Dene Duckworth of Chicago had been told most of her life that she could not have children. So it was a surprise when, at age 39, she became pregnant with her first child.
Despite having asthma, diabetes, high blood pressure, bipolar disorder and overactive parathyroid glands, Duckworth said her pregnancy was treated as normal.
The doctors “didn’t know how serious my health issues were during my first pregnancy,” said Duckworth, who lost her baby at five months.
Less than a year later, when she learned of her second pregnancy, her clinicians flagged her pregnancy as high risk. Duckworth, who is a Medicaid beneficiary, was told to follow protocols that included close monitoring and a prenatal regimen that consisted of hormonal injections and vitamin supplements. Duckworth also received nutritional counseling to control her diabetes and behavioral healthcare services.
In July 2018, Duckworth gave birth to a healthy baby boy.
“I believe all pregnancies should be considered a high-risk pregnancy,” she said. “You never know what type of pregnancy a person is actually having—they can look healthy, but something could go wrong at any time.”
But some of Duckworth’s issues resulted from providers not sharing information about her conditions, which experts say helps fuel the nation’s high rate of maternal deaths.
A recent Centers for Disease Control and Prevention study found that of the estimated 700 annual maternal deaths in the U.S., 3 in 5 could be prevented with greater access to care, earlier and more accurate diagnoses, and greater recognition of warning signs.
A big problem in maternal healthcare has been the lack of continuity before, during and up to a year after pregnancy, said Andria Cornell, associate director of women’s and infant health at the Association of Maternal & Child Health Programs.
“There’s a fragmentation in how we understand birth outcomes, how we measure and evaluate the quality of care and the support that a person receives based on these various time points,” Cornell said.
These days, Duckworth does not visit the doctor as often as she did when she was pregnant. With her son having been born without complications, she’s left with questions regarding what she can do or where she can go to get the same attention for her ongoing health issues that she received while pregnant.
“What is the next step now?” Duckworth asked. “They were watching me closely while I was pregnant, but all of the things that were going on may potentially be going on now.”
Duckworth is likely to receive some care through the emergency department, as many other Medicaid patients continue to do, despite efforts to curb ED care.
The CDC study found that more than half (60%) of maternal deaths during its study period were caused by hypertensive disorders of pregnancy that occurred up to six days postpartum. Cerebrovascular accidents occurred most frequently up to 42 days postpartum. Deaths caused by cardiomyopathy occurred most often 43 to 365 days postpartum.
Dr. David Baker, executive vice president for healthcare quality evaluation at the Joint Commission, wants emergency department clinicians to be better trained to identify and address maternal or postpartum health issues.
He said many new mothers experience a severe complication such as excessive bleeding after they have been discharged, forcing them to go to the ED.
“One of the problems is that they’re not necessarily seeing the obstetrician/gynecologist who was treating them before, and they may not have rapid access to all of the patient’s information,” Baker said.
A 2015 study published in the Journal of Clinical Gynecology and Obstetrics found that of 2,022 patients who delivered at Jersey Shore University Medical Center during the study period, 154 visited the ED postpartum. Of those, 73% of the visits were caused by obstetrical complications. The researcher concluded that postpartum ED visit rates could be used as a measure of both efficiency and safety of obstetrical practice.
The Joint Commission has worked to improve the quality and safety of perinatal care through its performance measures for hospitals. In 2017, the commission formed a working group to identify major drivers of maternal morality, and it identified excessive bleeding and high blood pressure as factors.
In February, the commission said it would begin reporting hospitals with consistently high rates of cesarean sections—a common cause for postpartum hemorrhaging and infections—in low-risk pregnancies.
Groups like the Association of Maternal & Child Health Programs as well as the American College of Obstetricians and Gynecologists have led efforts to provide more standardized and thorough approaches to maternal care.
Dr. Lisa Hollier, the immediate past president of the American College of Obstetricians and Gynecologists, sees progress in states establishing maternal mortality review committees that study cases of maternal deaths and follow recommendations to improve those outcomes. Currently 38 states have such committees. Nine other states are forming them.
From 2006 to 2013, California cut its maternal mortality rate by 50% from 16.9 deaths for every 100,000 live births through its Maternal Quality Care Collaborative. The collaborative created and promoted quality-improvement practices that have been adopted by nearly all California birthing hospitals.
“They have had a tremendous reduction in the overall rate of maternal mortality since they began doing the reviews to get the data they need to know which programs to prioritize and implement,” Hollier said.
However, many state review committees are not well funded and rely on volunteers.
Recently, state legislatures have begun to take on the funding and operation of maternal mortality review committees, as well as extending Medicaid coverage for postpartum care from its current limit of two months to one year to address the fact that roughly a third of maternal deaths occur within one year after the delivery.
Cornell said she was optimistic the recent groundswell of support to improve maternal health would lead to greater funding.
“Many of these policy levers will really accelerate the environment and climate for optimal maternal health that are really essential to be put in place,” Cornell said.