During a Grey’s Anatomy episode back in April, fictional doctor Arizona Robbins used a hemorrhage cart to save the life of a woman who began bleeding excessively during childbirth. The show writers tweeted credit where credit was due: “Arizona's hemorrhage cart is a real thing! It was pioneered by Dr. Elliott Main who works with California Maternal Quality Care Collaborative [CMQCC].”
In short, these carts are equipped with the instruments needed to treat postpartum hemorrhage as swiftly as possible and are part of the CMQCC’s initiative to reduce pregnancy-related emergencies in the state (more on that later). “A hemorrhage cart is like a crash cart. It has meds, balloons, fluids. It makes a significant difference,” Dr. Main, who is a professor of obstetrics and gynecology at Stanford University and medical director at CMQCC, tells SELF. “This is a setting where minutes matter.”
It turns out, the CMQCC’s initiatives are a large part of the reason that California has successfully cut it’s maternal death rate, while the rest of the country has seen a sharp rise in pregnancy-related deaths over the past several years.
While it’s still considered fairly rare for a person to die due to pregnancy or childbirth, these tragic occurrences happen much more frequently in the U.S. than in other wealthy countries.
Between 2000 and 2014, the national pregnancy-related mortality rate rose 27 percent, from 19 deaths per 100,000 live births to 24 per 100,000, according to the most recent available data from the Centers for Disease Control and Prevention (CDC). The 2015 maternal mortality rate in the U.S. was calculated at 26.4 deaths per 100,000 live births—sandwiched between Uzbekistan’s 26.2 and Kazakhstan’s 26.5. By contrast, Finland and Norway’s rate were both 3.8 deaths per 100,000 live births. Denmark, Sweden, Ireland, and Italy were all around 4; Canada’s was 7.3, and the U.K., Portugal, and Germany were all around 9.
Pregnancy-related mortality, as defined by the CDC, is a death from any direct or indirect obstetric cause during pregnancy or within a year of pregnancy, regardless of the outcome of that pregnancy. Maternal mortality is defined as death from any cause related to or made worse by pregnancy (but not including accidental/incidental causes) during pregnancy and birth or within 42 days of childbirth, according to the definition used by the World Health Organization (WHO).
The top causes of pregnancy-related death in the U.S. are complications related to cardiovascular diseases and other chronic health conditions like diabetes, infections, hemorrhage, blood clots, and pregnancy-induced blood pressure disorders (like preeclampsia) and heart failure, according to the CDC.
There are significant racial disparities in maternal mortality rates in the U.S. Black women in this country are three to four times more likely to die from pregnancy- or childbirth-related causes, according to the CDC. A variety of factors are thought to contribute to this discrepancy, but experts agree that the problem likely stems, at least in part, from systemic racism.
The reason why the maternal mortality rate is so much higher in the U.S. compared to other developed places can’t really be linked to one single issue—there are a few factors at play.
Part of the increase in U.S. maternal mortality is that we’ve gotten better at reporting it, William Callaghan, M.D., chief of the Maternal and Infant Health Branch of the Division of Reproductive Health at the CDC, tells SELF. In 2003, death certificates were updated to include a dedicated question asking whether the person was pregnant within the past year, at the time of death or within 42 days of death. In one study that looked at the effectiveness of using these check boxes to identify pregnancy-related deaths in Maryland between 2001 and 2008, it found that 64.5 percent of pregnancy-related deaths in the state were identified through the use of the check boxes.
But Dr. Callaghan also believes many states’ rates could actually be lower than reported. This was the case in Texas, where after its shocking maternal mortality rate made headlines in 2016, it was discovered that erroneous data collection led to misidentifying more than half of these deaths as pregnancy-related. (For example, if a woman died while pregnant or within 42 days of giving birth due to an accidental circumstance, like a car crash, that should not be considered a pregnancy-related death.)
Another possibility is that women are dying from causes that in the past were not quite as common, Dr. Callaghan adds. “Cardiovascular disease is contributing a lot to the increase,” he notes. It was actually the top cause of pregnancy-related death in a recently published review from the California Department of Public Health (CDPH) of the state’s pregnancy-related deaths. Other factors include increases in drug abuse, obesity, and diabetes, Dr. Callaghan adds.
Dr. Main says that the medical community in the U.S. is also doing a poor job of caring for women in between pregnancies. Countries with universal health coverage tend to see significantly better pregnancy outcomes, thanks in part to being able to access health care throughout their lives. Many states in the U.S. allow pregnant women to qualify for Medicaid at higher income levels, meaning people who might make too much money to qualify for Medicaid but not enough to afford private insurance only gain access to medical care after becoming pregnant. In turn, some women may have heart problems or other health issues that go undiagnosed until cardiovascular complications in pregnancy arise.
The CDPH cites “delayed recognition of and response to clinical warning signs” as another factor. Take the U.S. and U.K., for example: If you compare the outcomes for pregnancy-related conditions that are treatable if recognized in time (such as hemorrhage and preeclampsia), you’ll find a rather sizable gap: Unlike the U.S., the U.K. standardized its approaches to such emergencies decades ago; in recent years, its hemorrhage death rate (5.6 percent of pregnancy-related deaths) is roughly half of what it is in the U.S. (11.5 percent).
Dr. Main also agrees that patients often aren’t being listened to about concerning symptoms: “We’re trying to get the right balance,” he says. “We don’t want to overmedicalize birth, but we want the patient to be heard. If you have risk factors, that should be enough to trigger further evaluation of your symptoms.” Pregnancy-induced heart failure, for instance, may show up months after birth, and because its symptoms overlap with those that a woman may experience during late pregnancy or early postpartum (such as swelling, shortness of breath), they can be mistakenly written off as normal by doctors and patients.
Ultimately, “Maternal mortality is a summation of multiple causes; it’s one of those things that’s not easy to pin on one specific factor,” Dr. Main says. He also notes that more older women are having babies, which can mean a more medically complicated maternal population. “But that’s not a reason to die, you just need more attention from care providers,” Dr. Main says.
Unlike the rates across much of the rest of the country, California's maternal mortality rate declined 55 percent between 2009 and 2013.
Back in 2006, public health officials in California became alarmed when they noticed the state’s pregnancy-related mortality rate had spiked dramatically: from 7.7 deaths per 100,000 live births in 1999 to 16.9 per 100,000 in 2006. So Dr. Main and his colleagues at Stanford University and the CDPH decided to do something about it. They got to work examining the top causes of death, determining which were most preventable, and deciding the actions most likely to stop these complications from turning deadly.
“We wanted to honor these tragedies by learning from them and making improvements,” Dr. Main says. That’s when the CMQCC was born, an organization “committed to ending preventable morbidity, mortality and racial disparities in California maternity care,” as the website states.
California’s unparalleled success is largely thanks to CMQCC’s toolkits, which outline standardized response protocols to the most common and preventable causes of in-hospital maternal mortality.
After CMQCC helped 200 California hospitals implement the evidence-based care laid out in the toolkits, the maternal mortality rate in the state declined 55 percent between 2009 and 2013, down to 7.3 deaths per 100,000 live births. (That’s a reduction of more than half in four years.)
“We developed a set of best practices and key steps. We focused on the most preventable causes of maternal death: hemorrhage and hypertension,” Dr. Main says. “In these cases, death is 90 percent preventable.”
But even though these causes of death are considered preventable, they still increased in prevalence in recent years, making these toolkits all the more valuable. Hypertensive disorders related to pregnancy including preeclampsia and eclampsia affects an estimated 3 to 10 percent of pregnancies. In a study that compared preeclampsia rates between 1980 and 2010, the rate of all preeclampsia increased from 3.4 percent in 1980 to 3.8 percent in 2010; while that jump might seem small, the researchers wrote that the shift was driven by the increase in the rate of severe preeclampsia, which increased from 0.3 percent in 1980 to 1.4 percent in 2010. Between 1999 and 2009, the obstetric hemorrhage rate increased from 1.5 percent to 4 percent of pregnancies.
In addition to support in implementing the toolkits, CMQCC also provides hospitals with performance data, such as their C-section and elective early delivery rates and complication statistics, which can help them see where improvements are needed. The toolkit library has since expanded to include safety protocols for addressing blood clots and strategies for reducing C-section rates in first-time deliveries.
In 2015, the toolkits were turned into national patient safety bundles and implemented in 18 states through the American College of Obstetricians and Gynecologists’ Alliance for Innovation on Maternal Health (AIM). “There are 13 key steps in the bundle, which are explained in the toolkit. It’s very easy to follow,” Dr. Main explains.
According to the CMQCC’s checklist, for instance, a hemorrhage cart should contain things like sutures to repair cervical lacerations, medications that help increase postpartum contractions or encourage clotting, forceps, sponges, scissors, clamps, an IV-starting kit, a speculum, a bright light on wheels, a balloon for inserting into the uterus and filling with saline to apply pressure that stems blood flow, and diagrams depicting how to perform such procedures. The toolkit also advises hospitals to keep blood products handy.
“Any delivery hospital can implement these protocols,” a CDPH spokesperson told SELF in an email. The free, downloadable toolkits offer “detailed pages of instructions that include a checklist of what a delivery hospital should have.”
Having these interventions in place sounds pretty straightforward and logical—but this type of standardized approach to common pregnancy complications is surprisingly revolutionary.
There have been a number of protocols for maternal care previously developed by organizations like ACOG, the Society for Maternal-Fetal Medicine (SMFM), the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), among others. But, "What California was able to do was to develop the first bundle of best practices for hospital teams," Jeanne Mahoney, RN, senior director of the Alliance for Innovation on Maternal Health, told SELF in an email. Through the CMQCC's initiatives, each hospital unit follows a single, standardized protocol, as opposed to, say, an ob/gyn, a midwife, and an anesthesiologist each having their own protocols that are not necessarily uniform, as Mahoney explained.
Dr. Main notes that the problems start when, in a setting where minutes matter, everyone has learned to deal with emergencies in a different manner. An organized team response is crucial, especially in emergency situations.
“If you have a plan, you can train to it, drill on it, debrief staff on how they did,” Dr. Main says. “If you can develop a culture of safety, you can make a big impact.”
But the work isn’t over: Black women in California are still three times more likely to die from pregnancy-related causes than all other ethnic groups.
“We still have a long way to go,” Dr. Main says. “Clearly there are issues that need further work in improving care of African-American women. Unfortunately, being black is a risk factor for maternal mortality.”
Racial disparities in maternal death rates cut across socioeconomic classes, and only a very small portion are attributable to risk factors like smoking or obesity. Racism directly contributes to health problems that can affect pregnancy outcomes, and racial bias by health-care workers adds another layer of increased danger. Dr. Callaghan puts it bluntly: “African Americans don’t get the same level of care that white women do.”
For anyone choosing a maternity hospital, the CDPH recommends going as far as speaking up and questioning hospital personnel about how prepared they are for these types of emergencies.
Until efforts like those going on in California become the norm, “Women are encouraged to be their own health advocates,” the CDPH spokesperson said. “Inquire about the hospital’s ability to address their risk factors that could lead to adverse outcomes.”
For instance, don’t hesitate to reach out to different hospitals to ask whether an anesthesiologist, obstetrician, and neonatologist will be available to you 24/7. And don’t let doctors brush off your concerns as a case of paranoid pregnant person.
Another good question to ask is whether the hospital participates in its state's perinatal quality collaborative (PQC), the CDPH spokesperson noted in an email. These are state or multi-state networks of teams that work to improve the quality of care for mothers and babies, as the CDC explains. A hospital’s participation “indicates an ongoing commitment to quality and safety efforts,” the spokesperson continued.
It may be embarrassing to ask these questions, or seem scary to plan for the worst, but it might just save your life.