Q & A Maternity and Birthing

How California Reduced Its Maternal Deaths: A Q&A With Dr. Elliott Main

Tanya H. Lee

The Golden State focused on common serious complications—hemorrhage and preeclampsia—and adapted its care and monitoring.

Rates of serious complications such as hemorrhage and preeclampsia, a condition defined by high blood pressure and organ damage during pregnancy, are high among U.S. women. In 2013, Black women in this country were only slightly less likely to die during childbirth than women in Syria. And, at 28 deaths per 100,000 live births, the U.S. maternal death rate is the highest in the developed world.

And it’s only increasing in virtually all states and the District of Columbia. The one exception is California, where the state cut its maternal fatality rate almost by half between 2008 and 2013.

Most of that reduction can be attributed to the work of the California Maternal Quality Care Collaborative (CMQCC) and its many partners. Dr. Elliott Main, CMQCC’s medical director, talked with Rewire about what his state has been doing to save lives and what challenges remain. Main is an OB-GYN who serves on the faculties of Stanford University and the University of California at San Francisco.

Rewire: How do you measure maternal mortality?

Dr. Elliott Main: There’s not a straightforward answer. You may think it is easy to count maternal deaths. But it’s surprisingly hard, not because defining death is hard but because defining whether it was related to pregnancy is hard. It’s sort of obvious if you die in labor and delivery from hemorrhage. But if you have a complication in pregnancy like preeclampsia, you can have a stroke and be in the intensive care unit (ICU) for a couple of weeks before you die. Then the death certificate’s not filled out by an obstetrician but by an ICU professional who focuses on the stroke and not the preeclampsia that led to the stroke.

In the United States, we knew we were missing a bunch of [pregnancy-related deaths in statistical reports], so the U.S. added a pregnancy check box on death certificates [that states may or may not use]. It asks if the woman was pregnant or within 42 days of birth and if the woman was pregnant within a year of the time of death. Those are not easy questions. The coroner may not have all of the clinical information, or an early pregnancy may not be disclosed.

We don’t really know what the true rates are until we do linkage and case review, which is what maternal mortality review committees do at the state level. You ask how many women have died during pregnancy or 42 days of childbirth or within a year, and then you try to determine whether [the death] was related to the pregnancy.

Even now, we don’t know the exact numbers for maternal mortality, but they are clearly higher than they should be and the rate clearly has risen.

Rewire: Why has the U.S. maternal death rate been rising?

EM: We know that the current pregnant population is different than it was 20 years ago. Women tend to be older during the pregnancy, heavier, and have more underlying health conditions, such as heart disease, diabetes, and hypertension. And perhaps they’re not as physically fit. But none of those per se should cause death. It just means that you have to be more on your A game as an obstetrician caring for women with risk factors.

Interventions, things like induction of labor and [cesarean sections], have also risen during this period. A third of women are having a C-section now. A C-section is a pretty safe procedure, but it’s still major surgery. And if you do something hundreds of thousands of times, even a low rate of major complications will bite you sooner or later.

The biggest complication of a C-section is the potential risk during your next delivery. Those rates are low, but they are real. Earlier this year, there was a famous case in Los Angeles in August where [TV host] Judge Glenda Hatchett’s daughter-in-law, a very healthy young woman who had an uncomplicated pregnancy, went in for a repeat C-section, suffered a major hemorrhage, and died.

Another story was also reported in August where a healthy young woman undergoing a repeat C-section had a major hemorrhage and nearly died. As is not uncommon when major hemorrhages or serious complications occur in childbirth, she had pretty significant post-traumatic stress disorder (PTSD).

That’s actually an interesting unwritten story: the high rate of PTSD after major pregnancy complications. Some estimates indicate the PTSD rate after a major complication or near-miss is as high in pregnant women as it is in soldiers returning from Afghanistan and Iraq.

Rewire: What steps has California taken to reduce maternal mortality?

EM: We’ve developed safety protocols for hemorrhage and preeclampsia after studies showed that nationwide these are the most common causes of maternal mortality [along with heart disease]—and the most preventable. These detail structured, organized team responses to emergencies so they don’t skid out of control.

That really did not exist before. Everybody went about it their own way, so no one could train people because there were so many different ways of dealing with emergencies. We have some new advances, but the most important is having a team response and having an organized plan. [So far, four-fifths of California’s birthing hospitals have adopted the safety bundles.] Now we’re working on preventing first birth C-sections.

Rewire: It seems the interventions you focus on all take place in the hospital during the birth, rather than on prenatal or postnatal care?

EM: The cause of death determines where you have to go to make improvements. For hemorrhage and preeclampsia, the causes of death are hospital-centered. It’s about bleeding to death at the time of delivery of the placenta or about not treating severe hypertension that presented in the hospital.

For other projects, it’s going to be outpatient services. We’re now working on a project addressing opioid use disorder among pregnant women. It’s a significant cause in some states of deaths during pregnancy or postpartum.

Rewire: Aside from an obvious moral imperative, one way to convince people to implement interventions is that they save money. Do you have a cost-benefit analysis for your work?

EM: It’s a simple fact: If you die, you don’t cost the system as much. So you have to look at maternal morbidity or injury: How many days are you spending in the ICU and so forth? ICUs are hugely expensive.

For maternal morbidity, there are studies indicating that hemorrhage costs our Medicaid system, Medi-Cal in California, over $100 million every year. And [gestational] hypertensive disorders cost about $110 million in 2011. You can’t save all of that, but even if you saved 10 percent or 20 percent, that’s a pretty big deal.

For opioid use, you have neonatal abstinence syndrome [a treatable condition experienced by some infants exposed to drugs in utero]. Affected babies of mothers on opioids can spend 20 to 30 days in the NICU.

So there is real money to be saved, not so much in [preventing] maternal deaths but looking at the whole picture of maternal morbidity that didn’t result in death. And there’s the fact that right now we’re 49th on maternal mortality. So we look at it as the canary in the mineshaft telling us that there’s a problem in maternity care.

Rewire: Do you still see a disparity in California between deaths of Black mothers and other mothers?

EM: Nationally the maternal mortality ratio for Black women is three to four times higher than for whites. It has the greatest disparity of any public health measure. We worry about infant mortality or prematurity rates that are one and a half to two times higher for Blacks. That’s a big deal. This is three to four times higher. It’s a really big deal. You don’t see higher disparities anywhere else.

The good news is that after we’ve done our projects in California, we’ve reduced Black maternal mortality by half. The bad news is that we still have a threefold disparity because we’ve reduced the rate for whites by half. We still have a ways to go in terms of reducing the difference between whites and Blacks. It is interesting to note that Latino women in California actually do almost as well as whites.

Rewire: What do you see as the major challenges in getting the rate for Black women down even further?

EM: Part of it is the level of care and resources at the hospitals where Black women deliver. Part of it is underlying medical conditions, but a lot of it is how women are treated. Black women are treated differently than white women. It is really clear that if you’re an African-American women delivering in a low-resourced facility that’s not focused on emergency care in obstetrics, you have a higher rate of issues.

You find low-resourced facilities in poor areas and in rural areas, though most rural hospitals do a fairly good job of triaging, so I can’t say that the rise in the maternal mortality rate is due to a lot of small, rural hospitals. We have a lot of those, but that’s not where the deaths are occurring.

Rewire: What it is that makes California different?

EM: I think we had a forward-looking department of public health, and we had a group of providers—doctors and nurses and midwives—who wanted to take the analysis of the data and turn it into quality improvement projects. And then it’s been all about partnering with everyone we can find. This is our role at CMQCC, to partner with our state department of public health, our hospital association, our Medicaid agency, professional organizations, to get everybody thinking along the same lines. We also have a very good data system in California, we give hospitals a lot of feedback on how they’re doing in regard to maternal morbidity and mortality in a rapid cycle way, not waiting two or three years for results, but just months. So far, 200 of our 240 hospitals where babies are delivered are using our protocols.

This interview was lightly edited for length and clarity.

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