Centers of Excellence and Maternal Mortality

Americans today are 50% more likely to die in the period surrounding childbirth than their own mothers.

                                                                                                   Neel Shah

Our increasing maternal mortality rate is gathering attention both nationally and internationally. We rank last among developed nations (33rd) for maternal mortalities and this rate is increasing. According to the Centers for Disease Control and Prevention (CDC), in 2021 there were 32.9 maternal deaths per 100,000 live births, up from the 2019 rate of 20.1 maternal mortalities per/100,000 live births, and up yet again from the 2020 rate of 23.8 maternal mortalities per 100,000 live births. This rate and its continued increase should be intolerable to every single person in the U.S., not to mention every single organization providing prenatal, labor and delivery, and postpartum care. But for the most part, responses to these high numbers meet with several excuses.

To put this into perspective, the maternal mortality rate in the U.S. was 9 per 100,000 births in 1979. In 2000, the rate was 8 maternal mortalities per 100,000 births.

So, what’s happening?

The CDC offers advancing maternal age in the U.S. as one reason often given for the increase in maternal mortality. In 2021, the maternal mortality rate for women under 25 was 20.4 per 100,000 live births. For women aged 25 through 39, the maternal mortality rate was 31.3 per 100,000 live births. For women over 39 years of age, the maternal mortality rate was 138.5 per 100,000 live births. This excuse about age of mothers ignores the issue that the other countries with 2-4 maternal deaths per 100,000 live births are obviously dealing with the same problem, but with much greater success.

We are surely not the only country in the world faced with an aging population. How do providers in other countries cope with advancing maternal age? Perhaps it’s time someone on the government committees looking at our high maternal mortality rate actually visit with physicians in other countries with low maternal mortality rates. 

 A second reason often put forward for these horrendous maternal mortality rates in the U.S. is that there are mounting co-morbidities in our pregnancy population. In plain English, this simply means the delivering provider takes the position, “The rising co-morbidities are beyond my control.” There must be other countries which have mothers who smoke cigarettes or pot, or are overweight, have diabetes, hypertension, preeclampsia, eclampsia, COPD, and other health problems which make pregnancy more complex. Again, other countries with maternal mortality rates of 2-4 per 100,000 births are dealing successfully with these same co-morbidity problems.  

I’ve posted several times here on Substack that there’s no mystery as to why our maternal mortality rates are so high. ProPublica’s story about Lauren, a 32-year-old NICU (neonatal intensive care unit) nurse who apparently had a normal prenatal course, presented at term, had a spontaneous labor, and hypertension, delivered the baby, with apparently good Apgars, and had a stroke. She had hypertension which wasn’t monitored or treated, so most likely her stroke was due to the rupture of a normal vessel in her brain due to extreme high blood pressure. Note that her delivery doctor, once she delivered, did not return to take care of her. He called a neurologist, who gave an excuse for not coming in. It should be noted that the doctor who delivered Lauren had had several maternal deaths.

Our federal government has two fixed responses to almost every problem in medicine. The first one is threatening hospitals in general, and healthcare providers in particular. It’s easier to threaten one or two people than address the real problem when the underlying cause for maternal mortalities is a systems problem.

The second major government response is to throw money at a problem. Now the Centers for Medicare & Medicaid Services (CMS) wants to spend 168 million dollars to create a Centers of Excellence program aimed at awarding hospitals for collecting data on maternal care. My concern is that few CMS staff creating the checklist to qualify for this Centers of Excellence program have ever delivered a baby or had to make complex antepartum decisions.

So, for 168 million dollars, what is supposed to happen? Why of course, their favorite refrain, DATA COLLECTION! Most physicians, me included, are intimately acquainted with the weaknesses of the electronic medical record (EMR). The EMR is horribly complex and often coding does not accurately represent what actually happened. I would like to proffer the suggestion that none of the EMR data will represent the real reasons for maternal deaths. Moreover, CMS has no way of knowing which codes represent reality and which do not.

Now, rather than actually making plans to remedy our sky-rocketing maternal mortality rate, we are collecting and waiting, and while we are doing so the maternal mortality rate will continue to rise.

How would I fix this problem? First, a nod must be given to the devil of complexity. There is NOT just ONE cause for a woman’s death. There are many huge systems causes requiring not only huge systems solutions, but multiple huge simultaneous systems solutions.

I have over four decades of obstetrical experience delivered approximately 6000 babies with no maternal mortality and no mothers with eclampsia. I never abandoned my patient once she delivered. I saw my patients every time they came to my office. No, I didn’t momentarily stick my head in the door while someone entered data into a computer. I sat down with my patients and their families—yes, I invited dads and children to prenatal visits. I could observe the family dynamics and whether a mother would be likely to develop postpartum depression. I saw my patients as often as I thought necessary even if that meant they came to the office more often than insurance would cover. My patients knew me, knew I would be there for their delivery, and trusted me.

Center’s of Excellence will not be able to provide the kind of care needed to bring down the maternal mortality rate because the current business model for prenatal care, labor and delivery, and postpartum creates a simplistic model for an extremely complex medical process.

The $168 million dollars the Centers of Excellence are putting into collecting data would be much better spent sending practicing physicians to the countries with low maternal mortality rates and observing how it’s done. And to bring physicians from countries with low maternal mortality rates to this country to observe how the U.S. manages pregnancy, labor and delivery, and postpartum care and make recommendations for improvements. We should be looking at what makes other countries so successful in keeping their maternal mortality rates so low. Instead the CMS is spending millions to create a gold-star award system for hospitals to collect data, data which will continue to have no real substantive connection with reducing the U.S. maternal mortality rate.