Problems found with maternal deaths in California

A new report from the state Department of Public Health reveals that the maternal death rate more than doubled in California between 1998 and 2008, increasing to a number higher than the national rate.

The report, which was released April 26, also reviewed many of the pregnancy-related deaths from 2002 and 2003 — the most recent years with more detailed data available during the course of the study — and found that nearly 40 percent of the deaths may have been preventable.

“California has higher rates than many states and the Healthy People 2020 goal — and the trends are worsening,” said Christine Morton, PhD, referring to the goal set each decade by a consortium of state and federal agencies under the auspices of the U.S. Department of Health and Human Services. Morton is a research sociologist and program manager for the California Maternal Quality Care Collaborative, one of the organizations subcontracted by the state to perform the reviews and analyze the findings. CMQCC is housed in the Division of Neonatology in the Department of Pediatrics at Stanford and works with state and local agencies and nonprofit groups that focus on improving maternity care.

The report highlights findings from California’s first-ever statewide review of maternal deaths. It states that California women now die at a rate of 14.0 per 100,000 live births, or about 50 maternal deaths per year statewide. This exceeds both the national rate of 13.3 deaths per 100,000 births and the Healthy People 2020 goal of 11.4 deaths per 100,000 births. The maternal mortality rate accounts for all women who die from pregnancy-related causes within 42 days of giving birth.

The report also shows a disturbing inequity: The maternal death rate in California is about four times higher among African-American women than among white or Latina women, and the gap in maternal death rates between African-American women and other groups has widened in recent years.

While the total number of fatalities may seem small, maternal mortality is considered an important public health marker, partly because these numbers represent the tip of the iceberg in terms of rising trends of injury and illness among a young and healthy population. Increasing maternal mortality is not limited to California; some other heavily populated states, such as New York, have also seen a rise in recent years. In addition, there has been a rise in serious birth-related injuries in the United States.

“This increase certainly is disturbing, especially since we estimate that for every maternal death there are a number of near misses,” said Sheila Cohen, MD, an emeritus professor of anesthesiology at Stanford and a member of the panel that reviewed medical records of women who died.

The rise in maternal mortality in California may be partly explained by better record-keeping and by social or epidemiological factors, including rising average maternal age, increasing rates of pre-existing illness such as obesity and hypertension among pregnant women, and lower social support for these women, the report found. But the report notes that these factors do not fully explain the increase in maternal mortality and further reviews are needed. Morton said that future studies should “extend our analysis to quality of care in hospitals where women obtain care, and look at community factors where women live as well as individual health factors.”

In addition to looking at deaths within 42 days of pregnancy, the report also examined “pregnancy-related” deaths, those among women who died of pregnancy-related causes within a year of giving birth.

The report analyzed pregnancy-related deaths that occurred in 2002 and 2003, finding that, of 386 California women who died during childbirth or within one year of a live birth or fetal death, 98 deaths were pregnancy-related. The deceased women’s medical records were reviewed by a panel of obstetricians, obstetric anesthesiologists, midwives and nurses to determine the cause of death, what factors led to the death and the chance to alter that outcome, as well as to identify quality improvement opportunities.

One of the key findings of the report is that the cause of death recorded on the death certificate was less specific than the cause of death determined by the committee. Based on the committee review, the most common pregnancy-related causes of death were, in descending order, cardiomyopathy and other cardiovascular conditions, pre-eclampsia/eclampsia, amniotic fluid embolism, hemorrhage and sepsis.

Women who died of pregnancy-related causes were disproportionately of lower socioeconomic status as determined by insurance status, marital status and education level. Some deaths, such as those from motor vehicle accidents, were not related to pregnancy. In other cases, deaths that had not been classified as pregnancy-related on the women’s death certificates were reclassified by the review panel as pregnancy-related, such as those occurring three to five months postpartum and due to undiagnosed cardiomyopathy.

The panel was able to determine preventability for 96 of the 98 pregnancy-related deaths, with 38 percent deemed having a good or strong chance to have altered the outcome. Opportunities for improving care included earlier recognition and evidence-based management of obstetric emergencies, training for timely recognition and response to warning signs such as changes in pain, heart rate and blood pressure; better communication between care providers; and more opportunities for care staff to become certified in procedures such as pregnancy CPR.

“There are clear opportunities to prevent some of these deaths,” said Morton. “It will require group effort from hospitals, physicians and nursing staff working together to implement evidence-based quality improvement programs.” The state will also need to continue monitoring maternal deaths so that factors that change the maternal death rate can continue to be tracked, she said. Steps taken to lower maternal mortality rates would not only save women’s lives, but could also help to reduce morbidity and permanent disability associated with pregnancy.

Ongoing studies are now exploring how many California women experience life-altering complications of pregnancy such as loss of their uterus or permanent disability.

Future work by CMQCC will focus on the quality improvement opportunities identified in deaths due to pre-eclampsia/eclampsia, where 60 percent had a strong or good chance of being prevented. Maurice Druzin, MD, professor of obstetrics and gynecology and of pediatrics and a member of California’s pregnancy-related mortality review committee, will head up the CMQCC task force that will begin work in July on developing best practice guidelines around management and treatment of this prevalent and preventable condition.

The report was supported by federal Title V block grant funds received from the California Department of Public Health; Center for Family Health; Maternal, Child and Adolescent Health Division.