Labor and Delivery Nurses: Why Are Maternal Deaths on the Rise?

Sarah was an ICU nurse married to John, a high school teacher. They had tried for over 4 years to have a baby.

Sarah watched her colleagues get pregnant and attended seemingly endless baby showers. Finally in year five of their marriage she became pregnant.

They were overjoyed. Sarah didn’t complain about nausea early on in her pregnancy because it was daily proof that she was pregnant. She couldn’t wait to show her bump and didn’t mourn her waistline. Being a Mom was all she’d wanted for so long.

When the time came, she felt excited and safe going into labor. It was at the hospital where she worked, and her labor was induced, but she delivered vaginally and normally in 8 hours. Nothing could have prepared her for holding her new daughter. She and John were euphoric.

When the euphoria began to wear off, Sarah told her husband she didn’t feel well. She complained of a headache and placed her hand on her upper abdomen. “I just don’t feel good”. Before she could ask for an emesis bag, Sarah threw up. Her blood pressure was 162/106 and still no one actually did anything- just treat her for pain. Sarah looked up at her husband. “I really don’t feel good, honey.”

Her pain steadily got worse. Her blood pressure did not go down. Within a short time she was in a full-blown seizure and despite resuscitative efforts, Sarah died before ever seeing her daughter again.

Sarah could have been treated for pre-eclampsia and eclampsia but instead died from a missed diagnosis.

United States

While maternal deaths are declining in the rest of the world, the maternal mortality rate is increasing here at home. Given recent improvements in health care, it is shocking to realize that pregnant women are safer in almost any other country than the United States. The U.S ranks higher in maternal mortality than many other wealthy countries.

According to the CDC, pregnancy-related deaths increased from 7 per live 100,000 births in 1987 to 16 per live 100,000 births in 2012, and increased 20% from 2000 to 2013.

How Are They Reported?

Fully half of maternal deaths occur more than 24 hours after childbirth and up to a year later. Pregnancy-related deaths are defined as deaths that occur up to one year after the end of pregnancy related to a pregnancy complication. Pregnancy-associated deaths are defined as deaths that occur up to one year after the end of pregnancy, regardless of the cause. Pregnancy-associated but not related deaths are defined as deaths that occur up to one year after the end of pregnancy for non-related cause (such as a car accident).

According to the CDC, maternal deaths are under reported, because pregnancy-related causes are not always noted on a death certificate.

Not every state requires a doctor to report if a woman was pregnant or recently gave birth on the death certificate. In addition, there is no legislation mandating state level maternal-mortality review committees.

Causes of Death

What are the causes of death? There is no one cause. Almost 50% of deaths that occur during pregnancy are caused by hemorrhage, cardiovascular and coronary conditions, embolism, ectopic pregnancy and abnormal placental implantation.  

Causes vary by how much time has elapsed since birth. Causes of 56% of deaths that occurred within 43 days after pregnancy include:

  • Hemorrhage
  • Cardiovascular and coronary conditions
  • Preeclampsia and eclampsia

Causes of 60% of deaths that occurred within 44 days to one year after pregnancy include:

  • Cardiomyopathy
  • Mental health conditions
  • Embolism 

Researchers tell us that the increase in deaths in recent years has been driven largely by heart problems and chronic medical conditions, like diabetes and obesity, as well as substance use and obesity.

High-Risk Pregnancies

Multiple risk factors have been identified:

  • Obesity
  • High blood pressure
  • African American ethnicity
  • Maternal age > than age 40
  • Kidney disease
  • Diabetes
  • Caesarean births

Lack of Emergency Preparedness

Even though perinatal care is a high-volume service line, complication rates for both vaginal and cesarean deliveries nationwide differ significantly across hospitals. 

Hospitals are well prepared for baby emergencies but not for maternal emergencies. As a result, newborns receive excellent care but the same cannot be said of their mothers.

Doulas

Some believe having doulas, or birth coaches, could help improve birth outcomes and reduce complications.  Hiring a doula can be expensive. Doulas charge up to $1,500 per birth.

Currently only a small number of women use doulas nationwide. Legislation to expand Medicare insurance to cover doulas has been proposed to provide theadditional physical and emotional support during pregnancy and childbirth.

Maternal Mortality Review Committees (MMRC)

MMRCs play a critical role in preventing maternal deaths

Only half of the states have a comprehensive maternal morbidity review process.

According to the CDC, MMRCs review each case and answer 6 key questions. 

  1. Was the death pregnancy-related?
  2. What was the underlying cause of death?
  3. Was the death preventable?
  4. What were the factors that contributed to the death?
  5. What are the recommendations and actions that address those contributing factors?
  6. What is the anticipated impact of those actions if implemented?

Recommendations

The most common themes towards preventing pregnancy-related complications include:  

  • Improve training of providers and nurses
  • Enforce policies and procedures
  • Reduce variability by following best practices

Many maternal deaths, such as Sarah’s, are preventable with early diagnosis and treatment. Improved screening, communication, and appropriate level of care determination are critical to making sure both Mom and baby go home safely.

Continuing education for nurses is a must. L&D nurses can make a difference by educating themselves and following evidence-based practice.  

Beth Hawkes MSN, RN-BC - August 31, 2018