Last week, to little fanfare, the Agency for Healthcare Research and Quality (AHRQ) released a shocking report on complications and adverse events for hospital births. Although it hasn’t gotten the media attention it deserves, the results have stirred frantic conversations in labor and delivery units throughout the United States.
“The rate of severe maternal morbidity at delivery—as defined by 21 conditions and procedures—increased 45 percent from 2006 through 2015, from 101 to 147 per 10,000 delivery hospitalizations,” the brief concluded. “Severe maternal morbidity” means unexpected complications during delivery that affect a mother significantly afterward. The brief also noted continued and worrisome disparities in pregnancy and birth complications: “in-hospital mortality was 3 times higher for Blacks than Whites in 2015.”
AHRQ used data from its Healthcare Cost and Utilization Project (HCUP) for the decade leading up to 2016 due to the consistency of data before a late-2015 change to coding. The purpose was for the federal agency to investigate maternal morbidity (ill health or disease) and mortality (death), identifying areas of particular concern. They certainly found some troubling trends in safety, consistency, and overall population health.
Let’s Break Down Some More Findings
For example, over the decade several life-threatening conditions more than doubled, including rates of infection at delivery, acute kidney failure, and shock. Further, of those deliveries involving shock, one-third also involved having a hysterectomy.
As for age differences, severe maternal morbidity was highest among women 40 years and older (248 per 10,000 deliveries). It was lowest for those aged 20-29 years (136 per 10,000 deliveries). Interestingly, those under the age of 20 also saw more complications than their 20-29-year-old peers did when delivering babies.
On average, black mothers were younger than white mothers, but the rate of severe maternal morbidity was between 112-115 percent higher for blacks than for whites in 2006 (164 versus 76) and in 2015 (241 versus 114). Further, while deaths did decrease for all races and ethnicities, in-hospital deaths were three times higher for black women than for white women in 2015 (11 versus 4 per 100,000 deliveries).
This highlights that there has been no change in black-white disparities over the decade and suggests that age is only a part of the equation. As comparison, Hispanics and Asians/Pacific Islanders also had higher rates of severe maternal morbidity than whites in both years, but their comparative disparities decreased over time.
Poor, Medicaid, and Urban Moms Do Worst
Deliveries that involved severe maternal morbidity were more likely to occur at hospitals that typically serve poorer communities. Particularly, hospitals that have a mission to serve vulnerable populations (44 percent vs. 35 percent), minority-serving (53 percent vs. 44 percent), teaching (71 percent vs. 67 percent), and public (16 percent vs.12 percent) hospitals. Thus, it is no surprise that in 2015, rates of severe maternal morbidity were highest among mothers who were considered poor, were uninsured, or were on Medicaid.
It was also shown that women who lived in large urban areas were more likely to experience severe maternal morbidity during hospital deliveries. But there were geographic differences in this outcome. During the decade, worse outcomes were more likely to occur at hospitals located in the Northeast (18 percent vs. 16 percent) and the South (44 percent vs. 40 percent) than at hospitals in the Midwest (17 percent vs. 21 percent) and the West (21 percent vs. 23 percent). But patient demographics, incomes, and access to hospitals may have more of an impact than the location of the hospital itself.
In fact, the Centers for Disease Control and Prevention (CDC) suggests that increased complications during labor and delivery are due to overall shifts in the U.S. population. For instance, increases in maternal age have contributed to more births in women older than 40, who have greater severe morbidity.
Additionally, pre-existing medical conditions have increased among Americans, many of which are related to pre-pregnancy obesity. Thus, there are certainly a number of underlying and confounding factors associated with maternal morbidity and mortality.
But It’s Not All Explained by Poor Health and Age
Nevertheless, all the demographic shifts cannot account for the disturbing statistics AHRQ found in rates of hospital infection or major complications. In an effort to help hospitals reduce the occurrence of severe maternal morbidity, AHRQ developed the Safety Program for Perinatal Care, a set of recommendations from other agency programs and training systems. The aim is to improve communication between hospital staff, and therefore overall quality of care in labor and delivery units.
While the hospital recommendations do not specifically address how community-level factors increase pregnancy-related complications that lead to morbidity and mortality, like cardiovascular disease and mental health issues, they may help shape what kinds of measures hospitals take to predict and prevent such complications.
With these data in hand, state and federal agencies, patient safety experts, and health systems should evaluate maternal morbidity trends in greater depth, then commit to immediately working to improve delivery care for mothers and children.
Lastly, an important takeaway for communities, states, and policymakers in particular, is that we cannot be concerned about maternal morbidity and mortality only during pregnancy. There is a much more that can be done to educate all women of reproductive age about the benefits and risks of certain behaviors, such as smoking, overeating, and lack of exercise.
We can also incentivize and encourage women to make good decisions about their lives and bodies long before they are in labor. We should also hold hospitals more accountable for their outcomes.