MOTHERS IN MEDICINE
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patient has a caesarian section as her rural obstetrician is worried
Casey won’t get to the hospital at the right time.
Rural Kentucky women face greater issues with drugs than in
many other parts of the country. In Kentucky, 31% of maternal
deaths are from drug intoxication or overdose. This is primarily in
our rural counties rather than in the urban areas of Louisville or
Lexington. Cardiovascular conditions and pulmonary emboli represent
the next two identifiable conditions associated with maternal
mortality in Kentucky.
Beyond the SDOH, nationally there have been concerns over
mortality and morbidity associated with the health care system.
As with many other medical procedures, patient safety is highly
associated with higher volume of procedures performed. The National
Quality Forum reports that across the country, a woman
delivering in low-volume rural hospitals faces a 31% higher risk
of post-partum hemorrhage than in an urban teaching hospital,
though both have significant numbers of indigent women. Office
visits pre-conception and throughout pregnancy are for identifying
and monitoring women at higher risk for pregnancy and delivery
complications. Women who fail to set up or attend these visits
due to drug abuse are not identified and the opportunity for early
intervention is lost. Nationally, there is wide variance in consistent
use of tools to identify social and medical risks for women. The
adherence to evidence-based standards during labor and delivery
also varies widely across the country.
In order to achieve greater adoption of standards, the Joint
Commission has introduced two new measures to assure earlier
identification and treatment of hypertension/pre-eclampsia and
post-partum hemorrhage. The Alliance for Innovation on Maternal
Health (AIM) has received federal dollars for the development of
Patient Safety Bundles. These are evidence-based standards focused
on venous thromboembolism, opioid use disorders, hemorrhage,
hypertension/pre-eclampsia, disparities of care, safe reduction in
C-section rates and standardized admission criteria. These steps
should ideally result in greater standardization of processes with
reduction in maternal deaths and injuries.
In 2018, USA Today and the Courier-Journal reported on hospital
associated maternal deaths. Much of their focus was on lack
of standardization of maternal death review boards. The newspaper
series noted that Kentucky has a review board, but it does not
publish results or recommendations to reduce maternal injury. It
also indicated that the Kentucky morbidity rate of 1,163 events per
100,000 deliveries placed Kentucky 32 out of 47 reporting states.
Not only that, but the makeup of the review board was changed to
include more non-medical positions and fewer medical experts.
Certainly the safety of delivery is much better now than it was
90 years ago when the New York study was published, but as a
nation and as a state, we are behind other Western countries. The
greater recognition of maternal risk is stepping up efforts to ensure
evidence-based care. More needs to be done for the Cierras and
Caseys of our Commonwealth. Racial biases, poor access to care
and the high prevalence of substance abuse all require concerted
action, not passively waiting for women to show up for active care.
Medical doctors are part of the solution, but not exclusively so.
Reducing harm to pregnant women and improving birth outcomes
will take societal action at local and national levels.
References:
Kentucky Cabinet for Health and Family Services. Maternal Mortality Review
2019 Annual Report. Department for Public Health, Division of Maternal and
Child Health, Frankfort, KY, 2019.
National Quality Forum, Maternal Morbidity and Mortality Environmental
Scan DRAFT REPORT,
July 31, 2020 https://www.qualityforum.org/Maternal_Morbidity_and_Mortality.
aspx (last accessed Aug. 9, 2020
Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health
Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.
Am J Public Health. 2015;105(12):e60-e76. doi:10.2105/AJPH.2015.302903
Rivara FP, Fihn SD. Severe Maternal Morbidity and Mortality: JAMA Network
Open Call for Papers. JAMA Netw Open. 2020;3(1):e200045. doi:10.1001/jamanetworkopen.2020.0045
Metro Louisville Department for Health and Wellness, Healthy Babies Louisville,
https://louisvilleky.gov/government/health-wellness/healthy-babies-louisville
(last accessed Aug. 9, 2020)
Alexander R. Green, MD, MPH, Dana R. Carney, PhD, Daniel J. Pallin, MD,
MPH, Long H. Ngo, PhD, Kristal L. Raymond, MPH, Lisa I. Iezzoni, MD,
MSc, and Mahzarin R. Banaji, PhD. Implicit Bias among Physicians and its
Prediction of Thrombolysis Decisions for Black and White Patients. Published
online June 27, 2020.
Dr. James is the Chief Medical Officer for WellCare of Kentucky.
Pregnancy-associated death/maternal
mortality
Pregnancy-associated, but not related
death
Pregnancy-related death
World Health Organization definition of
maternal death
DEFINITIONS
Death while pregnant or within one year of the end of the pregnancy regardless of the cause of
death.
Death during pregnancy or within one year of the end of the pregnancy from a cause of death
unrelated to pregnancy.
Death during pregnancy or within one year of the end of the pregnancy from a pregnancy
complication, a chain of events initiated by a pregnancy, or the aggravation of an unrelated
condition by the physiologic effects of pregnancy
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of
the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes
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