CDC Telebriefing: Pregnancy-Related Deaths Happen Before, During, and Up to a Year After Delivery

Operator: Thank you for standing by.  The call will start in approximately one more minute.  Again, thank you for standing by.

Welcome and thank you for standing by.  At this time, all participants are in a listen-only mode.  During the question and answer session, please press star 1.  Today’s conference is being recorded.  If you have any objections, you may disconnect at this time.  Now I would like to turn the meeting over to Kathy.  Thank you, you may begin.

Kathy Harben:  Thank you, Diane.  Thank you all for joining us today for the release of a new CDC vital signs.  This has the latest data on pregnancy-related deaths.  We’re joined today by the Principle Deputy Director, Dr. Ann Schuchat, and also by Rear Admiral Dr. Wanda Barfield.  She is the director of CDC’s Division of Reproductive Health, and she is also an Assistant Surgeon General in the U.S. Public Health Service.  Dr. Schuchat and Barfield will stay on for the Q&A session.  During the Q&A, we’ll also be joined by Dr. Emily Peterson.  She is a medical officer in the Division of Reproductive Health, lead of CDC’s Pregnancy Mortality Surveillance System, and also the lead author of the Vital Signs article.  I’ll now turn the call over to Dr. Schuchat.

Dr. Schuchat: Good afternoon and thank you for joining us today. CDC works 24/7 to protect Americans against health threats. Each month in CDC’s Vital Signs report, we focus on one of these threats – and what can be done about it.

Today’s report contains a new perspective on the issue of pregnancy-related death in our country. That is the death of a woman during pregnancy, at delivery and even up to a year afterward from a pregnancy complication, which is a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.  Tragically, nearly 700 women still die each year of complications of pregnancy in the United States. These are women in their prime, who leave loved ones behind-often stunned with what has happened.

Today’s Vital Signs brings us new insight into key opportunities to make these tragic occurrences as rare as possible, through a variety of prevention strategies that we hope can make an impact.

So, here’s the big picture of what we report learned in this Vital Signs-

Nearly a third (31%) of pregnancy-related deaths happen during pregnancy, just over a third (36%) happen during delivery or the week after, and exactly a third (33%) happen one week to one year after delivery. The leading causes of death differ when women die during pregnancy vs. thereafter.  Heart disease and stroke caused more than 1 in 3 deaths overall. Obstetric emergencies, like severe bleeding and amniotic fluid embolism (which is, when amniotic fluid enters a mother’s bloodstream), caused most deaths at the time of delivery. In the week after delivery, severe bleeding, high blood pressure, and infection were most common.  Cardiomyopathy (or weakened heart muscle) caused the largest portion of deaths in the time period six weeks to 1 year after delivery. Our most recent data confirm persistent racial disparities. From 2011-2015, black and American Indian/Alaska Native women were about three times as likely to die from a pregnancy-related cause as white women.  Alarmingly, states Mortality Review Committees found that about 3 in 5 pregnancy-related deaths could potentially be prevented. Our new analysis of these data found that the proportion of these deaths that are preventable didn’t differ by race/ethnicity.

Preventing pregnancy-related deaths need actions from states and communities in which pregnant and postpartum women live, as well as the healthcare providers, facilities and systems that serve them.

There are big-picture systems-level changes we can help ensure all pregnant women receive high quality care during pregnancy, at delivery, and up to a year afterward. Two examples are standardizing response to obstetric emergencies and making it easier for women to receive the prenatal and postpartum care that they need. There are some basic tenants of quality care – like detecting and managing chronic conditions before, during, and after pregnancy and having open, ongoing conversations with women about warning signs and acting quickly to address them.

Making some of these improvements will not be easy. It could require reworking systems that have been in place for years. The good news, though, is that there are already systematic approaches being developed and implemented in many areas around the country that can be used as a model to support improvements to save the lives of women.

The bottom line is that too many women are dying largely from preventable deaths associated with their pregnancies.  We have the means to close gaps in the care they receive. We can’t prevent every one of these tragedies, but we can and should do more.

Now, I’m going to turn it over to Dr. Wanda Barfield, who will share specific findings of today’s report.

Dr. Barfield: Thank you, Dr. Schuchat.

In this Vital Signs, CDC analyzed two data sources to get both a quantitative and a qualitative perspective on this issue and potential solutions. First, for the quantitative piece, we examined 2011-2015 national data from CDC’s Pregnancy Mortality Surveillance System, or PMSS.  Then, for the qualitative picture, we turned to detailed data on pregnancy-related deaths from 2013-2017 from 13 State Maternal Mortality Review Committees.

I’d like to stop here and briefly explain what these Maternal Mortality Review Committees, or MMRCs, as we call them, are. MMRCs are multidisciplinary groups of experts at the state or local level that review maternal deaths –  and the circumstances around them – to better understand how to prevent future deaths. These committees examine all available data sources, including medical records and social services records, to determine the factors that contributed to the death, determine preventability, and suggest specific prevention strategies. This is a critical level of information we cannot get from reviewing just death certificates alone, and this is why MMRCs are so important to our understanding of this issue.  Analysis of data from the MMRCs found that, as Dr. Schuchat mentioned, 3 in 5 deaths were preventable and that each was the result of several missed opportunities along the way. The MMRCs highlighted specific suggestions of promising prevention strategies to address contributing factors at the healthcare provider, facility and system levels, as well as at the patient and community levels. For instance. At the healthcare facility and systems levels, strategies included – standardizing response to obstetric emergencies as a way to make sure women receive recommended care when hemorrhaging or experiencing infection. Also, developing policies to ensure high-risk women are delivered at hospitals with specialized healthcare providers and equipment, a concept we refer to as “risk-appropriate care.” And third, encouraging cross-communication and collaboration among providers. At the state and community levels, MMRCs suggested – addressing social determinants of health, including providing access to housing and transportation were important issues. Also, addressing delivery hospitals for risk-appropriate care. At the healthcare provider level, strategies included helping patients manage chronic conditions, communicating about warning signs, and using tools to flag warning signs early. At the patient and family level, the MMRCs underscored the value in knowing and communicating about warning symptoms of complications.

So, we have a lot of opportunity for improvement and preventing maternal deaths. This is something we at CDC are deeply committed to.  As we’ve discussed throughout this briefing, we are continuing to work on surveillance and data analysis to monitor this issue at the national level. But, we are also supporting state and local efforts. We provide technical assistance and resources to MMRCs, so that they can effectively review maternal deaths and make valuable prevention recommendations. We’re very excited that this fall, through the Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees funding opportunity, we will provide up to as many as 25 MMRCs across the country to collect robust, accurate data that can inform data-driven actions and eliminate preventable maternal deaths. We already fund the efforts of 13 state perinatal quality collaboratives. These are state-based initiatives that aim to improve the quality of care that mothers and their babies receive. These groups play a critical role in translating the information coming from MMRCs into quality, standardized care. We talked a little bit earlier about “risk-appropriate care.” To help states standardize their assessment of delivery hospitals for the level of maternal and newborn care that they provide, CDC offers the CDC Levels of Care Assessment Tool (also known as LOCATe) and provides technical assistance to those who want to use it.

And, finally, through this work, the work Vital Signs, we are working to educate the public about pregnancy-related death and how to prevent it. This is a very complex issue. The factors that contribute to maternal deaths are as diverse as the women themselves. So, our prevention efforts must be as diverse. There is a role here for everyone to play. Now, I’ll turn back to our moderator, Kathy Harben.

Kathy Harben:  Thank you.  Diane, we’re now ready for questions.

Operation: Thank you.  We will now begin the question and answer session.

If you would like to ask a question, please press star 1.  You’ll be prompted to record your name, to withdraw your question, please press star 2.  One moment please to see we have any questions or comments.

Susan, WABD Radio, your line is now open.

WABE Radio: Hello.  Thank you for taking my question.  I’m calling from Georgia, so my question is basically first are we still number one on the list with the worst maternal death rate, and also lack of Ob/Gyns in rural areas.  Is that something you guys would consider as one of those causes?  Thank you.

Dr. Barfield: Yes, thank you for the question.  So the challenge we have in maternal mortality is that numbers have not declined, and we compared to other developed countries as relatively poor in our maternal mortality rate.  So your point is well taken in that we have a lot we need to do to improve maternal mortality in the United States.  In terms of your other question about Georgia in particular, there are many other parts of the country as well as Georgia where the rural setting is really a challenge with respect to maternal mortality.  Part of the tools that we’re trying to address is the opportunity to look at risk appropriate care and to identify resources as well as innovative opportunities to address the rural challenge for mothers.  Issues of access to care are very important.

Kathy Harben: Next question, please.

Operator: Our next question comes from Erin Michael, Healio.com.  Your line is open.

Primary Care Today:  I’m calling from Primary Care Today.  Is there anything that primary care physicians specifically can do to prevent pregnancy-related deaths?

Dr. Barfield:  Yes. Primary care providers as well as many other providers, even in areas that may not be obstetric, have an important role to play.  The findings show that chronic decide plays a major role in maternal mortality.  So the way that we can all help is through identifying women with chronic conditions and giving them the opportunity to understand their conditions and better manage their health.

Kathy Harben: Next question, please.

Operator: Our next question comes from Marie Rosenthal.  Infectious Disease.

Infectious Disease:  Hi. I actually have two questions. I was wondering if you could elaborate a little bit on the infectious causes of death.  Are we talking about bloodstream infections?  Wound infections?  And then I was wondering if there was a difference in the deaths between a cesarean or vaginal delivery.

Emily Peterson: Hi. This is Emily Peterson. Yes, infection would include both bloodstream infection, wound infections, and others such as kidney infections.  In this analysis, we did not analyze vaginal birth compared to cesarean section.

Kathy Harben: Next question, please.

Operator: Again, as a reminder, if you have further questions or communities, please press star one.

Joetta is on the line from WTVT your line is open.

WTVT: Thank you for taking my question.  I was wondering if you could elaborate on the cardiomyopathy.  Are you suggesting these were preexisting conditions that were exacerbated by the pregnancy (which we call the stress test) or were these cardiomyopathies that develop as a result of the pregnancy?

Emily Peterson: Thanks for the question.  This is Emily Peterson.  So, the cardiomyopathy does include pericardium cardiomyopathy, which presents in late pregnancy or within five months of pregnancy generally. But the cardiomyopathy group also includes dilated cardiomyopathy and hypertrophic cardiomyopathy for other types of cardiomyopathy.  So, we would think the cardiomyopathy group includes both women who had preexisting heart disease that was identified and those identified in late pregnancy or postpartum.

WTVT: Can I ask one more question?  On the perinatal collaborative groups, how are they monitoring cardiomyopathy and what interventions have they instituted to try to decrease the deaths?

Emily Peterson: So, the perinatal quality collaboratives identify a variety of issues surrounding pregnancy and the postpartum period.  So, they do have the opportunity to try to better identify women who are at risk for cardiomyopathy.  But in terms of the specific protocols, it may vary depending on the PTC and what they identify as the priority.

WTVT: Okay.  Thank you.

Kathy Harben: Next question, please.

Operator: Ronny Reuben, The New York Times, your line is open.

New York Times: Thank you.  I was wondering if you can address the issue of racial bias in healthcare and healthcare systems.  To what extent is that playing a role in these very high relative rate of maternal deaths among black women and Native American/Alaskan women?  And did you look at the…was there a comparative analysis? I know you say 60% of the deaths are preventable across racial lines. But did you look at what factors more…  Are there time periods with the pregnancy and postpartum period that are more risky for black women and Native American women?  There was a mention of a higher death rate in the late postpartum period for black women.

Dr. Barfield: So. So, the study did show that during the late –

New York Times: I’m sorry. Is this Dr. Peterson?

Dr. Barfield: Oh. Hi. This is Admiral Wanda Barfield.

New York Times: OK.

Dr. Barfield: So, our analysis did show that black women were more likely to die from pregnancy-related complications at that later period.  However, your point is a little taken about the issues surrounding racial and ethnic disparities in maternal deaths. What we’re seeing in terms of the literature and work that’s going on through a variety of researchers throughout the country. There are really sort four major areas.  One is the impact of structural racism and implicit bias on health.  There has been a growing body of research that is showing that structural racism is playing a role with regard to these disparities.  For example, issues of prenatal care initiation that’s been associated with the endorsement of experiences of racism.  We’ve also seen persistent racial disparities regardless of certain factors such as educational attainment.  So, there is increasing concern that this plays a role.  In addition, to that and perhaps even layered with that is the variation in hospital quality.  So, that there’s been evidence that some disparities can be explained through variation in hospital quality and there have been recent studies that have shown racial and ethnic minority women deliver at different and lower quality hospitals than white women.  And that these hospitals disproportionately care for black women at delivery and they may have increased poor outcomes in those hospitals.  Even the hospital that is care for both black and white women that the hospital quality may be on the lower in those areas.  Then the other issue is really underlying chronic conditions.  So, chronic conditions such as hypertension or cardiovascular disease are more prevalent in black women, and these conditions are associated with the increased risk of pregnancy-related mortality.  Then sort of the last general issue is really access to care.  Again, access really to quality care.  And we’re seeing increasing evidence about the performance of access to risk appropriate care.  We know that for example, American Indian/Alaskan native women are more likely to live in rural areas and that may create additional challenges to getting, receiving access to quality care.  So, all these factors are contributing.

New York Times:  Just to clarify, you said there’s implicit bias getting prenatal care experience racism when prenatal care is initiated. Can you explain what you mean by that?

Dr. Barfield: So, for example. There may be factors in terms of when women are seen.  The types of discussions they’re having in terms of information.  Trying to be better informed in that care.  There’s also concerns about bias in the terms of the quality care they’re receiving in terms of advice, issues of trust, establishing the relationship with the provider.  So this is – these are issues that have been described in the literature in a variety of patient encounters with providers.  But it’s not just prenatal care. Again, the hospital factors as well as the postpartum period is another major area of concern with regard to bias. What we have seen from the stories that women have told – many are feeling they’re not being heard in terms of their concerns or conditions around the pregnancy and postpartum period.

New York Times:  Ok.  Thank you.

Inaudible …….. from pregnancy through the end.  Slightly more increase in problems through the end of the late postpartum period and maybe these things are developing early on and being missed.  But is there any other discrepancy along the way that you see?

Dr. Barfield: So, I think this is where the opportunity for Maternal Mortality Review Committees could really be helpful in this regard.  Because we know that care goes beyond the hospital facility and there are circumstances of care that women are experiencing that we need to more specifically address.  Particularly with regard to issues of discrimination and racism and care as well as the circumstances that they’re living in that may affect their health.  Next question?

Operator: Gabby inaudible of U.S. News and World Report.  Your line is now open.

U.S. News and World Report: Hi.  Thanks for doing the call.  So, there’s been concern from folks in the maternal health field that many states are not tracking this issue very closely.  Can you address that a little bit and just how comprehensive is this data and new analysis?

Dr. Schuchat: Let me begin. This is Dr. Schuchat.

This is a really important are, and the program has mentioned in the report, there are 13 state Maternal Mortality Review Communities that experiences described and we’re excited about the opportunity to support more through funding announcement in the fall.  But in the absence of data, it is very difficult to prioritize investments and improvement efforts.  So, we think it’s very important that every state be able to track their both mortality and severe morbidity that women experience so that priority improvements can be made.  The data quality, completeness, and timeliness are critical to us understanding this problem and getting better solutions.  Next question.

Operator: If you have any further questions or comment, suppress star 1 and record your name.  Please press star 1.

Kathy Harben: Thank you, Diane.  Hearing no more questions, I’d like to thank Dr. Schuchat,

Dr.  Barfield and Dr. Peterson for joining us today.  Thank you, also to the reporters who joined.  If you have follow up questions, you can reach us at CDC’s media office at 404-369-2386 or e-mail us at media@cdc.gov.  We will be posting a transcript later today on our newsroom website.  Thank you again, and this concludes our call.

Operator: This concludes today’s conference call.  Thank you for participating.  You may disconnect at this time.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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