Our country continues to be plagued by maternal deaths, and there are disparities in outcomes when stratified by race or ethnicity. So what’s going on? A new study that looks back over 18 years searches for some answers.
In 2017, 810 women died every day in childbirth. While 94% lived in middle or low-income countries, the US had its share. With approximately 660 deaths annually, we rank last among our peers, the high-income countries. Common causes of global maternal deaths include bleeding, infections, eclampsia (a form of pregnancy-related high blood pressure), and complications of delivery. This retrospective study looked at US maternal deaths associated with the complications of delivery.
Complications happen. Failure-to-rescue is a metric originally designed to assess how well hospitals can or cannot save patients who develop complications after surgery but now applied to all medical care. Unlike complication rates, failure-to-rescue captures hospital characteristics, including “preparedness, timely recognition, and appropriate response to complications.”
The Study
Researchers used the National Inpatient Sample, a 20% sampling of all hospitalizations in the US. Their analysis is retrospective. Severe maternal morbidity was identified from discharge data, from serious maternal complications such as heart failure or sepsis, and “life-saving” care such as an emergency hysterectomy or mechanical ventilation.
From the slightly under 74 million hospital deliveries between 1999 to 2017, almost 1 million were identified with severe maternal morbidity – 13.4/1,000 deliveries. Of those women, 4,328 died, the aggregate failure-to-rescue (FTR) rate for women with severe maternal morbidity was 4.3/1,000 [1]. These FTR deaths accounted for 88% of our maternal deaths, so understanding their cause is important to improving the quality of our care.
|
Race/ Ethnicity |
Severe maternal morbidity |
Maternal Deaths |
Adjusted Failure-to-Rescue |
Comparison |
|
White |
11.4/1,000 |
1,246 |
3.4/1,000 |
1 (Reference) |
|
Black |
22.4/1,000 |
1,156 |
6.1/1,000 |
1.79 |
|
Hispanic |
15.0/1,000 |
756 |
3.7/1,000 |
1.08 |
The FTR was adjusted for a variety of factors. [2] The trend for more maternal deaths among Black mothers (the slight increase for Hispanic mothers compared to White mothers was not statistically significant) held for rural, suburban, and urban hospitals. Paradoxically, the FTR for Black mothers was higher in urban teaching hospitals compared to non-teaching hospitals. Before you make too much of that, teaching hospitals are most frequently the sites for those who have had little prenatal care or those identified as high-risk patients.
During the study period,
- Failure to rescue maternal deaths fell from 11/1,000 to 3.2/1,000. The improvement was similar for each group, roughly 28%
- Severe maternal morbidity rose from 7.6/1,000 to 16.5/1,000 for all racial groups.
The improvement in FTR rates was greatest in those urban teaching hospitals and least in the rural facilities.
Among the factors found in the women who died, only age seemed to be “uncorrectable,” and perhaps being admitted on the weekend. Most of the other factors were entangled; lower household income often meant Medicaid or Medicare, which can be associated with diminished access to prenatal care and explain the higher obstetric co-morbidity of those women who died. More of the women who died underwent Cesarean births, but that too often results from factors outside of physician control.
I present this information because we can and should do better, but it is important to understand what quality improvement means in medicine. We have reduced deaths consistently over 20 years, despite mothers having more co-morbidities. Perhaps better prenatal care can make a difference in the two-fold difference in racial co-morbidity. (66% of black mother received prenatal care in the first trimester, 82% for white mothers, 72% for Hispanic moms) None of the 660 women should have died in 2018, but they represent 0.0017% of all births in that year. This small number demonstrates how difficult it is in the last mile in quality improvement, from 0.0017% to 0.0%.
[1] Failure-to-rescue (FTR) = Deaths/Women at risk. Because the number is so small, it is expressed in women per thousand. 4,328/1,000,00 therefore is reported as 4.3/1,000 rather than as 0.0043%
[2] Included were age, income, prior C-section, transfer from other hospitals, hospital location, and size. For the skeptical, lots of room for devilment.
Source: Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States Failure to Rescue Obstetrics Gynecology DOI: 10.1097/AOG.0000000000004362
