Deaths of new mothers have increased, likely for several reasons

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

The majority of pregnancy-related deaths in women are preventable. And today I am talking with a doctor about what can be done to help reduce the maternal mortality numbers.

Dr. Rachael Sampson is at Upstate completing a fellowship in maternal fetal medicine.

Welcome to "The Informed Patient," Dr. Sampson.

Rachael Sampson, MD: Thank you very much for having me.

Host Amber Smith: Can you define maternal mortality?

Rachael Sampson, MD: Maternal mortality refers to the death of a woman from complications of pregnancy or childbirth that occurred during the pregnancy or within six weeks after the pregnancy ends. So we're going to go through a lot of definitions here and a little bit of math because a lot of these definitions seem like the same thing. But there are nuances and are differences that really are driving our statistics and driving how we are trying to help patients and how we're trying to reduce these rates.

So it's one thing to talk about maternal mortality, but then another concept is, is it pregnancy related?

And I think that's something that patients often ask or that the public often asks me, because there is a difference between maternal mortality, pregnancy-related deaths and then pregnancy-associated deaths.

Host Amber Smith: But you said up to the time period six weeks after delivery?

Rachael Sampson, MD: That's when we talk about maternal mortality, and we can talk about maternal mortality rates in that context.

There's also a consideration to look at statistics based on pregnancy-related deaths. A pregnancy-related death is a death during pregnancy or within one year of the end of pregnancy from a pregnancy complication. So that chain of events -- and that ties into what we'll talk a little bit about later, maternal mortality review committees (MMRCs) -- was that chain of events related to pregnancy, or was it pregnancy associated? So a pregnancy-associated death, for instance, is a postpartum (after the baby is born) death from a car accident.

Host Amber Smith: I see. And this, just to be clear, has nothing to do with the baby, the infant, we're only talking about the mom?

Rachael Sampson, MD: It's a great question. So how do you tease the two out? And that's where a lot of these definitions and where a lot of the statistics become difficult. And I'm so thankful that we're on this podcast discussing these because traditionally these were things that nobody talked about. A lot of maternal health and women's health, we're realizing now, was really pushed down to the basement. Not great to talk about these topics. I don't know if I can use the term "sexy" -- it's not sexy to talk about these things, traditionally, is what we thought. And I just really want to thank you for talking about them and for making it accessible.

Host Amber Smith: Well, how common is maternal mortality, and also, how common is pregnancy-related death in America?

Rachael Sampson, MD: So I think the best thing to talk about, or what I'd like to focus on, is the maternal mortality, because that is, I don't want to say it's an easier concept to wrap your head around, but I like to compare apples to apples.

So when we talk about maternal mortality. This is where I get into the math. So we always base that on the number of maternal deaths per 100,000 live births. And that gets a little confusing because I'm not a math person, but if we look at every 100,000 live births in the United States, we look at the vital statistics, because this is where these numbers are coming from. We translate these definitions to: Looking at every 100,000 live births, how many moms died?

So a lot of what we hear in the news, and what's really concerning, is that in 1990 there were 10 maternal deaths per 100,000 live births. In 2021, there were 32, almost 33 -- 32.9 -- so there were 33 maternal deaths per 100,000 live births. So from a statistics point, that's a huge increase, to go from 10 to 33. And then when you translate that to how many actual moms have died, when we look at 2021, and this was a really big year, a really hallmark statistic, that I think obviously there are a lot of multifactorial reasons, but I think it really changed the momentum in this country, and I think it was really a call to action. Because in 2021, the data that came out, is that 1,205 maternal deaths occurred in the United States, and that's that number that we see in the news, and that's the one where we all stepped back and said, "What is happening? What can we do better?"

Host Amber Smith: Well, do we know why the numbers are going up in America?

Rachael Sampson, MD: So again, it's multifactorial. So I will take a step back and go back to statistics. And there are some parties that say, "Maybe we're better at reporting these. Maybe we're better at looking for them. Maybe we've come so far in the past 10 years, 20 years, 50 years -- right? -- 100 years. Maybe we're in such a better spot than our grandmothers and our great-grandmothers were that maybe we're just watching it better. We know what we're looking at, so we're reporting it. We used to call preeclampsia (a serious condition in a pregnancy) "toxemia of pregnancy." We literally thought there were toxins. There is some element of truth to that, but we know that there's much more to it, right?

Our science has become more refined. Our statistics have become more refined. So there is one party that says, "Well, maybe we're just doing better. And maybe that number is high because we've made that high by finding those."

Host Amber Smith: And I'm not discounting that, and I think that gives us hope, but the American College of Obstetricians and Gynecologists (ACOG) and the Safe Motherhood Initiative, which I'm a part of, and which Upstate is a part of, really made a conscious effort and really spoke and said that might be the case. However, there are obvious disparities that are of critical importance in our country, and we want to make those continued calls to action and not just say, "We read the data wrong, and we overread it. Well, how does the data in America compare with other parts of the world?

Rachael Sampson, MD: So I'm going to go back to the numbers. When we look at that 100,000 live births, if we take globally, and we lump together a lot of high-income countries -- all comers, high income, you have a certain GDP (gross domestic product) -- these are what your rates were.

And again, these are compiled, once we become worldwide, we have the World Health Organization, the United Nations. The U.N. has different arms of it: There's UNICEF. There's the United Nations Population Fund. They say that there are 12 deaths per 100,000 live births for high-income countries.

So if you look back, we haven't been in that order since 1990, when we had 10. In 2021, we were at 32.9, and in 2020 and 2019 we were around 20, increasing every year, 20.1 and 23. So I look at it as, we went from 10 to 20, and then really quickly from 20, we went to 33, and other countries were reporting on the order of 12.

If you look at countries such as Australia, and these are publicly available data, Australia, Austria, Japan, Spain, high-income countries, very reportable, very transparent statistics, two deaths per 100,000 in 2020, three deaths for one of those countries. So obviously the United States is lagging behind our counterparts.

And then when you look at low-income countries, we're on the order of a hundred, so 430 per 100,000 live births. Huge.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Rachael Sampson. She's completing a fellowship in maternal fetal medicine at Upstate.

You mentioned disparity. Is there a difference among different races of women or different ages of women when you look at maternal mortality?

Rachael Sampson, MD: Something that came from that 2021 data is that the death rate in black moms in that year, in that cohort, was more than 2.5 times that of white and Hispanic mothers.

So that greatest increase rose from 37 to 69.9, so 37 to almost 70 deaths per 100,000 live births in that 2021 cohort of data. That's looking at non-Hispanic white females, with a maternal mortality rate of 26.6, and then higher than Hispanic females, who had a maternal mortality rate of 28.

So that increase from 2015 to 2020 to 2021 really showed that there is a baseline jump, and I guess that's the question: What drove that? And we can get into that, if you're interested.

Host Amber Smith: Well, the pandemic happened during that time, right? At least part of that time. Did that influence the numbers, do you think? Did COVID play a role?

Rachael Sampson, MD: So a lot of interesting data supporting that, that yes, it did. As a physiologist, and as looking at physiology, normal physiology of pregnancy, the pathophysiology of COVID, when you mix those together, that's a perfect storm. Moms were sick. Moms died. And pregnancy, much like obesity, much like pre-existing hypertension, diabetes, is a huge risk factor for severe COVID and death from COVID. So I think COVID did affect that data, those numbers that we're seeing that are coming out from 2021.

We have provisional data from 2023. Again, this data is available, I'd say, on a rolling basis, but really it gets packaged and reviewed by, and again, we can talk about these MMRCs and the national committees.

So when we look at the 2023 data, when we look at that, it does seem like it came down a touch. And that, again, would contribute a little bit more to COVID, but again, we're still higher than other high-income nations. And although the 2023 data seems a little bit more in line with 2018, 2019, 2020, where I kind of said around 20 deaths per 100,000 live births, provisional data for 2023, we have about 19 deaths, maybe 20 deaths. Again, we'll see what the final is on that. I don't want to pinpoint solely COVID, and again, science is not perfect, and teasing that out is never going to be perfect. There are other things going on that are contributing to this.

Host Amber Smith: So what are the leading causes of maternal mortality?

Are all of these women dying in childbirth?

Rachael Sampson, MD: The most common, I will say, it's the postpartum period. And we have to look at it from different, I don't want to say perspectives, but different statistical methods.

So I think as a frontline clinician, as a clinician first, research scientist maybe second, to me, the postpartum period remains the scariest time. A lot of that, I think, comes from having been a general OB-GYN in the community for a long time. I think that patients, once they have the baby, and that's very common, I see that, I see that in my family -- you have the baby, you kind of think you're out of the woods. And I think that's something that OB-GYNs as a group are doing a lot better at: educating patients that the postpartum period is a really scary time.

Childbirth, in and of itself, yes, also a hugely scary time. A lot can go wrong, kind of gets into other things that there are different models for how to deliver, where to deliver. Do you feel comfortable delivering in a hospital? Some patients don't. Some patients prefer to deliver at a birthing center or at home. A lot of that has to be factored in to really get to "Where can we help most?" and "Where can we keep patients the safest?" Or give patients the tools so that if things don't go as planned or aren't safe, "How do we go to the next step?"

Host Amber Smith: The problems that you're talking about that might come up in the postpartum period, are these things unrelated to pregnancy, necessarily?

Are they things that develop during pregnancy?

Rachael Sampson, MD: So a lot of things that develop in pregnancy, a lot of them are related to preexisting conditions. Other times are solely pregnancy conditions.

So a perfect example that I like to use is diabetes in pregnancy. Some patients have an underlying glucose metabolism problem or an underlying metabolic syndrome. So that might affect them in a gynecologic visit. And then with counseling and appropriate intervention, that has been shown to decrease in incidents of gestational (during pregnancy) diabetes or maybe recurrent, preexisting diabetes in interval pregnancies.

So there are factors that are really tied into, again, postpartum diabetes, things like that. That's really not what the issue is, but that increases the risk of hypertension in pregnancy, and if hypertension does not become overt preeclampsia antenatally (before the birth). It's also important to highlight we see that all the time. That's a bread-and-butter to me, postpartum preeclampsia. And every day I diagnose patients with that. I admit them to the hospital, and they shake their head, and they say, "I never thought I could get that postpartum." And I think that's something that, we're working on, really highlighting that things can happen, but again, without scaring patients. And that's an important caveat of everything.

Host Amber Smith: So how many of these deaths do you think are preventable?

Rachael Sampson, MD: Eighty percent of these deaths are preventable, and the corollary of that is that 20%, only 20%, are truly not preventable.

So I think when we talk about preventability, that's something that is really looking at, was there at least some chance of the death being prevented by one or more reasonable changes to the patient, the family, the provider, the facility, the system or community factors?

And this is the definition that maternal mortality review committees use to determine if a death is preventable. So there's two questions. The first is, yes/no -- was this preventable? But the second is determining the chance to alter that outcome on a scale, no chance that this could have been altered, some chance or a good chance of changing that.

When we look at that 80% of 1,205 deaths, over 900 deaths that could have been preventable.

Host Amber Smith: So where are these maternal mortality review committees?

Rachael Sampson, MD: So these are state initiatives, or state led, and they are multidisciplinary. So what's wonderful about these is New York state, we have New Jersey, Pennsylvania, all places where I have practiced with ACOG.

And they're not just OB-GYNs. They're pathologists, because we're talking about autopsies. They are social workers. They are internal medicine doctors, cardiologists; they are community advocates. So it's really a multidisciplinary team that comes together in order to look at these causes in order to say, "Is there anything that could have prevented this?"

And/or "If the patient was not pregnant, would this have happened?"

And I think that's a really important clinical framework in order to frame it as an OB-GYN, because unfortunately in medicine, you can't control everything. And I think in obstetrics and gynecology, when you're dealing with two lives, and that perfect storm happens, that's really how you move it forward and how you make sure that you're doing right.

Host Amber Smith: The increase, these numbers that have gone up so much, it seems like really it's a crisis. What message do you have to health care providers? What do they need to know to catch these deaths and prevent them before they happen?

Rachael Sampson, MD: There's a lot. I think something that is kind of at the highlight of my list, just thinking offhand, is looking at implicit bias, looking at systemic and structural racism. I think that's a component that really has grown out of the past few years that I think was never part of our obstetric curriculum. That was never a consideration. I think that's something that, every day, physicians, not just OB-GYNs, but physicians, really need to look at when they are talking about mortality, morbidity (disease) and mortality in medicine. So I really think that's a really important one that's always at the front of my team's thought process, that when we talk about these numbers, we keep in mind that disparity and that that disparity persists -- socioeconomic, education factors, so behind all of those, we still have that.

Another thing, you're individualizing it, which is so important, precision medicine and individualizing it, but also the use of a bundle (guidelines to improve patient care) and checklists. And I think that those have a place, and I definitely appreciate those, and I do believe that there's high-quality evidence that says the use of a patient safety checklist and the use of a bundle does promote better outcomes because you have everybody on the same page running through the same things, and things aren't going to get missed or lost. What I sometimes worry about with the use of that is, are we putting a blanket over all patients, and is there more trouble coming from that?

So it's such a tough yin-yang to, go back and forth on that, but I think that keeping those in mind, we have, a lot of resources in place for maternal hemorrhage. We have a lot of resources in place for maternal hypertensive crisis. We have a lot of resources in place for venous thromboembolism, and that's pulmonary embolism clots related to pregnancy, because pregnancy is a hypercoagulable state (where bloods tends to clot easily).

We're becoming better, and we're putting more resources together for maternal mental health, which has also skyrocketed. That's something I didn't touch upon as of yet, but, again, from a medical point of view, I think doctors are very good at seeing a high blood pressure and knowing what to do. It's a lot harder for us with those less tangible signs and symptoms. And maternal mental health has really exploded and is a crisis, and that the mortality rates from that, again, were we not reporting them before? Were we not cued into them? Have they always been there? I don't know.

But the very fact that we talk about them now, and we see how high they are and that they're higher than other groups, other categories of death. When you have a point where sepsis (serious condition in reaction to infection or injury), it used to be called sepsis of childbirth, sepsis is still a concern, but less than maternal mental health and death from that, in a lot of cohorts, a lot of studies, that's really concerning.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast with your host, Amber Smith. My guest is Dr. Rachael Sampson, who is completing a fellowship in maternal fetal medicine at Upstate.

Is there anything that pregnant women or new moms need to keep in mind?

Rachael Sampson, MD: I think, again, I never want to scare patients. that's definitely not where I'm coming from, but to advocate for yourself and to keep advocating and do what you have to do to be heard. And if you don't feel well, make that known.

And if you still don't feel well, make it known even more and just persist because you know your body, and you know your body best. I just always want that. I want every patient to be heard.

Host Amber Smith: I think, like you said before, though, the tendency is, once you have the baby, and you're bringing the baby home, you think that's over, like that's in the past, the risks associated with being pregnant and delivering are over. But if that's not the case, especially with new moms that maybe don't know what to expect, it's a huge change.

Rachael Sampson, MD: It's huge. I think another really important change, or practice pattern, in the past, I'd say 10 years, is bringing patients back sooner.

I remember 10 years ago, 15 years ago, in medical school or pre-med, and you had a baby, and I remember the doctor saying, "I'll see you in six weeks." Didn't matter if you had a C-section, didn't matter if you had a vaginal birth. You went home for six weeks, and then you didn't go back to the doctor for six weeks because the doctor told you, "I won't see you for six weeks. I don't have to see you for six weeks." And now, when I was in practice, it was, "I'll see you in two weeks. That was very, very routine, and again, every practitioner has their different style. I said, "I'll see you in a week," or "Come see me. You will leave the hospital on Monday, Tuesday; come see me before the weekend. Come see me Thursday, Friday."

And again, traditionally patients said, "Well, is there something wrong with me? What's not right?" Even that awareness, I think, is helpful.

And I think that, again, if it's making it safer for us to have babies than it was for our grandmothers, I think that's fantastic.

Host Amber Smith: So when a new mom gets home with the baby, family and friends love to come over and see the baby, but is there something those people can do to help the mom or to be more aware of what might be going on with her?

Rachael Sampson, MD: I love that question. I think that any family support, just being there listening, and then I think, again, I use this word "checklist," but the blood pressure is ubiquitous in my world, and technology and devices have become so amazing, we can send patients home with these small blood pressure cuffs and just take the blood pressure. So my mom comes over, first thing she does is take my blood pressure. Then she looks and says how cute the baby is. Little things like that, it's little anecdotes that really make kind of a family checklist that, of course, the baby's here, and this is amazing, but how's mom? Let's check in and make sure that's not lost.

Host Amber Smith: Well, Dr. Sampson, thank you so much for making time to talk to us about maternal mortality.

Rachael Sampson, MD: Thank you for having me.

Host Amber Smith: My guest has been Dr. Rachael Sampson. She's completing a fellowship in maternal fetal medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

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