U.S. maternal mortality crisis: a deep dive

Our increasing maternal mortality rate is gathering attention both nationally and internationally. The U.S. is 33rd among developed nations, and the rate is increasing. Indeed, as Neel Shah notes:

Americans today are 50 percent more likely to die in the period surrounding childbirth than their own mothers.

In 1974, the U.S. maternal mortality rate was 9 per 100,000 live births. By 1980, the rate was 8 maternal deaths per 100,000 births. According to the CDC, our maternal mortality rate for 2021 was 32.9 maternal deaths per 100,000 live births, up from 23.8 per 100,000 live births in 2020 and 20.1 per 100,000 live births in 2019. For women of color, that rate is 70 maternal deaths per 100,000 live births.

Compare our maternal mortality rates to those of other developed countries. Today, the maternal mortality rate in Japan is 2 deaths per 100,000 live births. In the Scandinavian countries, it is 2 to 3 deaths per 100,000 live births. The average maternal mortality rate for developed countries is 12 maternal deaths per 100,000 live births.

Why is our maternal mortality rate so high and continuing to go up?

An often-quoted reason for our rising maternal mortality rate is advancing maternal age. For the year 2021, maternal mortality rates included 20.4 per 100,000 live births for women under the age of 25, a rate of 31.3 for those aged 25 through 39, and a rate of 138.5 are those aged over 39 years.

So, what’s happening? With one of the most expensive health care systems on the planet, why has the maternal mortality rate risen astronomically? And why has no one been able to figure out how to bring this rate back down?

I’ve written before about why there is no mystery as to why the U.S. maternal mortality rate is so high. As noted above, one reason given for the high rate in this country is the increasing number of older pregnant women with co-morbidities. Let’s face it. We are surely not the only country in the world working with mothers who smoke cigarettes, are overweight, have diabetes, hypertension, preeclampsia, eclampsia, and COPD, common factors that make pregnancy more complex.

Our federal government has two fixed responses to almost every problem in medicine. The first one is threatening hospitals in general and health care providers in particular. It’s easier to threaten one or two physicians or hospitals than address the real problem when the underlying cause for maternal mortalities is a systems problem.

The second major government response is to throw money at health care problems.

Now, the Centers for Medicare & Medicaid Services (CMS) wants to spend 168 million dollars to create a Centers of Excellence program aimed at awarding hospitals for providing good maternal care. I doubt many of the CMS staff creating this checklist to qualify for this Centers of Excellence program have ever delivered a baby or had to make complex birthing decisions.

So what will this investment in Centers of Excellence accomplish? Data collection! There are serious problems with looking for solutions in data collection. I have written about problems with bias in research studies (and lost several Substack subscribers as a result). We have the illusion that the conclusions in research studies are 100 percent correct all of the time. So merely collecting data is not going to solve the maternal mortality problem when the deaths result from systems problems, not a data set, a data set that does not include all of the factors involved in complex decision-making.

Most physicians, including myself, are intimately acquainted with the weaknesses of the electronic medical record (EMR). The EMR is horribly complex and often coding does not accurately represent what actually happened. I would like to proffer the suggestion that none of the EMR data will represent the real reasons for maternal deaths. The data may show that a woman hemorrhaged to death, but it will not show the reason the woman was allowed to hemorrhage to death—only that she hemorrhaged to death. Hence the real cause of death will remain unrecorded and never make it into a data set. EMR is a failed attempt to convert complex abstract disease management into checklists.

Now, rather than actually making plans to remedy our sky-rocketing maternal mortality rate by correcting system failures, we are collecting data that is magically supposed to make this hospital or that hospital a center of excellence.

How would I fix this problem?

Firstly, a nod must be given to the devil of complexity. There is not just a single cause for a woman’s death. There are many huge systems causes requiring corrections to huge systems and multiple huge systems simultaneously.

I have over four decades of obstetrical experience and delivered approximately 6,000 babies with no maternal mortality and no eclampsia. I saw my patients every time they came to my office. No, I didn’t momentarily stick my head in the door while someone entered data into a computer. I sat down with my patients and their families—yes, I invited dads and children to prenatal visits. I could observe the family dynamics and whether a mother would be likely to develop postpartum depression. I saw my patients as often as I thought necessary, even if that meant they came to the office more times than insurance would cover. My patients knew me, knew I would be there for their delivery, and trusted me. And I never abandoned my patients after they were delivered, either in the hospital or at home postpartum.

The Centers of Excellence will not be able to provide the kind of changes needed to bring down the maternal mortality rate because the current business model for prenatal care, labor and delivery, and postpartum creates a simplistic approach for an extremely complex medical process.

My suggestion?

The $168 million dollars the Centers of Excellence program is putting into collecting data would be much better spent sending practicing physicians to countries with low maternal mortality rates and observing how it’s done. And to bring physicians from countries with low maternal mortality rates to this country to observe how this country manages pregnancy, labor and delivery, and postpartum care and make recommendations for improvements. We should be looking at what makes other countries successful in keeping their maternal mortality rates so low rather than spending millions to create a gold-star award for hospitals that can collect data about their performance that has no real substantive connection with ways to reduce the U.S. maternal mortality rate.

It’s time to give up our love affair with data collection and look closely at the reasons for maternal mortality, reasons data collection cannot capture.

Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack. He is the author of Pregnancy Your Way: Choose a Safe and Happy Birth.

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