A call to arms against maternal mortality

Charles J. Lockwood, MD, MHCM

Charles J. Lockwood, MD, MHCMIf we truly want to “make America great again” we should start with a national effort to address our tragically high maternal mortality rate. This measure has traditionally been used to distinguish wealthy western industrialized nations from poorer developing ones. But in 2013, the United States ranked 60th in the world in maternal mortality.¹ Sadly, our national mortality rate reached its nadir when Reagan was still President in 1987, at 7.2 pregnancy-associated deaths per 100,000 births and steadily deteriorated thereafter, reaching 17.3 deaths per 100,000 in 2013.² In fairness, it must be pointed out that much of this increase in reported maternal mortality can be attributed to improved surveillance.³ However, we should take little comfort in the fact that we had previously been woefully undercounting maternal deaths! 

What is indisputable is that the major drivers of maternal death have changed appreciably over the past 20 years.² Today cardiovascular disease and cardiomyopathy combined account for more than a quarter of all deaths. Infection, venous thromboembolism (VTE) and hypertension, which previously accounted for most such deaths, now combined only account for one-third. That is not to say that we couldn’t be doing far more to prevent deaths from these causes as well.

We can only speculate on the reasons for this qualitative change in maternal mortality. However, one likely culprit is the obesity epidemic. Lisonkova and associates recently reported the results of a large cohort study from Washington State that examined the association between pre-pregnancy body mass index (BMI) and severe maternal morbidity and mortality.⁴ In a population of 743,630 women whose singleton gestations occurred between 2004 and 2013, the authors observed that rates of severe maternal morbidity or mortality increased from 143.2/10,000 births among women with normal body mass index to 167.9, 178.3 and 202.9/10,000 in women with Class I, 2 and 3 obesity, respectively. Cardiac morbidity and mortality increased in a commensurate fashion. Obesity is also a major risk factor for hypertension, VTE, and complications of anesthesia, all important causes of maternal mortality. Fortunately, obesity can be prevented, or at least ameliorated, through lifestyle changes, albeit requiring a significant commitment of physician time, energy and effort as well as herculean self-control by affected patients.

Another much-overlooked cause of maternal mortality is self-harm due to accidental overdose and suicide. In fact, in the state of Colorado between 2004 and 2012, accidental overdose and suicide were the most common causes of pregnancy-associated mortality.⁵ Thus, the opioid crisis must be added to our list of potentially preventable causes.

Contemporary OB/GYN has decided to make 2018 the year of the mother, the year we start lowering US maternal mortality rates. With this issue, we launch our Maternal Mortality Series edited by Carolyn Zelop, who has made reducing maternal deaths a major focus of her career. Carolyn has recruited a world-class cast of experts who will address the major causes of maternal severe morbidity and mortality including cardiac disease, hemorrhage, hypertension, sepsis, VTE, amniotic fluid embolism, complications of anesthesia, accidents/substance abuse, suicide and other less common origins of maternal death. Strategies to reduce maternal mortality through detection of women at risk, introduction of preventative measures, and effective acute management will be outlined. I consider this one of the most important series that Contemporary OB/GYN has ever undertaken.  I look forward to hearing your feedback as the series unfolds.

Dr. Lockwood, editor in chief, can be reached at DrLockwood@ubm.com.

REFERENCES

1. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. 13;384(9947):980-1004. Epub 2014 May 2. Erratum in: Lancet. 2014 Sep 13;384(9947):956. PMID:24797575

2. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html (accessed 11/21/17)

3. Joseph KS, Lisonkova S, Muraca GM, Razaz N, Sabr Y, Mehrabadi A, Schisterman EF. Factors Underlying the Temporal Increase in Maternal Mortality in the United States. Obstet Gynecol. 2017 Jan;129(1):91-100.

4. Lisonkova S, Muraca GM, Potts J, Liauw J, Chan WS, Skoll A, Lim KI. Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity. JAMA. 2017 Nov 14;318(18):1777-1786.

5. Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, Binswanger IA. Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstet Gynecol. 2016 Dec;128(6):1233-1240.