When the maternal mortality rate in the United States reached 16.8 maternal deaths per 100,000 live births in 2010, higher than other developed countries, there were calls for an organized, national response [1-4]. Many key agencies and obstetric care leaders acknowledge that health outcomes for mothers in the United States are worsening, particularly for African–American women. These advocates also argue that the United States needs a systems-level approach with input from all stakeholders to respond to maternal death and to address rising rates of severe maternal morbidities; this contention is a welcome approach. In this commentary, I argue that integrating efforts that focus on “risk” (the measurement, analysis, and prevention of maternal mortality and morbidity) must be balanced with meaningful efforts to support the “normality” of physiologic birth among low-risk women in hospital settings.
But what do we mean by morbidity? Who is at risk? These are not easy questions to answer. Maternal morbidity encompasses a broad range of physiologic and psychological complications and conditions, at varying levels of severity. However, there is no standard definition for maternal morbidity, and no systematic ongoing data collection for population-based maternal morbidity in the United States . Creanga and colleagues note that maternal morbidity can be framed as disease-specific (e.g., eclampsia, hemorrhage, or depression), as organ–system dysfunction, or in terms of management criteria, to identify interventions such as hysterectomy, for example . Definitions of this type, however, miss morbidities such as significant perineal trauma and pelvic floor damage. Some childbirth advocates argue that cesarean surgery, for any reason, may be considered morbidity—in that a woman's body experienced a major physical trauma in the course of childbirth.
One issue in identifying and measuring the scope and extent of maternal morbidity is that U.S. data sources are not well suited for documenting maternal health status. Women move through the maternity care system from preconception to postpartum care in different health care settings even for one childbirth episode, including multiple reproductive episodes over their lifetimes. Hospital discharge data were originally designed to optimize billing, not to thoroughly document health status. In addition, many elements on birth certificate records are of varying reliability. Even with these data challenges, researchers have documented the rising rate of maternal morbidity in the United States, with estimates of 50 near-miss and 100 severe morbidity events for every maternal death, affecting approximately 35,000 and 70,000 women each year, respectively . One study of maternal morbidity rates (comparing 1998–1999 to 2008–2009) observed increases of 75 percent and 114 percent among delivery and postpartum hospitalizations in this time frame . There are also racial disparities in severe maternal morbidities with rates for African–American women three to four times those for women of other race/ethnicities .
The causal mechanisms driving maternal morbidity, however, are a source of clinical practice tension and epidemiological dilemmas. Many studies examining severe morbidity use administrative data sources and are unable to fully investigate hypotheses about relative contributions of practitioner- and systems-level factors to maternal morbidity and mortality. Researchers are left to hypothesize causal factors based on limited, pre-collected data: women's demographic characteristics and/or health status. As a result, the increasing numbers of women who enter pregnancy with higher rates of obesity, hypertension, diabetes, abnormal placentation, etc., are typically the first and only factors considered in these studies. Studies utilizing medical chart review within a single facility or health care system have more information on systems and practitioner factors and their relative contribution to preventable cases of maternal morbidity [9-11]. These factors include the systems-level gaps in effective regionalization of maternal levels of care; nurse staffing and training issues; and practitioner-level factors shown to be contributory to preventable mortality and morbidity, such as delays in diagnosis and treatment [10, 12]. These studies, however, may not be generalizable, although they can point to needed context-specific quality improvement efforts, such as clinician training or education around treatment protocols.
When most women giving birth are relatively young and healthy, maternity clinicians can be lulled into a false sense of complacency about maternal complications, because even with suboptimal care, most women do not die. Because there are currently inadequate data to track even severe maternal morbidity, clinicians may not be aware how their practice patterns, or the overuse and underuse of interventions, affect maternal health outcomes. Maternity clinicians who care about quality improvement recognize the “normalization of deviance” in clinical practice. This is a sociologic concept applied to health care, referring to the patterned ways that common, routine nonconformities and mistakes become normalized in health care delivery systems . These patterns are systematically produced by the interconnection among environment, organizations, cognition, and action. Normalization of deviance can apply to those who are prone to view childbirth as inherently risky and to those who view childbirth as inherently uncomplicated—the reality is that childbirth can be both.
Missing from the U.S. landscape of severe maternal morbidity is the question, “What can we learn if we ask women and their families about their experiences with a severe pregnancy or childbirth complication?” We need to find out what we miss when we look only at their experience from a medical-clinical perspective. My colleagues and I have been conducting research: listening to women's accounts of the care and information they received before, during, and after their experiences of severe morbidities, as they define them . Their accounts are insightful, detail-oriented, and heartbreaking, reflecting women's carefully considered analyses of how their ordeals unfolded. Women's assessments about what might have been done differently echo similar opportunities for improved care that clinicians identify. Our qualitative data spotlight how social systems and policies to support women after they are discharged are woefully inadequate. The ramifications of their physical ordeals and the social, emotional, and financial repercussions are ongoing—in many cases, even years later.
My current collaborative research explores another overlooked area of inquiry: what we can learn from talking with maternity clinicians about their experiences of providing clinical care in cases of maternal morbidity. Listening to clinicians and analyzing their assessments of what happened, what might have been done differently, and how the experiences affected their emotional states and senses of efficacy as clinicians can show us how their experiences may affect their future clinical practice. The American College of Obstetricians and Gynecologists has begun to address positive and constructive ways to assist maternity clinicians after an unexpected bad outcome with the production of a video, “Healing Our Own: Adverse Events in Obstetrics and Gynecology.” More work is ongoing in this area, but much more is needed.
Until we look further into the circumstances and contexts surrounding each case, we will be unlikely to address the big question, “Why are maternal outcomes worsening and why do racial disparities exist and persist?” and the even bigger question of how to turn the trend around. It is not just that women are entering pregnancy “older, fatter, and sicker,” although that may be a part of the story . The practitioner and systems-level factors are much more difficult to fully investigate, as our data sources and current methodologies are not set up to grant these equal weight to the admittedly limited data we have on women from birth certificate and hospital discharge data. To improve maternity outcomes, we need optimal data systems to gather relevant patient, practitioner, and systems-level information.
Most recently, work is underway to develop and validate a quality measure for severe maternal morbidity that can be derived from administrative data to inform quality improvement efforts at the local, regional, and national levels. This work has found that ICU admission and/or transfusion of four or more units of blood products during the birth hospitalization is a sensitive and specific measure that captures most severe maternal morbidities [7, 16]. This type of measure would allow hospitals to identify events in near-real time, thus facilitating an in-depth review of cases for purposes of quality improvement. In March 2014, The National Partnership for Maternal Safety (http://www.safehealthcareforeverywoman.org/national-partnership.html) was announced. A multi-stakeholder initiative, its goal is for every birthing facility in the United States to have three designated core Patient Safety Bundles (obstetric hemorrhage, severe hypertension, and venous thromboembolism) implemented within 3 years. The overarching theme is that birthing facilities and maternity clinicians need to prepare for, and better respond to, emergency situations. These are welcome developments.
Will a focus on preventing maternal morbidity and developing “risk”-appropriate care further skew maternity practices and popular beliefs about the dangers of childbirth? Many key players in the U.S. maternity care system acknowledge unacceptable levels of overuse of procedures that have been shown to cause harm to women and babies [17, 18]. Efforts to reduce maternal morbidity and mortality are incomplete if we neglect to support the normality of birth and work to reduce overuse of nonmedically indicated procedures. If hospitals are to better prepare for obstetric emergencies, a vision of safe and healthy maternity care includes meaningful support of normal physiologic (vaginal) birth in the settings where most women give birth—hospitals .
Many childbirth advocates in the United States support women's demands for institutional support of normal, physiologic childbirth, including the opportunity for vaginal birth after a prior cesarean section. Applying, as many have advocated, a rights-based framework for a safe maternity care system designed to reduce preventable morbidity and mortality logically calls for an optimal maternity care system designed to increase normal, physiologic birth centered around the needs and desires of pregnant women. In 1994, writing about the emerging consensus around changing UK maternity care policy, Sheila Kitzinger argued, “The woman must be the focus of maternity care…in control of what is happening to her and able to make decisions based on her needs” . This focus should hold true for all women, for every type of birth experience.
Women who experience a maternal morbidity, at any level of severity, have the right to responsive and respectful care from practitioners who are trained and up-to-date in management of high-risk scenarios, and who work in systems with access to necessary equipment, medications, and teams trained to work effectively across and within departments. In high-risk situations, it is appropriate for a maternity practitioner to consult with a perinatologist, cardiologist, or other specialist. Similarly, in low-risk situations, maternity practitioners can and should consult and work with specialists in education and labor support. These specialists include childbirth educators who, from the outset of prenatal care, can guide women through nutrition, exercise, and information to optimize their health and readiness for the marathon of labor and childbirth; doulas to provide hands-on support throughout labor, birth, and postpartum; and perinatal nurses trained to recognize signs of possible problems through their expert clinical assessment of the wellbeing of the fetus and woman. Approaches to preventing maternal mortality and morbidity need not solely occur within discursive and clinical frameworks of risk; indeed if they do, they remain isolated from the necessary resources to provide a comprehensive system of maternity care that offers the right care to the right woman at the right time, every time.