Dr. Boufford is the President of the New York Academy of Medicine and Chair of the State of New York Public Health and Health Planning Council and Peter Schafer is Deputy Director for Family Health and Disparities in the Academy’s Center for Health Policy and Programs
Maternal mortality–the death of a mother during childbirth or soon after labor and delivery–is thought by most people to be a thing of the past. Or something that occurs in only the poorest countries of the world where basic health care services are absent. The reality is that here in the United States, where we have both wealth and the world’s most advanced medical resources, women still regularly lose their lives after childbirth—we rank 50th in the world in preventing maternal mortality.
Here in New York, things are no better. Our state is almost at the bottom of the national list (47th out of 50 states) in preventing maternal deaths and disparities among women are huge. In our city, black women are 12 times more likely to die within a year of childbirth than white women and the gap is widening. The rate was seven times more likely in 2005. Asian women are also three times more likely to experience maternal mortality than white women.
The Power of Prevention
Current prevention efforts emphasize managing hospital procedures that manage post-delivery complications that sometimes end in maternal death. When it comes to protecting maternal health, that’s often too late in the game to intervene. We need to treat the chronic conditions that elevate risk, before a woman becomes pregnant, by developing primary prevention strategies that can yield substantial benefits.
Obesity, pre-existing chronic conditions (commonly hypertension, asthma, and heart disease) and older age all contribute to maternal mortality. Helping women plan a healthy pregnancy—especially if they are older than 35 or have a chronic health problem—is an important place to begin.
In New York State, 56 percent of all pregnancies are unintended, women who live below or just 200 percent above the poverty level ($11,770 annual income) are also more likely to have an unplanned or mistimed (by two or more years) pregnancy. Nationally, 20 percent of white women, 35 percent of Hispanic women and 45 percent of black women report mistimed pregnancies, according to the National Center for Health Statistics. But it is possible to give women more control over their reproductive choices.
Community-focused initiatives such as a program formerly run in Baltimore are part of the solution.
In a program [conducted by Schafer and colleagues] designed and implemented in an economically distressed black community, there was a sharp increase in short ( less than 12 month) intervals between pregnancies among program clients. The women explained that although they did not want more children, their contraception was not effective.
They also were not taking advantage of their postpartum physician visits. Significantly, while more than 90 percent of the new mothers in the program took their babies to well-child visits, less than 25 percent of the women went to their routine doctor’s visit. The program’s staff responded by bringing family planning education, counseling and contraceptives directly to the women through nurse practitioner home visits and community health worker follow-up visits. This initiative was extremely effective in reducing short-interval pregnancies. The rate dropped from 20.2 percent to 12.8 percent for program participants.
Protecting Mothers in New York
The State of New York’s Prevention Agenda goal is to reduce overall maternal mortality by 10 percent and racial and ethnic disparities in maternal mortality by 10 percent by 2018. To advance this objective, the New York State Public Health Committee (PHC) reviewed and adopted a New York State Department of Health report on maternal mortality (available here) that makes recommendations to reduce maternal mortality. The report focuses on pre-hospital strategies, specifically:
- Integration of preconception and interconception care in routine outpatient care for women of reproductive age (including mothers at pediatric well-child visits), that involves asking women basic questions to assess their desire for pregnancy, and, if appropriate, helping to initiate contraception.
- A special focus on family planning for women with chronic conditions and other risk factors, with an emphasis on the Health Home program of care engagement and management to Medicaid beneficiaries with multiple chronic conditions.
- Instituting systems and protocols for early identification and management of high-risk pregnancies.
The benefits of reducing high-risk, unintended pregnancies go beyond the critical need to reduce maternal mortality. Many near-miss situations where women survive, but suffer serious and costly complications in labor and delivery can also be prevented. Talking to women about near-miss experiences could lead to increased awareness of the circumstances that cause maternal deaths.
The solutions we are now exploring in New York State and through our work at the Academy will greatly aid the design of interventions that may lead to model practices that will make unconscionable rates of maternal mortality a thing of the past in the U.S. and around the world.
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