By Michelle Murtha, RN

Women in the United States are more likely to die from childbirth or pregnancy-related causes than women in all other developed nations, according to the Centers for Disease Control and Prevention (CDC). More than 700 women die each year in the United States due to pregnancy and childbirth-related complications. The CDC ranks Arkansas as the third-highest maternal mortality rate in the nation. Arkansas has 35 maternal deaths per 100,000 live births, compared with the national average of 20 deaths per 100,000 live births.

While maternal mortality is increasing, serious morbidity is increasing even faster. The CDC reports more than 60,000 new mothers annually experience serious or life-threatening complications. From 1993 to 2014, the serious-complication rate more than doubled. New mothers needing resuscitation from heart failure increased by 175 percent; the need for endotracheal tubes and treatment of sepsis both increased by 75 percent. Cesarean births (C-sections) have increased from less than 5 percent in the 1960s to 33 percent in 2016 – about twice the rate in European countries. C-sections increase the risk for hemorrhages, blood clots, infections and uterine ruptures in subsequent pregnancies. The rate of women who have induced labor has more than doubled in the last 20 years, leading to prolonged labor and increased risk of hemorrhage.

The reasons for this increase include a combination of factors: lack of access to care; pre-existing chronic conditions like pre-pregnancy obesity, hypertension, diabetes and cardiovascular disease; increases in maternal age and drug addiction; and the use of tobacco products and alcohol. 

The risk of pregnancy-related deaths for black women is three to four times higher than for white or Hispanic women. Even healthy women who give birth are at risk for these complications.

The leading causes of maternal death are hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection and pre-existing chronic conditions mentioned above. 

The most common preventable errors that lead to maternal mortality and morbidity include: failure to adequately control blood pressure in hypertensive women, failure to diagnose and treat pulmonary edema in women with preeclampsia, and insufficient attention to vital signs or hemorrhage following cesarean birth.

The cost of caring for severe maternal morbidity costs billions of dollars a year.

Arkansas’ strategy

The postpartum period is a critical time to ensure women and their newborns are healthy. It is important for women, family members and health care professionals to be educated about the warning signs that can potentially lead to maternal death. 

Efforts to reduce maternal mortality and morbidity in Arkansas started with implementing maternal safety bundles in hospitals. Developed and endorsed by national multidisciplinary organizations, maternal safety bundles include action measures for:

  • Obstetrical hemorrhage
  • Severe hypertension/preeclampsia
  • Prevention of venous thromboembolism
  • Reduction of low-risk primary cesarean births/support for intended vaginal births
  • Reduction of peripartum racial disparities
  • Postpartum care access and standards

Education of new mothers and their families is vital to reduce maternal mortality and morbidity. Moms need to be aware of the many changes their body goes through during pregnancy and delivery and that there will be discomfort, soreness and fatigue. However, some discomforts and warning signs may need medical attention. 

New mothers should be encouraged to trust their instincts about their bodies and pay attention to these warning signs: 

  • Bleeding that’s heavier than normal menstrual periods or worsens 
  • Discharge, pain or redness that does not go away or gets worse 
  • Feelings of sadness that last longer than 10 days after giving birth 
  • Fever higher than 100.4˚ F 
  • Pain or burning when going to the bathroom 
  • Pain, swelling and tenderness in legs, especially the calves 
  • Red streaks on breasts or painful lumps in a breast
  • Headache that does not get better after taking medicine or headache with vision changes 
  • Severe pain in lower stomach, feeling nauseous or vomiting 
  • Foul-smelling vaginal discharge 

Critical warning signs include:

  • Bleeding that can’t be controlled 
  • Chest pain
  • Trouble breathing
  • Shortness of breath
  • Seizures 
  • Signs of shock 
  • Mother has thoughts of hurting herself and/or the baby

The University of Arkansas for Medical Sciences (UAMS) Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) and Center for Distance Health (CDH) hosted the Perinatal Outcomes Workgroup by Education and Research (POWER) networking event in April 2017 for every Arkansas facility that provides obstetric services. 

The training focused on implementing patient safety bundles for two leading causes of maternal mortality: postpartum hemorrhage and hypertensive emergencies in pregnancy. Each facility participating in POWER received components of both safety bundles, national resources that are spearheading safety bundle implementation and hyperlinks to supporting literature. POWER worked with participating facilities to identify aspects of the bundle they needed to develop and potential barriers to implementation. The goal is for every facility to successfully implement both safety bundles and assign a staff mentor to facilitate the process. 

Under the direction of Arkansas Medicaid, AFMC’s Medicaid Quality Improvement team is focusing on educating new mothers about post-birth warning signs specific to maternal mortality. Teaching all women to recognize potentially life-threatening signs of post-birth complications can save lives.

Mrs. Murtha is an AFMC quality manager.