What Family Physicians Can Do to Reduce Maternal Mortality
Am Fam Physician. 2019 Oct 15;100(8):460-461.
Maternal health is in a state of crisis in communities across the United States, where rates of severe maternal morbidity nearly tripled between 1993 and 2014 and maternal mortality increased by more than 50% between 1990 and 2013.1,2 Approximately 45% of maternal deaths occur in the first 42 days postpartum, before most patients have returned for a follow-up visit.3 Patients who are pregnant with multiple chronic medical conditions are at greater risk of morbidity and mortality, as are those who are low income, black, or Native American.4 Rural communities face particular perinatal health concerns with higher rates of infant mortality and a rising tide of hospital obstetric unit closures.5,6 Finally, racism and poverty are structural features of society that precede social and clinical determinants, intersect with geography, and shape postpartum health and maternal mortality.
Approximately one-third of U.S. women who are pregnant report having received care from a family physician in the previous year.7 Family physicians regularly provide prenatal care, labor and delivery care, and postpartum care as well as primary care before and after pregnancy. They often treat patients who are among those most vulnerable to maternal morbidity and mortality, including Medicaid beneficiaries, people of color, low-income families, and rural residents.8,9 Therefore, family physicians have a unique role and opportunity to support improvements in maternal health.
Reducing Clinical Risks
The article in this issue on postpartum care10 and a recent committee opinion by the American College of Obstetricians and Gynecologists11 recommend more frequent and earlier postpartum visits than the standard single six-week follow-up visit, which may lead to enhanced opportunities to meet the clinical needs of patients with complex conditions, including those with hypertensive disorders or gestational diabetes mellitus. Family physicians can use these visits to screen for depression and intimate partner violence and to provide supportive counseling for breastfeeding, incontinence, constipation, and contraception. Family physicians may also play a role in screening for substance use and other mental illnesses beyond depression, reducing stigma, and supporting emotional health and well-being. Well-child visits or unanticipated sick-child visits also offer an opportunity for family physicians to check in with parents about their own physical and mental health.12
Addressing Social Determinants
Family physicians play a role outside of clinic visits in the health of families and communities and can screen patients in the postpartum period for social determinants that may raise risks for maternal mortality, including housing instability, food insecurity, community violence, firearms access, financial insecurity, and social isolation.13 Physicians can advocate for programs and policies that make a difference. For example, in advocating for continuous insurance coverage, family physicians can help the many patients—including 55% of those who have public insurance coverage when they give birth—who experience a disruption in health insurance coverage during the first six months postpartum.14 In addition, they can support access to nonclinical and community-based services (e.g., postpartum doulas, community health workers, breastfeeding support, visiting nurses, parenting support, child care) that match the demographics of patients in the postpartum period, which support positive birth outcomes.15
Supporting Rural Communities
More than one-half of rural hospitals with obstetrics units depend on family physicians to attend births.16 Family physicians who practice in rural communities recognize that many general recommendations for postpartum care— especially for high acuity, clinically complex patients—may not be feasible in all rural settings. Solutions for meeting the needs of patients during the postpartum period will likely differ among rural communities and may include referral networks, hospital cooperatives, shared services, or telemedicine.17
Working Toward Health Equity
Family physicians care for a diverse patient population and would benefit from adopting recommended practices for reducing racial and ethnic disparities in perinatal health.18 Steps may include establishing systems to ensure documentation of self-identified race, educating clinicians and staff about implicit racial bias and shared decision-making, creating mechanisms for patients and families to report inequitable care, or adding a checkbox to intake forms to indicate whether racial bias, poverty, language barriers, or other social determinants are causing or exacerbating illness.18
Primary care teams should be attentive listeners and cognizant of health equity and literacy issues, realizing that patients may express their clinical concerns in ways that may not conform to medical paradigms.19 Although there is no genetic or biologic basis for race,20 the data show black race is a risk factor of maternal morbidity and mortality, independent of health or socioeconomic factors.21 This indicates that inherent bias in the medical system plays a role in maternal health outcomes (i.e., that racism is the risk factor, not race itself). To engage deeply and meaningfully with equity work, it is beneficial to acknowledge historical and contemporary aspects of power and to recognize one's own privilege and role in perpetuating or disrupting systems of oppression.22
Focusing on clinical care during the postpartum period is a critical first step, but preventing maternal mortality goes beyond the clinic walls and extends into communities. Family physicians can catalyze efforts to ensure the safety of all people who give birth and to support well-being during the postpartum period.
Referencesshow all references
1. Centers for Disease Control and Prevention. Severe maternal morbidit y in the United States. Published November 2017. Accessed April 11, 2019. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html...
2. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 [published correction appears in Lancet. 2017;389(10064):e1]. Lancet. 2016;388(10053):1775–1812.
3. Review to Action. Report from nine maternal mortality review committees. Accessed April 11, 2019. https://www.cdcfoundation.org/sites/default/files/files/ReportfromNineMMRCs.pdf
4. Admon LK, Winkelman TN, Zivin K, et al. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States. Obstet Gynecol. 2018;132(5):1158–1166.
5. Centers for Disease Control and Prevention. Infant mortality rates in rural and urban areas in the United States, 2014. September 6, 2017. Accessed April 11, 2019. https://www.cdc.gov/nchs/products/databriefs/db285.htm
6. Hung P, Henning-Smith CE, Casey MM, et al. Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004–2014 [published correction appears in Health Aff (Millwood). 2018;37(4):679]. Health Aff (Millwood). 2017;36(9):1663–1671.
7. Kozhimannil KB, Fontaine P. Care from family physicians reported by pregnant women in the United States. Ann Fam Med. 2013;11(4):350–354.
8. Gregory DS, Wu V, Tuladhar P. The pregnant patient: managing common acute medical problems. Am Fam Physician. 2018;98(9):595–602.
9. ACOG Committee opinion no. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 pt 1):384–388.
10. Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the fourth trimester. Am Fam Physician. 2019;100(8):485–491. https://www.aafp.org/afp/2019/1015/p485.html
11. ACOG Committee opinion no. 736: Optimizing postpartum care. Obstet Gynecol. 2018;131(5):e140–e150.
12. Rosener SE, Barr WB, Frayne DJ, et al. Interconception care for mothers during well-child visits with family physicians: an IMPLICIT network study. Ann Fam Med. 2016;14(4):350–355.
13. Lu MC. Reducing maternal mortality in the United States. JAMA. 2018;320(12):1237–1238.
14. Daw JR, Hatfield LA, Swartz K, et al. Women in the United States experience high rates of coverage “churn” in months before and after childbirth. Health Aff (Millwood). 2017;36(4):598–606.
15. Kozhimannil KB, Vogelsang CA, Hardeman RR, et al. Disrupting the pathways of social determinants of health: doula support during pregnancy and childbirth. J Am Board Fam Med. 2016;29(3):308–317.
16. Kozhimannil KB, Casey MM, Hung P, et al. The rural obstetric workforce in US hospitals: challenges and opportunities. J Rural Health. 2015;31(4):365–372.
17. Mann S, McKay K, Brown H. The maternal health compact. N Engl J Med. 2017;376(14):1304–1305.
18. Council on Patient Safety in Women's Health Care. Reduction of peripartum racial/ethnic disparities (+AIM). October 2016. Accessed May 2, 2019. https://safehealthcareforeverywoman.org/patient-safety-bundles/reduction-of-peripartum-racialethnic-disparities/
19. Robert Wood Johnson Foundation. Discrimination in America: experiences and views of American women. December 2017. Accessed April 11, 2019. https://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2017/rwjf441994
20. American Association of Physical Anthropologists. AAPA statement on race & racism. March 8, 2019. Accessed May 2, 2019. http://www.physanth.org/about/position-statements/aapa-statement-race-and-racism-2019/
21. Nelson DB, Moniz MH, Davis MM. Population-level factors associated with maternal mortality in the United States, 1997–2012. BMC Public Health. 2018;18(1):1007.
22. Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives—the role of health professionals. N Engl J Med. 2016;375(22):2113–2115.
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