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The World Confronts Maternal Mortality

Dr. Sigounas welcomed visitors from five countries, saying they  "offer a range of experiences whose approaches may potentially be replicable, scalable or applied to national contexts at the regional or even global level."
HRSA Administrator Dr. George Sigounas welcomed visitors from six countries on Tuesday for HRSA's International Maternal Mortality Summit, saying they "offer a range of experiences whose approaches may potentially be replicable, scalable or applied to national contextsat the regional or even global level."

"For every maternal death, there are nearly 100 pregnant women who have suffered from a traumatic event or near-death experience in childbirth ... Maternal mortality and morbidity are serious concerns in the United States and around the world ...We can do more to prevent this loss of life and illness." - George Sigounas, MS, Ph.D., HRSA Administrator

 

Dr. Doris Chou of the World Health Organization said maternal deaths are undercounted around the globe -- even in countries with model maternal health programs. She spoke during Day One of HRSA's International Maternal Mortality Summit
Dr. Doris Chou of the World Health Organization said maternal deaths are undercounted around the globe -- even in countries with model maternal health programs. She spoke during Day One of the summit.

 

Maternal mortality rates in the United States have tripled over the past 25 years. They're highest among minority moms -- in the U.S., as in most developed countries. And women today are more likely to die following childbirth than their mothers were, often of complications from treatable conditions like preeclampsia that go undetected, misdiagnosed or ignored.

Each year, about 700 women die of pregnancy-related causes in the U.S., the CDC reports. Notwithstanding advances in medicine and medical technologies, pregnancy-related morbidity in the United States continues to affect 50,000 women. Yet, 60 percent of deaths are preventable.

"Something is very wrong with that picture," U.S. Surgeon General, VADM Jerome Adams, told a standing-room audience on Tuesday, at the start of a three-day symposium on the most sensitive of topics. Sponsored by HRSA's Office of Global Health, the conference drew maternal health authorities from Brazil, Canada, Finland, India, Rwanda and the United Kingdom.

From left to right: Laura Kavanagh, Acting Associate Administrator, HRSA Bureau of Maternal and Child Health;  VADM Jerome Adams, M.D., U.S. Surgeon General; Dr. Bill Callaghan, Chief of the Maternal and Infant Health Branch in the CDC Division of Reproductive Health
From left to right: Laura Kavanagh, Acting Associate Administrator, HRSA Bureau of Maternal and Child Health; VADM Jerome Adams, M.D., U.S. Surgeon General; Dr. Bill Callaghan, Chief of the Maternal and Infant Health Branch in the CDC Division of Reproductive Health.

 

All six countries are notable for low maternal mortality, or success in lowering high rates.

All had remarkably similar stories to tell about the difficulties of serving rural areas; the under-utilization of nurse-midwives to deliver more consistent care over the course of pregnancy;  and the problem of bridging cultural and communications gaps, not only among recent immigrant populations, but also with their socially,  geographically and economically isolated countrymen and women.

"We must consider the ripple effect" on families and the communities, the Surgeon General added -- as both infant and child mortality are higher among families that have "lost a mom during birth."

Dr. Monica Neri said Brazilian health  authorities have faced an especially chal- lenging task in convincing local clinicians to move away from established practices that run counter to global standards.

The meeting "is one effort to shine a light on factors that contribute to the risk of a difficult pregnancy," said MCHB Acting Administrator Laura Kavanagh, "to improve access to care that is early, appropriate, and effective; to ensure that deliveries are successful and complications are addressed skillfully; and to inform and educate providers and mothers on risks, warning signs, and continuing care."

One in four pregnancy-related deaths are linked to heart conditions. Women also fall ill to infections (including flu), blood clots, high blood pressure and depression. Some are at higher risk than others, and they tend to be women of color -- whether it's a new Syrian immigrant in Finland, or a villager in Brazil, or an African-American mother-to-be in the U.S., where the risks are 3 to 4 times higher than for non-Hispanic white women.

Other common complications arise from caesarian sections, which are increasing in places like Brazil to the point of "banality," as is the use of opioid painkillers during labor, reported Dr. Monica Neri of the Brazilian Ministry of Health.

Dr. William Callaghan of the CDC added that a lack of uniformity nationwide has led to underreporting on causation in maternal death certificates -- limiting the evidence base on the root causes of maternal mortality, both locally and globally, though many are widely understood.

His comment would become a common thread through much of the day, as overseas experts cited outmoded reporting and record keeping at the state, district or provincial level as a major research, administrative and logistical impediment.

"People really want to know," said Dr. Chou of WHO, "what is the number?"

The current best estimate is that more than 800 women die each day worldwide from complications of pregnancy. But so pervasive is the problem of underreporting that183 member states of WHO have requested formal evaluations of their national systems.

(Left to right) Arja Ruponen, Ministerial Health Advisor, Finland; Dr. Dinesh Baswal, Deputy Commissioner, Ministry of Health & Family Welfare, India; and Dr. Heather Scott, Dalhousie University,  Professor of Obstetrics and Gynecology, Nova Scotia, field questions from Dr. Doris Chou, WHO.
(Left to right) Arja Ruponen, Ministerial Health Advisor, Finland; Dr. Dinesh Baswal, Deputy Commissioner, Ministry of Health & Family Welfare, India; and Dr. Heather Scott, Dalhousie University,  Professor of Obstetrics and Gynecology, Nova Scotia, field questions from Dr. Doris Chou, WHO. Conferees seemed to agree that the global standard, 42-day period after a woman gives birth -- which typically marks the end of a pregnancy for reporting purposes and maternal services -- is too short to include postpartum conditions that can strike long after delivery, sometimes fatally.

 

In Canada, reported Dr. Heather Scott, provincial authorities "have no responsibility to report these numbers to the national government," and at least one province has opted out of reporting maternal deaths altogether.

Marian Knight

Marian Knight of Oxford University described the U.K.'s "Anonymous Inquiry" system, in which teams of discrete investigators go over cases of maternal fatality in fine detail, collecting health records, behavioral health in-take reports, evidence of domestic violence or substance misuse,  or an underlying health condition or family propensity. The investigators then "anonymize" their findings for inclusion in a national database that is considered a world model.

Such cases are "sentinel events," she explained, and key to understanding the health of local populations and zeroing in on at-risk communities.

Another promising practice in the U.K. is assigning midwives to eligible mothers-to-be for the duration of their pregnancies, to ensure continuity of care and the safe arrival of their babies, Knight said. "All of our complications can be prevented at some point in the cycle -- pre-pregnancy, during pregnancy, during delivery or after pregnancy."

Among efforts in the U.S., Dr. Sigounas cited HRSA's Maternal and Child Health Title V Block Grant Program, and three initiatives in particular – the Healthy Start and Home Visiting programs, and the Alliance for Innovation on Maternal Health and Safety.  HRSA-supported Health Centers also serve some 8 million children and their mothers annually, at a time when proximity to skilled care is a mounting global concern, often due to workforce shortages. Most health centers are now certified, Patient-Centered, Medical Homes.

Date Last Reviewed:  June 2018