Last week, to little fanfare, the Agency for Healthcare Research and Quality (AHRQ) released a shocking report on the state of women’s health as it pertains to complications and adverse events while giving birth in hospitals. Although it hasn’t gotten the media attention it deserves, the results have stirred frantic conversations in labor and delivery units throughout the U.S. “The rate of severe maternal morbidity at delivery—as defined by 21 conditions and procedures—increased 45% from 2006 through 2015, from 101 to 147 per 10,000 delivery hospitalizations,” the brief concluded. It went on to note that there are continued and worrisome disparities for women as well, saying that, “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 reporting metrics during that time, and preceding a late-2015 change to coding. The purpose was for the federal agency to investigate maternal morbidity (incidence of ill health or disease) and mortality (incidence of death), while also identifying areas of particular concern. And they certainly found some troubling trends in safety, consistency and overall population health.
For example, at a high-level the rate of severe complications increased from 101 per 10,000 delivery hospitalizations in 2006 to 147 per 10,000 in 2015 (45% overall increase). And over the decade, there were several life-threatening conditions that more than doubled, including rates of sepsis at delivery, acute renal failure, and shock. Further, of those deliveries involving shock, 1/3 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). And 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.
On average, Black mothers were younger than White mothers. But the rate of severe maternal morbidity was between 112-115% higher for Blacks than for Whites in 2006 (164 vs. 76) and in 2015 (241 vs. 114). Further, while deaths did decrease for all races/ethnicities, in-hospital mortality was 3X higher for Black women than for White women in 2015 (11 vs. 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 Asian/Pacific Islanders also had higher rates of severe maternal morbidity than Whites in both years, but comparative disparities decreased over time.
Of special interest to AHRQ was the distribution in hospital performance outcomes as they pertain to labor and delivery. When examining deliveries that did and did not involve severe maternal morbidity, those that did were more likely to occur at hospitals that typically serve poorer communities. Particularly, hospitals that have a mission to serve vulnerable populations (44% vs. 35%), minority-serving (53% vs. 44%), teaching (71% vs. 67%), and public (16% vs.12%) hospitals. Thus, it is no surprise that in 2015, rates of severe maternal morbidity were highest among mothers who were considered poor, those who were uninsured, or 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. However geographic differences were present. During the decade, worse outcomes were more likely to occur at hospitals located in the Northeast (18% vs. 16%) and the South (44% vs. 40%) than at hospitals in the Midwest (17% vs. 21%) and the West (21% vs. 23%). 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 those over 40 who have greater severe morbidity. Additionally, pre-existing medical conditions throughout the population have increased, 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.
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 for based on best practices 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 potentially 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 taking immediate action to increase individual efforts for protecting 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. As well as incentivize and encourage good decision-making about their lives and bodies long before they are in labor. There are also efforts that can be undertaken to hold hospitals more accountable for their outcomes as we attempt to shift to a value-based system of health care.
Health Policy, Human Rights, Big Ideas. Strategic Vision.