Maternal death in rural America

" target="_blank">In 2018, maternal mortality is a major topic of discussion in obstetrical, public health and political circles. Contemporary OB/GYNhas dedicated a great deal of editorial space this year to articles and commentary on causes and consequences of these deaths. There clearly are many issues to explore about death of US mothers during pregnancy and the puerperium, including who is dying and why, and what can be done about it. 

Disparities in care received by certain patients and populations have been the focus of strong pushes for solutions from multiple sources. With health disparities, the focus typically is on race/ethnicity and socioeconomic factors as they relate to access to and quality of care. But an often forgotten disparity is geographic location. Earlier this year, an article in The New England Journal of Medicinediscussed the challenges of improving rural health care,¹ and one in JAMA² addressed general aspects of care, especially for rural hospitals and the current reimbursement system. 

Maternity realities in rural America

The American College of Obstetricians and Gynecologists (ACOG) describes rural America as representing 75% of the national landmass and being home to 22.8% of US women aged 18 and older, with substantial variance in ethnic and racial composition.³ ACOG Committee Opinion #586 outlines health disparities for rural women. Significantly, it notes that data describing both health and outcomes for these patients are limited overall, although risks related to level of rurality are evident. Clearly the challenges for a state such as Pennsylvania (reported to have the third largest rural population in the United States) will be different than those for states such as Montana or Alaska, which have smaller absolute numbers of rural residents spread over a much larger geographic area. But some statistics stand out. 

Overall, rural women are less likely to receive any preventative health care and screenings. Fewer than half of rural women live within a 30-minute drive to a hospital with perinatal services, and over 10% have a drive of 100 miles or more. Some states, such as Wyoming, have no tertiary care centers for pregnant women at all.³ And because overall health outcomes generally are worse in rural communities due to increased incidences of obesity, cancer, cardiovascular disease, opioid use, and violent deaths, it would seem reasonable to assume that these outcomes would be echoed in the maternal death rates seen in rural communities.

Nationally, rural health care availability is under attack with closure of hospitals and lack of medical personnel in communities, as described by Dr. Lockwood in this month’s editorial. ACOG reports that in 2010, 49% of the nation’s counties lacked an obstetrician-gynecologist, leaving over 10 million women-or 8% of those in our country-without that service. The challenge is even greater when one looks at hospital-based obstetrical services (or lack of) and birth outcomes in rural communities.^3,4 Clearly, the impact of closing a maternity ward in a rural hospital where the next nearest obstetrical unit is 100 miles away would be very different than in an urban community with another center of care less than 10 miles away. 

It is possible that pregnancy-associated deaths, rather than pregnancy-related deaths, may provide a unique window into the socioeconomic and cultural challenges faced by rural communities. Teasing out the possible differences, however, is not possible with our current system of state-collected data. State and national statistics, therefore, are inevitably dominated by the cause of maternal deaths in population centers simply due to sample size. To begin to address this problem, policy makers need to look at aggregate rural-based data to see if the causes of mortality and morbidity there are similar to those in urban settings and determine if interventions for urban patients can be applied to those in rural settings. 

For example, maternal deaths from motor vehicle accidents may be more common in remote rural settings due to the long distances at high speeds that rural women travel on a regular basis to obtain care. In that setting, seat belt education may be more important than it would be in a metropolitan area. Postpartum hemorrhage (PPH) deaths may be more preventable if tranexamic acid and cryoprecipitate were available as well as six to eight units of total blood products in the hospital blood bank, together with streamlined procedures for obtaining those products in emergency situations. Or interventions in a rural setting may focus on early recognition of risk of PPH or active blood loss, basic stabilization techniques and prompt transport rather than a detailed mass transfusion protocol. 

Data collection and analysis challenges

In addressing any health care disparity, accurate data are critical to identifying specific problems and tailoring interventions to address actual issues rather than issues “perceived” by “outsiders.” Because the absolute numbers of maternal deaths are small in rural states given their overall lower populations and birth rates, it is impossible for a single state to have numbers sufficient to accurately interpret data without aggregation of five or more years of information. With current published state reports, it is also impossible to aggregate data across states because they use different definitions and presentations for their aggregate state data. Until recently, that has stood in the way of accurate data collection and management across the nation.   

Working toward solutions: ACOG maternal mortality task force

In 2017, to help address these challenges and better identify sources of health care disparities in rural settings, ACOG District VIII launched a Maternal Mortality Task Force. District VIII is uniquely situated to collect data on rural maternity care and deaths. District VIII is made up of 12 states as well as Guam, American Samoa, Alberta, British Columbia, and Central America. Those states alone make up over 50% of the land mass of the United States but only about 15% of the US population resides in those areas. Much of the population in the 12 states is concentrated in one or two urban settings (e.g., Alaska with Anchorage and Juno). Using data standards developed by the Centers for Disease Control (CDC) and the Association of Maternal and Child Health Programs (AMCHP) and employed by the national Maternal Mortality Review Information Application (or MMRIA) database, it is possible to capture information about the distance from the woman’s home to where she delivered as well as the level of maternity care available where the delivery occurred. The data collected also include details of a patient’s circumstances, building an extensive narrative that covers all aspects of her experience of pregnancy and then presenting those facts in standardized format for examination and analysis.  

The ACOG District VIII Task Force hopes to be able to aggregate the data over the 12 states using the structure of the MMRIA database. Without specifying state or county, data will be combined across the region, using references of distance from hospitals and levels of care as the standard. That, in turn, will produce samples sizes large enough to allow examination of rural vs urban causes of death on an annual or biannual basis. This larger data pool would also allow for quicker identification of unique evolving issues (Hantavirus, suicides or motor vehicle accidents) and evaluation of intervention strategies. Because the 12 states have some of the largest populations of indigenous people, a detailed data collection of this type may also be of great assistance in documenting data for increased maternal morbidity and mortality associated with this particular group and guiding interventions. 

To accomplish this ambitious goal, the sections in District VIII are working with their respective departments of health to enact legislation as needed to support MMRCs and to encourage and empower individual departments of health to provide their data through MMRIA to the CDC. As more states enter data into the CDC database, the task force will look at the reports, identify issues to address, identify already established interventions a state may have that can be exported to other states in the region and continue to educate our district providers as to steps they can take to decrease our unacceptable national maternal mortality statistics and disparities. 

References:

• Iglehart JK.  The Challenging Quest to Improve Rural Health Care – Health Policy report. N Engl J Med. 2018;378:473-479.
• Murphy KM, Hughes LS, Conway P. A path to sustain rural hospitals. JAMA. 2018;319(12):1193-1194.
• American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 586:  Health disparities in rural women.  2014 Feb;(2 Pt 1):384-388.
• Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA. 2018;319(12):1239-1247.
• Shah NT. Eroding access and quality of childbirth care in rural US counties. JAMA. 2018;319(12):1203-1204.
• Wetzel LM. Maternal mortality statistics; data collection methods improving but still a challenge. Contemp OB/GYN. 2018:63(1):24-27.