On the Other Side of the Rails
Critical Needs of Pregnant and Postpartum Patients in the Emergency Department
Perhaps you have heard the United States ranks worst in maternal mortality and morbidity statistics of all high-income countries and is described as the deadliest country to have a baby. This alarming stat may come as stark news if you have not heard this before. A robust website by the World Bank provides a graph on the maternal mortality ratio per 100,000 live births from 2000-2017. While nearly all countries demonstrate a decline over this time, the sharp rise in U.S. maternal deaths sits alongside countries such as the Dominican Republic, Jamaica, Kuwait, Lebanon, and other low-income or waring countries.
So, what leads to maternal death? The primary causes include hemorrhage, hypertensive diseases, and infection. The risk of a woman in a low-income country succumbing to a childbirth-related death is 120 times higher than compared to her counterpart living in a high income country. That is unless you live in the United States.
Over the last twenty years, the CDC reports a significant rise in maternal mortality and morbidity in the United States related to hypertensive disorders, postpartum hemorrhage, deep vein thrombosis, and pulmonary embolism. Additionally, data confirms significantly higher ratios of maternal morbidity and mortality in African American, Native American, and Alaskan Native women regardless of socioeconomic or educational status.
These findings demonstrate inequities and disparities in receipt of adequate comprehensive maternal care fueled by racism and unaddressed implicit bias by health care professionals. Black women and Native American and Alaska Natives saw pregnancy-related mortality rates of 40.8 and 29.7 deaths per 100,000 births, respectively. White women experienced a rate of 12.7 and Hispanic women 11.5. The total pregnancy-related mortality rates increased from 15 to 17 per 100,000 births between 2007-2008 and 2015-2016. Although deaths are relatively rare, for every woman that dies related to childbirth, 70 more come close.
According to an NPR article, it is estimated 700-900 women die every year due to pregnancy or a related complication and over 50,000 childbearing women experience a severe maternal morbidity (near-miss) event.
With approximately three in five deaths preventable and most occurring in the postpartum period, it is likely ED staff will encounter a postpartum mother within the first year after giving birth. With no single intervention being the magic bullet, several initiatives have started around the country to address quality improvement programs for pregnant and postpartum women. The American College of Obstetricians and Gynecologists (ACOG) released a national communication in October 2018 listing four things any hospital can do now to prevent maternal mortality. ACOG recommendations include: 1) focusing on implementing protocols to address the main preventable causes of complications and death during pregnancy and postpartum, 2) implementing meetings/huddles to review each patient’s risk status, 3) practicing obstetrical simulations of emergent situations, and 4) formalizing existing relationships between lower resource hospitals that transfer to higher levels of care.
A state-wide initiative in New Jersey has emerged and is being replicated across the country to urge providers to “Stop. Look. Listen!” The aim is to increase professional and public awareness of pregnancy-related deaths, encourage women to report pregnancy-related medical issues, and increase awareness and responsiveness of health care professionals. Much discussion and education for the public and providers alike centers on the analogy of a double-edged sword, aptly called ‘denial and delay’. New mothers often self-dismiss or diminish their symptoms and wait too long to call for help. On the other hand, the provider may delay face-to-face assessment and or diminish the mother’s early symptoms to commonly experienced postpartum pain and fatigue.
EVERY mother in every country should be afforded proper medical care. Childbirth is the leading reason people go to hospitals but not the primary reason people are admitted. What should be done when a pregnant woman or a postpartum mother (one year or less) arrives at the emergency department? Regardless of where women live, acting immediately for her to receive proper care is critical.
If she has high blood pressure, don’t wait to take it again – ACT
If she says she is bleeding, recognize hemorrhage and – ACT
If she is short of breath with chest pain – ACT
If you are unfamiliar with obstetric/postpartum patients – CALL A PROVIDER WHO IS
Practice emergency safety protocols for obstetric conditions – BE PREPARED WITH FREQUENT DRILLS
Freely downloaded Toolkits are available from the California Maternal Quality Care Collaborative outlining treatment protocol for the common primary obstetric emergencies: DVT, Preeclampsia, Cardiovascular conditions, and Hemorrhage. Learn about these tools and implement recommendations in all settings.
Lastly, if you are unaware of the conversation of how implicit bias and racism intersect with maternal outcomes in the United States, become informed. Black women living in the Southern Poverty Block are acutely at risk. Many groups, including March for Moms, are working to advance state and federal policy to address maternal health disparities for Black women. Initiatives include policy work that mandates every state create maternal mortality review boards, implement implicit bias training for all health professionals, extend Medicaid coverage to one year, and advocate for paid family leave. The March for Moms welcomes your participation on the Washington D.C. Mall on May 3, 2020. The purpose is to publicly demonstrate (for the fourth consecutive year) the need for immediate national attention to this public health crisis. More information can be found at the March for Moms website to learn more about what you can do to improve outcomes for families in your community.
Infographic: Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. Retrieved January 20, 2020 from https://www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/infographic.html. Please refer to website for updates. Materials developed by CDC. Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention. This material is available on the CDC website for no charge.
Ginger Breedlove, PhD, CNM, FACNM, FAAN, is the President of the March for Moms Board and is a past president of the American College of Nurse-Midwives. Presently, she owns a consulting company, Grow Midwives, LLC.
How to contribute
We encourage submissions from any reader who has been touched by the healthcare system. Some contributors may be involved directly in patient care and might want to share the impact a patient, family, or colleague had on them. Others may want to write about life “on the other side of the rails” …those moments when the caregiver becomes the patient…or maybe sees healthcare from the vantage point of a family member. Inquiries can be sent to [email protected]