifery intervention and should be a priority if PPH deaths are to be prevented. Ongoing studies are comparing the relative efficacy of oral and intravenous iron.
  3. PPH management. For many years, the focus of PPH research has been on the optimal way to prevent PPH. Repeated studies have shown the importance of atonic uterus as a cause of PPH and that oxytocin (usually given intramuscularly, but as an intravenous infusion in high-risk cases) is highly effective at reducing PPH rates.10 The use of prophylactic tranexamic acid (TXA) for high-risk women may also prove to be an important strategy. However, much attention has turned now to PPH treatment. The E-MOTIVE study demonstrated that routine, real-time measurement of blood loss, and the provision of a bundle of care (uterine massage, oxytocic, TXA, i.v. infusion, and examination) before blood loss reaches 500 ml (or 300 ml in high-risk cases) not only reduced blood loss but PPH deaths as well.11 The investigators found that many women with excessive blood loss remained untreated and the use of a routine blood loss collection drape improved treatment rates. Although the study was conducted in four sub-Saharan African countries, the study has implications for births in all settings, and the search is on for the production of low-cost, reusable, environmentally friendly blood loss measurement techniques. Ongoing studies will identify the optimal initial oxytocic to be used, and whether TXA can be given intramuscularly. In those with refractory PPH, external uterine compression and intrauterine devices (balloons of various types, suction or packing with gauze) are widely used, although both their absolute and relative efficacy are unknown. For those with surgical and placental causes of PPH, skilled surgery is needed to repair tears and ruptures, and to remove adherent placentas. At district hospitals, generalist doctors must be taught the relatively simple surgical skills needed to manage refractory PPH short of hysterectomy: uterine compression sutures, uterine artery ligation, and uterine tourniquet. All can be done prior to referral to higher level hospital if required.
  4. Health systems. In the countries where most maternal deaths occur, healthcare workers work against the odds to provide safer services for women. But fully staffed primary and secondary health services free at the point of use are rare, and there is often inadequate emergency transport between levels of care. Weak governance structures mean that the already precarious rural government health systems are often further depleted by corruption, disrespectful care and staff non-attendance, with women needing to provide bribes to obtain even basic care. This burden disproportionately affects the poorest and leads to their reluctance to attend health centres. It also results in long delays in obtaining effective emergency care as women seek money, functioning health units, and taxi drivers willing to transport bleeding or dying women in their vehicles. Strengthening fragile health systems will take increased funding along with powerful national leadership. Funding is necessary to ensure that all health centres and hospitals are functioning effectively and that there are secure and effective supply chains for vital medication and consumables. Community transport systems are a priority, along with anti-shock garments to keep women alive during transfer. But there are also local, low-cost actions that can make a real difference. Community mobilisation through women’s groups can empower women, leading to mutual support, improved emergency transport and care-seeking behaviour. Improved local management is needed so that staff themselves receive respectful care, continuous professional development and appropriate pay. The use of WhatsApp (or its local equivalent) is proving very useful to disseminate quality improvement (QI) messages, request and receive advice, and to arrange transfers between facilities. It also assists when it comes to achieving rapid maternal and perinatal death review, a process that aids staff to self-reflect while the case is still fresh in their minds. Simple, facility-based QI projects using QI journals can also help build a staff community and provide them with a sense of pride in their work.
  5. Blood transfusion. Although expensive and logistically complex to achieve, the provision of safe blood for transfusion is so important for saving women’s lives that it enters the list of critical interventions. In many low-income settings, the arrival of un-booked women in shock from PPH is a common occurrence, and although atonic uterus may respond to uterotonics and tamponade, many have retained placenta or uterine rupture and require immediate surgery. Taking these women to theatre when shocked, hypovolaemic and with coagulation abnormalities carries a very high mortality and preoperative blood transfusion is transformative. To achieve this, central and tertiary hospitals need well-organised blood banks with cross-matched blood and blood components (fresh frozen plasma, platelets and fibrinogen). All district hospitals need functional fridges with backup generators to store O Neg and group-specific blood for emergency transfusion. Freeze-dried plasma (that can be reconstituted with sterile water) is a new, accessible form of clotting factor, as it can be stored unrefrigerated for 2 years.

Over the last decades, many researchers have sought the ‘magic bullet’, a single intervention that will solve the problem of maternal mortality from PPH. Sadly, however, there are no simple fixes as PPH deaths largely result from system failures that are not easily solved. PPH death rates can be viewed as a marker of an effective healthcare system, testing not only the accessibility and function of rural maternity services, but also their ability to escalate care rapidly in cases of emergency so that women receive timely high-level surgical and anaesthetic interventions. The WHO PPH Roadmap provides a robust way forward to achieve this with its four pillars of advocacy, implementation, research and standard setting. But of these, implementation is key. Academics have been justifiably criticised for spending too much time focusing on trying to find new solutions, while forgetting the lessons of history that saw massive reductions in PPH deaths in western countries 100 years ago despite relatively primitive levels of care.12 We may argue about the optimal components of the intervention, but we should keep in mind the saying that ‘the best is the enemy of the good’. We cannot wait until we are sure what ‘perfect care’ looks like before we start making changes. The PPH Roadmap may set the agenda up to 2030, but the implementation of packages to improve PPH care must start now.

Has Maternal Mortality Really Doubled in the U.S.?

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Statistics have suggested a sharp increase in the number of American women dying as a complication of pregnancy since the late 1980s, but a closer look at the data hints that all is not as it seems

heartbeat graphic

Answers about the increases in U.S. maternal mortality are hard to pin down.

There is no charity walk to raise awareness about the 700 to 800 women that die each year during pregnancy or shortly after giving birth in the U.S. There are no dedicated colored-plastic wristbands. But statistics in recent years have revealed a worrisome trend: the rate of maternal mortality in the U.S. has more than doubled in the past few decades. Whereas 7.2 women died per 100,000 births in 1987, that number swelled to 17.8 deaths per 100,000 live births in 2009 and 2011. The uptick occurred even as maternal mortality dropped in less-developed settings around the world. Now women giving birth in the U.S. are at a higher risk of dying than those giving birth in China or Saudi Arabia. The reason for this disturbing trend has eluded researchers, however.

So what exactly is it about being in a family way that is getting worse in America? According to some experts at the U.S. Centers for Disease Control and Prevention (CDC), perhaps nothing. A deeper dive into the mortality data and the conditions under which they were collected suggests that the apparent doubling may not necessarily mean that more mothers are dying than ever before. Instead, administrative issues in the past may have camouflaged a problem that is only now coming to light.

Statistics for 40 states and the District of Columbia, gleaned from death certificates, indicate that whereas the reported maternal mortality rate from 1999 to 2002 was 9.8 per 100,000 live births, it jumped to 20.8 per 100,000 live births for the period 2010 to 2013. But the numbers in the latter period may have been affected by a small change in the forms that are filed when a person dies. Until relatively recently most states relied on a death certificate form that was created in 1989. A newer version of the form, released in 2003, added a dedicated question asking whether the person who died was currently or recently pregnant—effectively creating a flag for capturing maternal mortality. Specifically, this recently introduced question asks if the woman was pregnant within the past year, at the time of death or within 42 days of death.

The addition of this question means that the apparent increase in maternal mortality in the U.S. “is almost certainly not a real increase. It’s better detection from the new certificates,” says Robert Anderson, chief of the Mortality Statistics Branch with the CDC’s National Center for Health Statistics. “The numbers are going up but it’s most likely not because women are more likely to die,” he contends. (Anderson’s branch of CDC counts maternal mortality as death during pregnancy or in the following 42 days; some other researchers look at the whole year after giving birth.) States have been slow to switch over to the new form and even now two states—Alabama and West Virginia—still have not adopted it. But “as the certificate with the check box is being implemented over time, we are detecting more maternal deaths,” Anderson says. Another administrative change in how deaths were classified and coded internationally, called the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), is also widely believed to be a contributing factor to the uptick in death numbers.

Yet there may be more to the maternal mortality increase than better detection of an existing problem. Nicholas Kassebaum, a professor of anesthesiology and pain medicine at the University of Washington, has led an independent analysis looking atICD-9 and ICD-10 coding and maternal mortality, and says that it is very unlikely the rise in deaths comes merely from administrative shifts like transitioning to the newICD or introducing a check box. “I can’t completely rule out that there is some effect from changing in coding on the magnitude of maternal mortality,” Kassebaum says, but it’s likely a “small effect.” His team looks at all deaths—not just maternal mortality—so if those deaths had been misclassified elsewhere, they likely would have picked them up and seen a large shift in those numbers following the ICD and check-box transitions, he says.

U.S. maternal mortality rates continue to climb even as other developed countries improve.

A worrisome trend, undetected
Still, even if the newer death toll numbers are just more accurately representing the number of women who die due to complications during pregnancy and childbirth, it’s a large number that demands explanation. Certainly, childbirth becomes more dangerous when a woman is not healthy before she becomes pregnant, and a growing body of research suggests that poor health prior to pregnancy could be a contributing factor to the high U.S. death toll. Many studies have indicated that an increasing number of pregnant women in the U.S. have health conditions that could boost the risk of problematic complications including chronic health disease, hypertension and diabetes. More than half of the women in the U.S. who become pregnant are above a healthy weight. Women who are 35 or older are also at increased risk of complications during pregnancy. Poor prenatal care and barriers to accessing health care could be killing more women, too.

Inadequate postnatal care may be another driver of mortality in women—one that that doesn’t show up in the official U.S. data analysis by the National Center for Health Statistics because the deaths tend to occur more than 43 days after pregnancy ends. “We are good at responding to life-threatening crisis that may have killed women a generation ago,” Kassebaum observes. But, he notes, poor postnatal care in women who were significantly weakened by childbirth complications may be killing more women.

Why are more women dying between 43 days and a year after the end of pregnancy?

Racial Divide
One aspect of maternal mortality that has not changed over the years is the extent to which it varies by race. The risk of maternal mortality has remained about three to four times higher among black women than white women during the past six decades. Since 1999 maternal mortality has climbed among both black and white women—potentially due to those changes in death certificates and also how deaths are now coded in the U.S. using the ICD-10. Yet even with the cross-race increases in deaths related to pregnancy, in 2007 the maternal mortality rate for black women was still nearly three times higher than the rate for white women.

Maternal mortality rates for black women in the U.S. are roughly  three times higher than the rate for white women.

 

Researchers have shown that black women are not inherently more likely to have underlying pregnancy complications. Indeed, one national study that looked at five major common causes of maternal death and injury that collectively account for more than a quarter of all pregnancy-related deaths found that black women did not have a significantly higher prevalence than white women of those conditions—preeclampsia, eclampsia, obstetric hemorrhage, placental abruption and placenta previa. Yet black women were two to three times more likely to die than white women with the same complication.

For now, more interventions to keep women healthier even before they get pregnant, better care during and after pregnancy and better tracking of maternal deaths will be essential tools in the fight to save women from these preventable deaths.