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Bull World Health Organ 2015;93:135 | doi: Editorials 135 Although considered mainly as prob- lems of the developing world, maternal mortality and morbidity remain a chal- lenge in the United States of America (USA).1 Between 1990 and 2013, the maternal mortality ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per births1 and the country has now a higher ratio than those reported for most high-income countries and the Islamic Republic of Iran, Libya and Turkey.2 About half of all maternal deaths in the USA are preventable.2 Each year an estimated 12001 wom- en in the USA suffer complications dur- ing pregnancy or childbirth that prove fatal and suffer complications that are near-fatal – even though costs of maternity care in the USA in 2012 ex- ceeded 60 billion United States dollars.4 Three factors are probably contrib- uting to the upward trend in maternal mortality and morbidity in the USA.

First, there is inconsistent obstetric practice. Hospitals across the USA lack a standard approach to managing obstet- ric emergencies and the complications of pregnancy and childbirth are often identified too late. Nationally endorsed plans to manage obstetric emergencies and updated training and guidance on implementing these plans is a serious and ongoing need.5 A second factor is the increasing number of women who present at an- tenatal clinics with chronic conditions, such as hypertension, diabetes and obesity, which contribute to pregnancy- related complications. Many of these women could benefit from the closer coordination of antenatal and primary care – including case management and other community-based services that help them access care and overcome cost and other obstacles.

In the USA, women who lack health insurance are three to four times more likely to die of pregnancy-related complications than their insured counterparts.6 Another factor is the general lack of good data – and related analysis – on maternal health outcomes. Only half the USA’s states have maternal mortal- ity review boards and the data that are collected are not systematically used to guide changes that could reduce mater- nal mortality and morbidity. There is no national forum for the states to share either their best practices for reviewing maternal deaths or the relevant lessons that they may have learned. There is a growing effort by physicians, nurses and community organizations to address these three factors.

Hospitals are beginning to implement standard ap- proaches to managing obstetric emergen- cies so that, wherever a woman gives birth, she receives appropriate evidence-based care. Community initiatives are coordi- nating care for high-risk women to ensure good health and management of chronic conditions during and beyond pregnancy. More states are establishing or strengthen- ing maternal mortality review boards. Recent changes to national poli- cies should also help improve maternal health outcomes. In 2010 the Afford- able Care Act included antenatal and maternal care as essential health benefits that insurance plans must cover.

By ex- tending insurance coverage to pregnant women with low incomes, many states have lowered the economic hurdles that limit access to antenatal care for millions of women. As the health community solidifies the post-2015 agenda to end preventable maternal mortality, the USA needs to be brought into the global dia- logue on maternal health. Although ma- ternal mortality is relatively rare in the USA, one preventable maternal death is one too many. All states need to mobilize health providers, policy-makers and communities to make maternal health a priority. With increased awareness of maternal mortality and life-threatening events – and concrete actions to ensure that pregnant women get the quality care they need – many fatal and near-fatal complications could be prevented. â– Acknowledgements I thank Heather L Sings (Merck), Maria Schneider (Rabin Martin) and Dana Huber (Rabin Martin).

Competing interests: PA is the executive director of Merck for Mothers and owns Merck stock. References 1. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014.

Available from: reproductivehealth/publications/monitoring/ maternal-mortality-2013/en/ [cited 2014 Jul 18]. 2. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol.

2013 Oct;122(4):735–6. doi: org/10.1097/AOG.0b013e3182a7dc8c PMID: . Creanga AA, Berg CJ, Ko JY, Farr SL, Tong VT, Bruce FC, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt). 2014 Jan;23(1):3–9. doi: jwh.2013.4617 PMID: .

Welcome to HCUPnet [Internet]. Rockville: United States Agency for Healthcare Research and Quality; 2015. Available from: http:// hcupnet.ahrq.gov/ [cited 2015 Jan 13]. 5. D’Alton ME, Main EK, Menard MK, Levy BS.

The National Partnership for Maternal Safety. Obstet Gynecol. 2014 May;123(5):973–7. doi: http:// dx.doi.org/10.1097/AOG. PMID: . Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al.

Pregnancy-related mortality surveillance – United States, 1991–1999. MMWR Surveill Summ. 2003 Feb 21;52(2):1–8. PMID: Maternal mortality and morbidity in the United States of America Priya Agrawala a Merck for Mothers, Merck & Co. Inc., 1 Merck Drive, Mail Stop WS2A-56, Whitehouse Station, New Jersey, 08889, United States of America.

Correspondence to Priya Agrawal (email: [email protected] ). American Academy of Nursing President’s Message Global maternal mortality rate declines—Except in America The broad topics I will address this issue fall under Reproductive Rights and our value of social justice. The Academy stated mission and vision on policy and advocacy work is based on using the best available sci- entific evidence. This allows us to lend objectivity to complex, emotionally charged issues, such as mater- nal morbidity and mortality. It is out of that weighted objectivity that valid recommendations for modifying clinical practice can come.

I will cite the negative con- sequences that occur when the available evidence is not consistently embedded in practice. This message illustrates the negative consequences when clinical providers, health systems, and payers do not utilize these evidence-based practices. The specific concern is the alarmingly high rate of maternal mor- tality and morbidity in the United States. Each year in America, 50,000 women suffer life-threatening compli- cations (Young, 2018) and 700 of those die (The Editorial Board, 2018) from a natural event that has been going on since the beginning of time—child- birth. If those facts do not shock you, they should, especially when you consider that more than half of these deaths are preventable.

The majority of maternal deaths in the United States are attributed to hypertension and excessive blood loss. Implementing safety procedures that have been known to the health care profession for decades could prevent them. For example, closely monitoring high blood pressure and blood loss are just two low tech and low cost interventions that can alert nurses and physicians when a new mother is on a potential path of becoming seriously ill (Young, 2018). The steadily rising maternal death rate in the United States is now 26.4% per 100,000 births. (The Editorial Board, 2016) This statistic counters a global trend which shows maternal mortality rates dropping in the developed world. (Tavernise, 2016) Between 1990 and 2015, the number of maternal deaths in Germany, France, Japan, England, and Can- ada, has been flat or has declined. (The Editorial Board, 2016) All the while, the rate in the United States, which boasts one of the most advanced health care systems in the world, sees maternal mor- bidity and mortality climbing.

In America, maternal deaths suffered by women of color are the key factor driving the increase. (Lost mothers: Maternal mortal- ity rates in the U.S., 2018) In New York City, home of the country’s largest blackwhite disparity in the maternal death rate, the divide is getting larger. This widening gap is particu- larly troublesome considering the fact that the city’s overall maternal mortality rate has gone down. (Wald- man, 2018) Black women in New York City face a higher rate of harm than their white counterparts even when they are college educated, have a normal weight and are affluent. In fact, black women from the city’s wealthiest neighborhoods have poorer maternal outcomes than white, Asian, and Hispanic mothers from the city’s poorest areas. (Waldman, 2018) New York City has recently funded .8 million to underwrite an initiative to eliminate the blackwhite disparity in maternal deaths in that city. (Wald- man, 2018) The money will be used to improve data collection specific to pregnancy- and childbirth-related deaths, pay for implicit bias training for medical staff at private and public facilities and underwrite a city- wide awareness campaign for the public.

In addition, the city has taken steps to improve maternal care in its owned hospitals by offering specific training on how to identify and treat two of the most frequent causes of maternal death—hemorrhaging and blood clots. Another program innovation, the introduction of maternal care coordinators, will target high-risk moth- ers-to-be with additional assistance to navigate preg- nancy, prescriptions and public health benefits. The goal of this comprehensive effort is to reduce by half the number of pregnancy- and childbirth-related com- plications occurring in New York City during the next five years. This quality improvement pilot program came on the heels of an NPR series entitled “lost mothers: maternal mortality rates in the U.S.†(Waldman, 2018) The series focused on pregnant patients’ high hemorrhage rates in a Brooklyn hospital.

Only California, which has implemented many of the gold standard practices outlined in the Alliance for Innovation in Maternal Health Program (AIM), (Alliance for Innovation in Maternal Health) is the exception to this startling trend. AIM is a data-driven national safety and quality improvement program designed specifically to address issues related to maternal health. AIM “safety bundles,†an evidence- based list of quality-oriented practices and checklists, helped California bring down maternal complication rates 21% in just 24 months. As a result of implement- ing this quality improvement methodology designed to tackle the most common problems in childbirth, including heart attack, kidney failure, and blood clots, N u r s O u t l o o k significantly fewer California women found them- selves on ventilators or scheduled for a hysterectomy after giving birth. (Young, 2018) While New York City and California are stepping up to address maternal mortality in the short term, sev- eral other states have established review committees to investigate the issue, and the U.S.

Senate has pro- posed legislature to provide million in funding to reduce maternal mortality. (Waldman, 2018) In late August, Senator Kamala Harris (D-CA) introduced the Maternal Care Access and Reducing Emergencies (CARE) Act. The Care Access and Reducing Emergen- cies Act is aimed at addressing and reducing the disproportionate rates of maternal mortality and life-threatening pregnancy complications for African- American women in the United States. With a focus on addressing the racial disparities in maternal mor- tality, the bill would establish: Implicit bias training grants directed to medical schools, nursing schools, and other training pro- grams for health care providers to support implicit bias training.

Pregnancy medical home grants directed to up to 10 states to establish or operate statewide pregnancy medical home programs. The pregnancy medical home model incentivizes maternal health care pro- viders to deliver integrated health care services to pregnant women and new mothers, with the aim of reducing adverse maternal health outcomes, mater- nal deaths, and racial health disparities in maternal mortality. These alarming maternal morbidity and mortality rates point out the importance of science and evidence in shaping public safety advocacy. Using data and research to validate best practices helps health care providers minimize unnecessary care, save money, and move patients into appropriate pathways that pro- duce desired results. (Carroll, 2017) However, statisti- cal significance and clinical significance are not the same.

With a substantial cohort, statistical signifi- cance can be achieved but simply having a large sam- ple does not necessarily create the clinical significance needed to modify clinical practice. (Carroll, 2017) Knowledge gleaned from data and research calls out for a real-world perspective against which it can be evaluated and acted upon. Health systems, nurses, providers and insurers appear unable to hardwire the evidence of safety practices related to managing hypertension and blood loss in a highly reliable way. This is an oppor- tunity for nurse leaders to advocate for change based on this evidence. The need to advocate is now. The time for studying maternal mortality has long since passed.

Without our leadership, America will continue to be the most dangerous place in the developed world to give birth. R E F E R E N C E S Alliance for Innovation in Maternal Health. New York Times. Available online from verywoman.org/aim-program/ Carroll, A. (2017). What we mean when we say evidence- based medicine.

New York Times. Available online from we-mean-when-we-say-evidence-based-medicine. html. Lost mothers: Maternal mortality rates in the U.S. (2018). ProPublica and National Public Radio. Available online from mothers.

Tavernise, S. (2016). Maternal mortality rate in U.S. rises, defying global trend, study finds. New York Times. Available online from 09/22/health/maternal-mortality.html. The Editorial Board. (2016).

Global Burden of Disease Study 2015 provides GPS for global health 2030. The Lancet. Available online from The Editorial Board. (2018). High maternal death rate shames America among developed nations. USA Today.

Available online from story/opinion/2018/07/31/high-maternal-death-rate- shames-america-developed-nations-editorials- debates//. Waldman, A. (2018). New York City launches initiative to eliminate racial disparities in maternal death. Propubl- ica. Available online from article/new-york-city-launches-initiative-to-elimi nate-racial-disparities-in-maternal-death.

Young, A. (2018). Hospitals know how to protect mothers. They just aren’t doing it. USA Today. Available online from tigations/deadly-deliveries/2018/07/26/maternal-mor tality-rates-preeclampsia-postpartum-hemorrhage- safety//.

Karen S. Cox, PhD, RN, FACHE, FAAN Nursing Advocacy and Leadership, Children’s Mercy Hospital, Kansas City, MO Corresponding author: Karen S. Cox, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail address: [email protected] Available online August 24, /$ – see front matter 2018 Published by Elsevier Inc. mailto: [email protected] Global maternal mortality rate declines-Except in America References

Paper for above instructions

Maternal Mortality and Morbidity in the United States: An Urgent Call for Action

The issue of maternal mortality and morbidity in the United States is a critical public health challenge that continues to escalate, despite advances in medical care. This paper aims to highlight the current state of maternal health in the U.S. through a synthesis of recent findings, address the root causes contributing to high maternal mortality rates, and advocate for evidence-based interventions that could remedy the situation.

Current State of Maternal Mortality and Morbidity

Maternal mortality in the U.S. has seen a stark increase over the past few decades. According to estimates, the maternal mortality ratio in the U.S. more than doubled between 1990 and 2013, rising from 12 to an alarming 28 deaths per 100,000 live births (Agrawal et al., 2015). While maternal deaths are generally rare in high-income countries, the U.S. now reports a higher maternal mortality ratio than many developing nations, including Libya and Turkey (Agrawal et al., 2015). The Centers for Disease Control and Prevention (CDC) reports that around 700 women die annually as a result of complications related to pregnancy or childbirth (CDC, 2021). Notably, over half of these deaths are deemed preventable (Young, 2018).
The burden of maternal mortality is further exacerbated by significant disparities in maternal health outcomes along racial and socioeconomic lines. Black women in the U.S. face maternal mortality rates that are three to four times higher than those of their white counterparts, highlighting a systemic issue that extends beyond healthcare access (Waldman, 2018). In New York City, for example, affluent Black women still experience poorer maternal outcomes compared to women of other races living in lower-income areas (Waldman, 2018).

Factors Contributing to High Maternal Mortality Rates

Three primary factors can be identified as contributing to the ongoing crisis of maternal mortality in the United States:
1. Inconsistent Obstetric Practices: A lack of standardized protocols across hospitals has led to inconsistent management of obstetric emergencies. As Agrawal et al. (2015) highlight, there is an urgent need for national standards informed by guidelines and evidence-based care practices that ensure all women receive appropriate care during childbirth. This includes timely diagnosis and management of complications like hypertension and hemorrhaging.
2. Chronic Health Conditions: The increasing number of women with pre-existing chronic conditions such as diabetes, obesity, and hypertension presents significant challenges during pregnancy (Creanga et al., 2014). Further, many women lack adequate access to comprehensive antenatal care, which is crucial for managing their underlying health issues (CDC, 2021).
3. Data Inadequacies: The general lack of robust data and systematic analysis pertaining to maternal health outcomes hinders efforts to implement effective prevention strategies. While some states have established maternal mortality review boards, many are hampered by limited infrastructure for data collection and analysis (Main & Menard, 2013).

Evidence-Based Interventions

To confront and ultimately reduce the rates of maternal mortality and morbidity, a multi-faceted approach focusing on evidence-based interventions is essential:
1. Standardized Care Protocols: Implementing nationally endorsed protocols and training programs for healthcare providers that focus on managing obstetric emergencies can ensure consistent care delivery. For example, the Alliance for Innovation in Maternal Health (AIM) initiative, which targets common causes of maternal complications, has been effective in states like California, where maternal complication rates decreased significantly following its implementation (Alliance for Innovation in Maternal Health, 2018).
2. Enhanced Access to Care: Expanding healthcare access for low-income women must be prioritized. Legislative changes under the Affordable Care Act (ACA) have made strides in providing insurance coverage for antenatal care, yet gaps still remain (Young, 2018). Programs targeting maternal care coordination—especially for high-risk pregnancies—are vital for improving health outcomes (CDC, 2021).
3. Culturally Competent Care: Addressing racial disparities requires culturally competent care that encompasses implicit bias training for healthcare workers at hospitals and clinics (Waldman, 2018). Increased awareness around racial inequities in maternal health must be intertwined with training initiatives and outreach programs that cater to the specific needs of minority populations.
4. Data-Driven Policies: Strengthening maternal mortality review boards across states will bolster data collection and facilitate the sharing of best practices (Main & Menard, 2013). A national forum for states to discuss findings and recommendations could further enhance the informed implementation of effective policies.

Conclusion

The rising rates of maternal mortality and morbidity in the United States demand immediate attention and action. While substantial challenges exist, the integration of standardized protocols, improved access to care, cultural competence, and data-driven policies can create a roadmap toward improving maternal health outcomes. The stakes are high, as every preventable maternal death signifies not only a family loss but a systemic failure in healthcare delivery.
As advocates for maternal health, healthcare professionals must engage in these initiatives and work towards a united goal of making childbirth safe for every woman, regardless of her background or circumstances.
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References

1. Agrawal, P.A., Sings, H.L., & Schneider, M. (2015). Maternal mortality and morbidity in the United States: Where are we now? Bull World Health Organ, 93, 135. doi: [10.2471/BLT.15.151083](http://dx.doi.org/10.2471/BLT.15.151083)
2. Centers for Disease Control and Prevention (CDC). (2021). Pregnancy-related deaths. Retrieved from https://www.cdc.gov/reproductivehealth/maternal-mortality.html
3. Creanga, A.A., Berg, C.J., Ko, J.Y., Farr, S.L., Tong, V.T., Bruce, F.C., & et al. (2014). Maternal mortality in the United States: A new national problem. J Womens Health, 23(1), 3-9. doi:10.1089/jwh.2013.4617
4. Main, E.K., & Menard, M.K. (2013). Maternal mortality: Time for national action. Obstet Gynecol, 122(4), 735-736. doi: 10.1097/AOG.0b013e3182a7dc8c
5. Waldman, A. (2018). New York City launches initiative to eliminate racial disparities in maternal death. ProPublica. Retrieved from https://www.propublica.org/article/new-york-city-launches-initiative-to-eliminate-racial-disparities-in-maternal-death
6. Young, A. (2018). Hospitals know how to protect mothers. They just aren’t doing it. USA Today. Retrieved from https://www.usatoday.com/story/news/nation/2018/07/26/maternal-mortality-rates-preeclampsia-postpartum-hemorrhage-safety/360637002/
7. Alliance for Innovation in Maternal Health. (n.d.). Retrieved from https://www.aimhospitalquality.org
8. The Editorial Board. (2018). High maternal death rate shames America among developed nations. USA Today. Retrieved from https://www.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/848898002/
9. Tavener, S. (2016). Maternal mortality rate in U.S. rises, defying global trend. New York Times. Retrieved from https://www.nytimes.com/2016/09/22/health/maternal-mortality.html
10. Lost Mothers: Maternal mortality rates in the U.S. (2018). ProPublica and National Public Radio. Retrieved from https://www.propublica.org/series/lost-mothers-maternal-mortality-rates-in-the-us