What Nurses Need to Know
Today we continue our 2019 INSIGHT series showcasing maternal mortality. Earlier this year, we at the Mary K Center for Global Nursing Development published data showing the global problem of unacceptably high rates of maternal mortality.
Now we are focusing on the issues that persist in the United States. It is a disturbing picture, but one that should be examined more closely because the problems in this country are similar to those in others. We can all learn from each other.
Before we give the U.S. overview of maternal mortality, let’s define the term itself. We are using the definition that a maternal death occurs any time between conception and one year after the end of the pregnancy. (This is the definition used in a groundbreaking CDC 2018 Report entitled, Report from Nine Maternal Mortality Review Committees (Hereafter known as Nine Committees). The report was published to accomplish two significant goals: (1) To present the full picture of US maternal deaths, and (2) for the first time, to recommend ways to prevent these deaths. )
With that as a foundation, let’s move on so we can see what is happening in the U.S.
According to the Centers for Disease Control and Prevention (CDC), at least two women living in the U.S. die from complications that occur from giving birth every day. This translates into over 700 maternal deaths every year. This sobering fact gives the U.S. the unfortunate position of being ranked the worst in maternal deaths in the developed world, and ranking 47th globally.
This is not an isolated outlier, but rather has been part of a trend. Over the past three decades, the maternal mortality rate in the US has been increasing, not decreasing, as in other developed countries.
This far-reaching survey identified the alarming fact that approximately 60% of these deaths are preventable. It also reported that non-Hispanic black women suffer childbirth-related deaths at a rate three to four times higher than that of non-Hispanic white women. Overall pregnancy-related deaths varied by race also – whether the death occurred during delivery or at any other time.
These facts alone show a clear need to delve into the details, because there is opportunity to make progress. But that progress has to be made quickly.
The causes of all pregnancy-related deaths cluster around some major categories, similar to the global trends. The Nine Committees concluded that maternal deaths were caused by post-partum hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, or infection. Other leading causes include embolism preeclampsia and eclampsia , and mental health conditions.
Source: CDC 2018 Nine Committees Report
It is worth noting the timing of the mothers’ deaths reported by the Nine Committees:
- 38% died while pregnant
- 45% died within 42 days of delivery
- 17% died from 42 days to 1 year
Within these time-frame categories, leading causes of death varied:
- Hemorrhage and cardiovascular and coronary conditions were leading causes of death during pregnancy, followed by embolism.
- Infection was the leading cause of death for deaths within 42 days of the end of the pregnancy. Hemorrhage, cardiovascular and coronary conditions, and preeclampsia and eclampsia were also significant.
- Cardiomyopathy, mental health conditions and embolism were the three leadings causes of pregnancy-related deaths that occurred 43 days to one year after the end of the pregnancy.
The Nine Committees also identified that the leading underlying causes varied by race:
- Non-Hispanic black women suffered more from cardiomyopathy, preeclampsia/eclampsia, and embolism than non-Hispanic white women.
- Non-Hispanic white women suffered more from CV and coronary conditions, and infection. They also had a higher percentage of mental health conditions, such as post-partum depression, than non-Hispanic black women
(Note: There was not sufficient data to determine leading causes of pregnancy-related deaths among Hispanic women).
The chart below provides a detailed look at the differences by race/ethnicity.
Source: CDC 2018 Nine Committees Report
Leading Underly Causes of Pregnancy-Related Deaths, By Race/Ethnicity
Looking at the patient is imperative, of course, but we also have to look at the behaviors of the healthcare providers. NPR reported that only 6% of federal and state funding through block grants for “maternal and child health” actually go to the health of the mothers. What’s more is that hospitals can be unprepared for maternal emergencies – even when those hospitals have intensive care units for newborns.
NPR also reported that many US hospitals don’t have clear protocols for dealing with potentially fatal complications. Without these protocols, these symptoms are missed, and the mother dies. As nurses we need to make sure we educate ourselves on the symptoms and be on the alert.
It is beyond the scope of this blog to identify all the symptoms that could signal an imminent pregnancy-related death. It is possible, however, to outline some of the major ones.
The Association of Women’s Health, Obstetric, and Neonatal Nurses. (AWHONN) has developed insightful and practical materials to help nurses and patients pay attention to the symptoms that matter.
For post-birth deaths, the symptom checklist includes:
- Pain in chest – may mean a blood clot or a heart problem
- Obstructed breathing or shortness of breath – may signal a blood clot or a heart problem
- Seizures – may mean eclampsia
- Flat affect or desire to hurt oneself or someone – could be postpartum depression
- Bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger – could be obstetric hemorrhage
- Incision that is not healing – may mean an infection
- Red or swollen leg that is painful- could possibly be a blood clot
- Very painful headache, with vision changes or pain in upper right area – could mean high blood pressure or post-birth preeclampsia.
Identifying the issues is a productive first step towards eradicating maternal deaths. But it is only the first step.
Later this year we will continue with our INSIGHT series by providing an overview of the suggestions for preventing these deaths. In addition, we will address more specifically the issues surrounding hemorrhages, one of the primary causes of maternal mortality.
Lisa D. Cole, MA, RN
Director, Mary K Center for Global Nursing Development
P.S. If you have any input to share on best practices, treatments or educational programs that are helping decrease maternal mortality, please email us the specifics. We would love to consider it for an upcoming post when we will address postpartum hemorrhage and what’s working. Thank you in advance.
Note: A chart from the Lancet referred incompletely to the infant mortality rate in developing countries and was removed from the original post.