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Tuesday Mar 05, 2019

Our Maternal Mortality Rate Is Shameful

I was helping a patient with chronic pain and depression wean off opioids last year. Then, in the midst of that process, she got pregnant.

[woman undergoing ultrasound]

We expedited our plan and quickly got her off opioids. We kept her mental health stable through an approach of exercise, counseling, medication and mindfulness. She had a successful pregnancy and delivery. Although her pain remains an ongoing issue, which we are managing through integrative care, she is now the mother of a healthy baby boy.

Even with her chronic conditions, the patient has several factors in her favor compared to other new mothers. She has good social support from her partner, friends and family. She has a strong primary care network that also helps coordinate subspecialty care when needed. She has a great health benefits package through her work.

And, also relevant: She is white.

When we discuss the alarming trend of worsening maternal mortality rates in the United States, we need to talk about black women.(www.nationalpartnership.org) The maternal mortality ratio for white women is 12.4 per 100,000; it's more than three times higher for black women at 40 per 100,000, according to the CDC.(www.cdc.gov) These disparities persist in multivariable analysis for other women of color, too.(www.ncbi.nlm.nih.gov)

Although infant mortality rates are consistently improving, the nation's already-high maternal death rate has spiked since 2000. In fact, an NPR and ProPublica investigation of maternal mortality(www.npr.org) found that not only were American women far more likely to die of pregnancy-related complications than their peers in other developed countries, the United States was the only country out of 14 where the rate of women dying is increasing.

The leading causes of pregnancy-related maternal death(www.cdc.gov) include cardiovascular and non-cardiovascular diseases, infection, hemorrhage, cardiomyopathy, pulmonary embolism, cerebrovascular accidents, and hypertension. But in digging deeper past these stats, it's clear the problem is a complex web involving lack of social support, chronic medical conditions with inadequate primary care and implicit biases in medicine.

The racial disparities span across socioeconomic status and education levels. A 2016 study conducted by the New York City Department of Health and Mental Hygiene(www1.nyc.gov) found that college-educated black women are more likely to suffer complications or death from pregnancy compared to white women who lack a high school degree. It's a painful reminder of the impact of institutional racism.

What can family physicians do to support our reproductive-age patients, especially women of color?

There's the obvious, of course: We need more family physicians in both rural and urban communities providing obstetric care, and they should be well trained in managing obstetric emergencies, through courses like Advanced Life Support in Obstetrics.

But there are several other areas, which are less obvious, that can have an even larger impact on curbing maternal mortality. Here, all family physicians can play a valuable role -- even those who don't provide obstetric care.

Of critical importance: Women need preconception access to primary care to improve management of chronic conditions, like obesity, hypertension and diabetes, which all pose real threats in pregnancy. And, as our opioid crisis grows among reproductive-age patients, we must aggressively integrate addiction medicine, as well as mental health, into preconception and prenatal care. All these efforts can be led by family physicians.

Our fractured health care system is a clear culprit in contributing to maternal deaths. A model family physicians can use to deliver care is maternity medical homes,(www.ihi.org) which are emerging as a platform to provide coordinated maternity care with a focus on quality, safety, access to care and primary care.

Family physicians can also use our learnings from the chronic disease care model of group visits and apply them to pregnancy. Centering Pregnancy(www.centeringhealthcare.org) is a group prenatal care model that encourages emotional support for behavior change, empowerment and health education.

Another factor to consider in maternal mortality: Half of all pregnancies in in the United States are unplanned. Family physicians play a critical role in reducing the rates of unplanned pregnancies through comprehensive sex education as well as widespread family planning. Unfortunately, we are sliding backward in this aspect of reproductive health, too, and the recent Title X gag rule(1 page PDF) is expected to have a disproportionately negative impact on women of color(www.elle.com) regarding access to family planning services.

So where do we go from here? Based on a substitute resolution passed by the AAFP Congress of Delegates (COD), the Academy is developing a maternal mortality task force, which will have its first meeting in April. The task force is expected to report back to the COD on issues related to evidence-based methods to decrease maternal morbidity and mortality; methods to increase recognition of implicit bias and reduce disparities in maternal morbidity and mortality; and strategies to improve resident education and support practicing family physicians in providing full-scope reproductive and maternity care.

Finally, we must advocate for our patients in order to dismantle social systems that disadvantage women of color. Certainly, training on implicit bias is beneficial for every health care professional. On a more systemic level, family physicians should advocate for policies that advance birth equity(www.marchofdimes.org) and fight systemic racism by supporting affordable housing, education, labor rights, access to quality health care and more.

Addressing maternal mortality is complicated, but it won't take Herculean efforts. Mahmoud Fathalla, M.D., Ph.D., former President of the International Federation of Gynecology and Obstetrics, once said, "Women are not dying because of untreatable diseases. They are dying because societies have yet to make the decision that their lives are worth saving."

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan.(twitter.com)

Read other Fresh Perspectives posts by this blogger.

Posted at 12:50PM Mar 05, 2019 by Natasha Bhuyan, M.D.

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