In August, Health Affairs published a study highlighting an alarming fact in maternal health: The incidence of childbirth complications varies significantly from hospital to hospital across the United States. The study – led by Laurent Glance and colleagues at the University of Rochester – found that “women delivering vaginally at a low-performing hospital had twice the rate of any major complications than women delivering vaginally at a high-performing hospital.” The difference in these complication rates for cesareans was five-fold.
It is well known that variation in care contributes to higher rates of mortality and morbidity in all areas of health care, explaining the push toward checklists and other quality improvement tools and interdisciplinary collaboration. Identifying the primary reasons for variation in obstetric complication rates – why women giving birth in high-performing hospitals have lower complications rates – could be critical to understanding the reasons behind the increasing rates of maternal mortality and morbidity in the U.S. This study, along with other disturbing statistics, underscores the significant need for improvements in maternity care.
Maternal Morbidity and Disparities
Since 1990, the maternal mortality ratio in the U.S. has more than doubled. We now rank 64th in the world, with 28 maternal deaths per 100,000 live births. American women are also suffering severe maternal morbidities at higher rates: more than 60,000 women a year experience a life-threatening condition during childbirth. Potential explanations for these troubling trends include improved reporting mechanisms and escalating rates of chronic health conditions like obesity, diabetes, and hypertension among childbearing women, which increase the likelihood of complications. However, a lack of standardized care is considered to be a major contributing factor to worsening maternal health outcomes.
Inconsistent care likely contributes to racial disparities in maternal health outcomes as well. As the U.S. Department of Health and Human Services reports, while all pregnant women share the same baseline risk of developing childbirth complications, black women are three to four times more likely to die from pregnancy- or childbirth-related complications than white women (even when income and education level are equivalent).
Improving Quality Obstetric Care
Eliminating variability is key to improving quality obstetric care for all women – a point that Katy Kozhimannil recently acknowledged on Health Affairs Blog. As Glance et al. note, the differences in childbirth complications were likely “the result of differences in clinical performance,” as opposed to other factors like hospital teaching status, cesarean rates, and hospital case-mix. A consistent approach to managing labor and obstetric emergencies can be an important step toward reducing disparities in outcomes.
Put simply, wide-ranging levels of care are perpetuating inconsistent and – too often – poor maternal health outcomes. There are standards of care that show the practices that lead to the best outcomes. However, simply knowing those practices deemed most effective does not always result in all women receiving high standards of care, especially during an emergency when standardization has lifesaving benefits (e.g., the well-established protocols used to manage a heart attack and stroke).
More work is needed to ensure that the 4 million women who give birth each year in the U.S. receive high-quality obstetric care regardless of where they seek it.
A National Movement
One promising effort currently underway is the national movement to standardize how hospitals manage the three leading causes of maternal death: obstetric hemorrhage, embolism, and hypertension.
Merck, through its Merck for Mothers initiative, is providing funding for programs being undertaken by three organizations – the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN); the American Congress of Obstetricians and Gynecologists (ACOG) District II; and the California Maternal Quality Care Collaborative (CMQCC) – to implement standard approaches for addressing obstetric emergencies over the next two years. The goal of these programs is to improve the abilities of nurses, physicians, and midwives to quickly recognize childbirth complications and respond to these emergencies with evidence-based care. The programs focus on the leading causes of maternal death in five geographies (California, Georgia, New Jersey, New York, and Washington, D.C.) – regions with some of the highest maternal mortality rates in the country.
To analyze the incidence of complications, the Glance et al. study relied on claims data, which do not always tell the full story, as ACOG recently pointed out. As part of ensuring evidence and data inform practice, AWHONN, ACOG II, and CMQCC are looking to other data sets, including clinical data from electronic medical records and linked databases. Lessons from these efforts may help the field understand population profiles and how complications occurred so providers can learn how better to prevent similar cases of mortality and morbidity in the future.
This month’s study revealed upsetting news about the state of childbirth in the U.S.: a pregnant woman who delivers in one hospital might receive different care – and experience a different outcome – than a woman who gives birth in another hospital. I believe every woman has a right to a safe and healthy pregnancy and childbirth no matter where she gives birth.
If we are committed to reversing the disturbing trends in maternal mortality and morbidity in the U.S., our country’s hospital and public health leaders must step up their efforts to standardize the care nurses, physicians, and midwives provide when managing obstetric emergencies. Only then will we make progress in improving quality care and overcoming disparities in maternal health outcomes.