Maternal Death Prevention

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Introduction   

Of the high-income, industrialized nations, the United States has the highest rates of maternal morbidity and mortality, with approximately 700 women dying from pregnancy-related complications (1, 2, 8, 11, 12, 15). Pregnancy-related deaths are declining in other high-income countries while they continue to escalate in the United States (6, 8, 13). In comparison to 10 other high-income countries, the maternal mortality rate in the United States is more than double that of the other countries (8). In 2021, more than 1,200 women died during pregnancy or the postpartum period, with most of these deaths being preventable (2).  

The World Health Organization (WHO) defines the maternal mortality ratio (MMR) as “the number of maternal deaths per 100,000 live births, where maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy.” (6, 8) The MMR is the most common indicator for comparisons of maternal health on a global level, but it does not specify the cause of death in relation to pregnancy and therefore does not include maternal deaths relating to accidental or incidental causes.  

Although technological advances in healthcare caused the MMR to decrease dramatically in the United States during the past century, the MMR has spiked in the past two decades in America for reasons explained later in this module (6). Maternal complications are the sixth leading cause of death in women aged 20 to 34 in America, with the MMR more than doubling between the years 2000 and 2014 (6). However, in Canada and the United Kingdom, the MMR fell by 44% during this same timeframe (6). 

Women of color and low economic status are affected the most by maternal death, with Hispanic women experiencing more than double the rate of maternal mortality since 2018 and non-Hispanic black women experiencing four times higher rates of pregnancy-related death than non-Hispanic white women (2, 6). Additionally, many counties in the United States lack the most basic maternity care resources with rural areas being hit the hardest due to an increase in hospital and clinic closings.  

Reports indicate that many pregnant women travel more than 30 minutes to reach the nearest facility with obstetric services (2). Chronic medical conditions, advanced maternal age, higher cesarean delivery rates, the opioid epidemic, and limited access to effective medical care have been cited as some of the contributors to maternal death (6). 

Classifications  

The Centers for Disease Control and Prevention (CDC) details three classifications of pregnancy-related death, which they define as death of a woman while pregnant or within one year of termination of pregnancy, irrespective of the cause (3, 6, 8): 

• Pregnancy-related: The death of a woman while pregnant or within one year of termination of pregnancy, from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes. (Example: the death of a woman from postpartum hemorrhage). 

• Pregnancy-associated but not pregnancy-related: The death of a woman while pregnant or within one year of termination of pregnancy due to a cause unrelated to pregnancy. (Example: the death of a pregnant woman from a motor vehicle accident). 

• Pregnancy-associated but undetermined if pregnancy-related: The death of a woman while pregnant or within one year of termination of pregnancy from a cause that cannot be determined or conclusively categorized as either pregnancy-related or not pregnancy related. (Example: a woman with an unknown mental health history who dies at six months postpartum from suicide). 

There are two national data sources for maternal death that are managed by the CDC: the National Vital Statistics System (NVSS) and the Pregnancy Mortality Surveillance System (PMSS). The National Vital Statistics System is managed by the National Center for Health Statistics (NCHS), and it relies exclusively on International Classification of Diseases, 10th Revision (ICD-10) codes assigned to causes of death listed on maternal death certificates in conjunction with the World Health Organization’s (WHO) definition of maternal death to determine maternal mortality rate.  

The PMSS utilizes death classifications from epidemiologists to classify causes of death into ten categories: hemorrhage, infection/sepsis, amniotic fluid embolism, thrombotic pulmonary or other embolism, hypertensive disorders of pregnancy, anesthesia complications, cerebrovascular accidents, cardiomyopathy, cardiovascular disease, and non-cardiovascular medical conditions (6, 10). The PMSS analyzes applicable vital records from all 50 states, New York City, Puerto Rico, and Washington, DC to determine the causes of pregnancy-related deaths (6). 

Multidisciplinary teams in individual states comprise maternal mortality review committees (MMRCs), and they are deemed the gold standard in identifying and reviewing pregnancy-associated and pregnancy-related deaths since they review all the available data, including prenatal, hospital, and autopsy records. MMRCs exist in two-thirds of states and classify deaths as preventable or non-preventable, while also making recommendations to prevent similar future deaths (6, 9). 

Statistical Data 

According to MMRCs from 2019, the populations and conditions with the highest rates of maternal death include (11, 12): 

• Age at death 30-34 
• High school graduate or GED (but no further education) 
• Urban residence 
• Timeframe of death 43-365 days post-partum (versus pregnancy, delivery, and earlier post-partum periods) 
• Rank order (highest to lowest) underlying causes of pregnancy-related deaths: mental health conditions, hemorrhage, cardiovascular conditions, infection 
• Homicide deaths more prevalent than suicide deaths 
• 84% of pregnancy-related deaths were preventable, versus 16% not being preventable. 

According to MMRCs from 2020, the populations and conditions with the highest rates of maternal death include (3, 11, 12): 

• Age at death 25-29 
• High school graduate or GED (but no further education) 
• Urban residence 
• Timeframe of death 43-365 days post-partum (versus pregnancy, delivery, and earlier post-partum periods) 
• Rank order (highest to lowest) underlying causes of pregnancy-related deaths: mental health conditions, cardiovascular conditions, infection, hemorrhage 
• Homicide deaths more prevalent than suicide deaths 
• 83.5% of pregnancy-related deaths were preventable, versus 16.5% not being preventable. 

The age of maternal death decreased from 2019 to 2020, and cardiovascular-related maternal deaths become more prevalent in 2020 (3, 11, 12). 

Statistics further indicate that women in the United States are more likely to be murdered during pregnancy or in the early post-partum period than to die from hypertensive disorders, hemorrhage, or infection (7). Pregnancy homicides are strongly correlated with intimate partner violence (IPV) and firearms (7). Globally, one in three women reports physical, sexual, or psychological abuse by a partner during their lifetime (7). Of all the high-income countries in the world, the United States has the highest prevalence of intimate partner violence (7). 

Causes  

The majority causes of maternal morbidity and mortality, according to MMRCs, are hemorrhage, cardiovascular/coronary conditions, cardiomyopathy, and infection. In non-Hispanic black women, preeclampsia, eclampsia, and embolism contribute to most maternal deaths, and mental health conditions are the leading cause of maternal mortality in non-Hispanic white women (6, 15). According to the CDC, cardiomyopathy, myocardial infarction, and cerebrovascular accidents cause almost 35% of pregnancy-related deaths while the highest in-hospital mortality rates are contributed to heart failure, arrhythmia, respiratory failure, shock, renal failure, and preeclampsia (6, 8). Rates of cardiomyopathy have increased in recent years due to increased maternal age and multifetal pregnancies (6). Cardiogenic shock causes death in almost 20% of pregnant women whereas pregnant women who do not experience cardiogenic shock die only 0.02% of the time (6). 

The increasing rate of hemorrhage-related deaths is due to the skyrocketing cases of cesarean deliveries. Cesarean delivery is associated with placenta previa and placenta accreta, which increases the rates of hemorrhage, infection, and thromboembolism (6). Accidental overdose and suicide have increased in post-partum women, with intimate partner violence, mental illness, and substance abuse also being causative factors of maternal death in pregnant and post-partum women (6, 11, 12). Rates of anxiety and depressive disorders in younger women are impacting maternal outcomes since these conditions tend to be exacerbated during pregnancy and the post-partum periods (11, 12).  

Pregnant women who have multiple chronic conditions are at an almost 300% higher risk of maternal morbidity than women who do not have chronic conditions (6). This is also an age issue since women with multiple chronic illnesses tend to be older than women with a single chronic health condition, or no chronic health conditions. Pre-pregnancy obesity is a major concern since it brings a higher risk for diabetes and cardiovascular disease, which can lead to maternal death (6, 8).  

Incarcerated women have more chronic medical conditions than non-incarcerated women and most likely did not receive adequate healthcare prior to incarceration. Even though state and federal prisons provide healthcare to all prisoners, the quality of care and reporting of data are highly variable due to the lack of standardization (8). 

Self-induced abortions are on the rise due to legislative restrictions on legal abortions, medication abortions, gestational age limits, mandatory waiting periods, parental consent laws, and funding cuts that affect healthcare providers and facilities. Self-induced abortions lead to maternal death, and studies indicate that improved insurance coverage for abortion care through Medicaid has decreased maternal morbidity by 16%, indicating that resources allocated for abortion care can save lives (6). 

Risk Factors 

There are several risk factors associated with increased maternal death. These include (2, 6, 8, 10): 

• Women of color, particularly Native American Indians, Alaskan Natives, African Americans, and Hispanics/Latinos 
• Low socioeconomic status/low social conditions 
• Homelessness, migrant worker status, prison incarceration 
• Women under the age of 18 and over the age of 35 
• Above average and below average body mass index 
• Chronic health conditions, such as hypertension, heart disease, diabetes, and depression 
• Low functioning immune system 
• Substance use and abuse 
• Mental health issues, including self-harm and suicide 
• Intimate partner violence 
• Weather extremes, such as rising temperatures and wildfire smoke 

Biased and discriminatory healthcare providers, low-quality healthcare programs and facilities, exposure to adverse social conditions, and decreased individual and family resources contribute to poor outcomes in the perinatal and postpartum periods (1, 2, 8, 10). Low social conditions include lack of access to high quality jobs, transportation, housing, healthy and nutritious foods, and safe environments (1, 6, 10).  

Women who have a history of experiencing societal discrimination, such as women of color and women of low socioeconomic status, tend to avoid seeking medical care, and when they do, they are less compliant with treatment plans. African American, Hispanic, and uninsured women report perceived discrimination during birth hospitalization (6). This is why it is critical that birthing centers and other medical centers train nurses and other healthcare personnel about the pervasive prevalence of bias in maternal-newborn care (6). 

According to a systematic review of the literature in 2020, more than 94% of 83 studies found a relationship between social factors and maternal outcomes (8). Contributing factors included maternal education, socioeconomic status, and racial and ethnic disparities. Access to health insurance continues to elude poor, young women of color. Maternal rates of morbidity and mortality continue to rise in the Southeastern United States, including the rural areas of the Mississippi Delta and Appalachia (8).  

Identified risk factors for cardiovascular death in pregnant and postpartum clients include increasing maternal age, obesity, and hypertensive disorders. Reducing these modifiable chronic conditions in women of reproductive age can help reduce the incidence of cardiovascular disease and major adverse events. Multidisciplinary care of pregnant clients with cardiovascular disease, including adequate risk assessment and evaluation for known and unknown cardiac disease is necessary to eliminate preventable maternal deaths (2, 6). 

Prevention 

There are many steps that nurses and other healthcare team members can take to help prevent maternal morbidity and mortality. These include (6, 9, 11, 12, 13): 

• Ensuring multidisciplinary care for pregnant clients with high-risk comorbidities 

• Eliminating racism in the healthcare industry 

• Improving healthcare provider training and simulation exercises 

• Providing client care education on early warning signs of pregnancy complications 

• Encouraging breastfeeding, smoking cessation, and physical activity in pregnant and post-partum clients 

• Encouraging spouses, partners, and other family members to support the pregnant client 

• Screening for maternal post-partum depression during well-child visits 

Pregnant and post-partum clients should take an active role in their health and ensure that they are attending family planning and health screening appointments, keeping up to date on immunizations, managing chronic conditions, understanding physical and mental health warning signs, and referring to educational resources to expand their knowledge of pregnancy and motherhood (9). 

Steps that facilities can take to improve maternal outcomes are (6, 9): 

• Improve team training 

• Improve team communication  

• Implement evidence-based safety bundles and toolkits to manage obstetric complications 

• Support data-driven MMRCs that provide specific recommendations for systems improvements to prevent future maternal deaths 

• Develop and disseminate appropriate client educational materials, including discharge instructions 

• Encourage healthcare providers to offer their services in rural, remote, and underserved areas 

• Support breastfeeding and other healthy maternal self-care practices 

• Implement and/or coordinate community services, such as home visiting programs 

Actions payors can take to improve maternal outcomes are (9): 

• Provide access to, and reimbursement for, preventative services (chronic disease screenings) 

• Offer a wide range of healthcare professionals in the health plan’s network 

• Cover programs that fund transportation to appointments, use of technology, chronic condition management, and language interpretation services 

• Reimburse healthcare facilities when clinicians spend time educating clients and providing perinatal, substance use, and mental health counseling 

• Implement incentives for improving maternal care of women of all ethnicities, socioeconomic statuses, and educational backgrounds 

The Joint Commission reported that communication failures were the second leading cause of maternal deaths during their review of sentinel events (6). Hiring and promoting leaders who value and encourage transparent communication as the foundation for a culture of safety, as well as implementing nonpunitive reporting of critical events can improve safety. Utilizing safety checklists, SBAR, and TeamSTEPPS can improve collaboration (6). 

Organizations and programs, such as the National Partnership for Maternal Safety (NPMS), California Maternal Quality Care Collaborative (CMQCC), Health Resources and Services Administration Maternal Child Health Bureau, Alliance for Innovation on Maternal Health (AIM), and the American College of Gynecologists (ACOG) Council on Patient Safety and Women’s Health Care can collaborate and disseminate information and support to assist healthcare professionals in delivering the best care possible to pregnant and postpartum women (1, 6). 

Additionally, the CDC offers the following campaigns and programs to help prevent maternal deaths (3, 4, 5): 

• Hear Her campaign: Shares potentially life-saving messages about urgent warning signs of maternal death 

• Pregnancy Mortality Surveillance System (PMSS): Helps understand the risk factors and causes of maternal death 

• Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM): Supports organizations that manage MMRCs to help prevent maternal mortality 

• Perinatal Quality Collaboratives (PQCs): Endorses state and multi-state networks that implement available methods to make quick changes to support maternal health 

• CDC Levels of Care Assessment Tool (CDC LOCATe): Shares a web-based tool to help states and jurisdictions create standardized assessments of care for pregnant and postpartum clients 

The CDC also recognizes April 11th to 17th each year as Black Maternal Health Week to bring attention to racial disparities in maternal health. During this week, the CDC encourages the use of the campaigns and programs listed above (5). 

The World Health Organization (WHO) program Strategies for Ending Preventable Maternal Mortality (EPMM) approaches maternal health from a human rights perspective. The program aims to (14, 15): 

• Empower girls, women, and communities 

• Protect the maternal-newborn connection 

• Provide frameworks to support countries in their legal, regulatory, and financial endeavors to support and protect pregnant and postpartum clients 

• Ensure that healthcare related to reproduction, women, and newborns is of high quality 

• Improve data collection and measurement related to maternal and newborn health 

• Address and mitigate inequities related to maternal-newborn care 

• Reinforce accountability to improve outcomes in maternal-newborn health 

Pending and existing legislature that addresses maternal mortality is necessary to ensure the safety of women. The Preventing Maternal Deaths Act (HR 1318), Maternal Care Access and Reducing Emergencies (CARE) Act, Rural Maternal and Obstetric Modernization of Services (MOMS) Act, and Mothers and Offspring Mortality and Morbidity Awareness (MOMMA) Act are legislative endeavors focused on creating safety for pregnant women and mothers. The CARE Act, introduced by Kamala Harris, aims to dismantle structural racism via training programs for healthcare clinicians (6). 

Conclusion

Despite the WHO’s, CDC’s, ACOG’s, and other government and medical organizations’ efforts to decrease maternal death in the United States, the situation continues to escalate. Nurses play a critical role in assessing pregnant and postpartum clients for risk factors of maternal death. Most importantly, nurses should prioritize their pregnant and postpartum clients’ mental health and domestic safety needs since homicide remains the number one cause of maternal death in the United States. 

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