Passing legislation to collect maternal death information could improve our ability prevent them

The Senate Health Committee will soon consider the Maternal Health Accountability Act of 2017 (S1112). If passed, this legislation would make grants available to support state-level efforts to form review committees, which, in turn, would specifically track and investigate pregnancy-related deaths, as well as study ways to prevent such deaths in the future.

The legislation comes at a time when the maternal mortality rate in the United States is not only increasing, it is the highest of any country in the developed world.

{mosads}One study of pregnancy-related deaths in California suggest that more than 40 percent of them could have likely been prevented. The antecedents of maternal deaths can be divided into three categories: 1) fixed maternal characteristics, 2) care during delivery, and 3) characteristics and care that vary during pre-and post-natal period.

As an example, death due to bleeding after a woman gives birth could result from vulnerabilities in the maternal pelvis (a fixed maternal characteristic), events during delivery, such as having a C-section (a function of delivery care), or failure to detect bleeding after a woman has given birth (the postnatal period).

Identifying postnatal bleeding alone as a cause of death does not provide enough information to determine how the death could have been prevented.

This legislation calls for changes to the ways that states are required to disclose maternal death information that could significantly improve our ability to identify how to prevent such deaths. One big change is mandatory reporting to state departments of health. Another is state-level investigations of each case along with case summaries to be reviewed by committees.

However, the information collected and disclosed will only be useful for decision-making if that information is rich enough to identify preventable causes of death. This can include structured information, such as checkboxes noting events during delivery, as well as unstructured information, such as narrative descriptions by experts about likely cause of death.

To ensure that the review committees called for in the legislation actually move the needle on maternal mortality, they must be interdisciplinary, including diverse peripartum healthcare providers (e.g., obstetricians, midwives, maternal-fetal medicine physicians), health services researchers, epidemiologists, geneticists, behavioral scientists, sociologists, and psychologists.

Without the views of a diverse panel of experts, it is inevitable that some nuances of how any individual death occurred may be missed.

These committees must also include acknowledgement and detection of racial bias and disparities in care. Black women are three to four times more likely to die of pregnancy and childbirth-related complications.

Chronic conditions that increase maternal mortality, such as diabetes and hypertension, are more frequent among African-American women. Failure to detect or treat these conditions in a timely way are likely compounded by African-American women anticipating and experiencing bias when being examined.

Committees that don’t explicitly address such racial bias will prevent scientists from determining the true causes of death and the best ways to prevent future bias.

Additionally, these committees must include an evaluation of the grant program itself. Evaluations typically have two parts: impact, looking at whether the program is working, and process, looking at how well it’s being implemented.  

Impact evaluation could include consistency and coverage of data collected by grant recipients, the usefulness and interpretability of measures to scientists who use them for analysis, and ultimately decreases in maternal mortality.

Process evaluation would assess issues like the timeliness of grant implementation and the ability of grants to meet the various needs of different states given their healthcare systems. With proper evaluation, there should be little reason to oppose the Maternal Health Accountability Act on the Senate floor, or the House counterpart — Preventing Maternal Deaths Act (H.R.1318).

Maternal death is a bipartisan concern. This legislation is a great step in the right direction for improving maternal care and preventing maternal mortality in the United States. If grant distribution, data collection, and evaluation are conducted with rigor and an interdisciplinary perspective, this country might be able to reverse that trend.

Tamar Krishnamurti is an assistant research professor in the Department of Engineering and Public Policy Carnegie Mellon University. She is also an assistant professor of Medicine at the University of Pittsburgh. Alex Davis is an assistant professor in the Department of Engineering and Public Policy at Carnegie Mellon University. Hyagriv N.Simhan is the executive vice chair for Obstetrical Services at Magee-Womens Hospital of UPMC.