1. Sofer, Dalia


One state-California-is defying the system.


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Between 1990 and 2015, maternal mortality decreased by about 44% worldwide. But in the United States-ranking last among developed nations-the rate increased by 26.6% in 48 states and Washington, DC, between 2000 and 2014. (California had a declining trend, while Texas had a sudden spike in 2011-12.)

Figure. Photo by Chr... - Click to enlarge in new window Photo by Christophe Launay / Aurora Photos.

Also on the rise is the U.S. rate of severe maternal morbidity, up by 45% between 2006 and 2015, according to the Healthcare Cost and Utilization Project (HCUP). The Centers for Disease Control and Prevention (CDC) specifies 21 indicators of severe maternal morbidity, including such conditions as renal failure and sepsis, as well as procedures performed during the hospital stay-such as blood transfusion and hysterectomy-that may or may not result in death. The most common indicators, per HCUP, were blood transfusion, followed by hysterectomy and disseminated intravascular coagulation.


From 2006 through 2015, the youngest (under 20 years) and oldest (40 years and older) women remained most likely to have births involving severe maternal morbidity, as did those with Medicaid coverage and those living in a zip code with the lowest median household income. Black women-accounting for nearly a quarter of cases-were the most likely to have births involving severe maternal morbidity. And, while rates of in-hospital mortality decreased for all races and ethnicities in 2015, in-hospital mortality remained three times higher for blacks than for whites.


The worsening rates of maternal mortality and morbidity are associated with multiple factors, according to Kathleen R. Simpson, editor-in-chief of MCN: American Journal of Maternal/Child Nursing. Better data is a factor, as tracking maternal health has improved in recent years. Another factor is the rise of chronic conditions: more women are overweight or obese, which can lead to hypertension, diabetes, and an increased risk of cesarean births. Pregnant women, on average, are also older than a generation ago. Lastly is the problem of inadequate access to health care, which disproportionately affects women of color. Simpson cited the example of Washington, DC, where several hospitals serving low-income neighborhoods recently shut down or limited their maternity services. "If you live far from the nearest facility, how will you get there?" she asked.


Babies have fared somewhat better than mothers. The U.S. perinatal mortality rate was essentially unchanged from 2014 through 2016. The rates for the three largest racial groups (black, white, and Hispanic) also were unchanged, as were those for most maternal age groups. However, the rate for black women remained about twice as high as those for white and Hispanic women.


A bright spot in this troubling picture is California, which in the mid-2000s had rates of maternal mortality and severe morbidity similar to those in the rest of the country but has since vastly improved. The three-year average maternal mortality rate in California is seven deaths per 100,000 live births, which is comparable to the rate of 7.2 in Western Europe and well below the overall U.S. rate of 28.


The dramatic turnaround in California was accomplished through a public-private partnership between the California Department of Public Health and the California Maternal Quality Care Collaborative. Among steps taken to improve maternal care were linking public health surveillance to action steps (including the development of quality improvement toolkits); mobilizing public and private partners such as state agencies, payers, purchasers, professional societies, hospital systems, clinicians, and patient groups; establishing a fast and easy data collection and reporting system; and implementing multipartner, large-scale interventions that integrated providers with public health services.


California's success, while encouraging, begs the question: Why isn't more being done at the federal level to improve maternal health nationwide?-Dalia Sofer




Fingar KR, et al HCUP Statistical Brief #243, Agency for Healthcare Research and Quality, Rockville, MD, 2018 Sept; Gregory ECW, et al. NCHS Data Brief 2018;316:1-8; Main EK, et al Health Aff 2018 37 9 1484-93