Maternal Mortality in the United States: Predictability and the Impact of Protocols on Fatal Postcesarean Pulmonary Embolism and Hypertension-Related Intracranial Hemorrhage EDITORIAL COMMENT

Maternal mortality rates in the United States have remained unchanged for several decades. The authors' institution created protocols for preventing maternal deaths from postcesarean pulmonary embolism (PE), intracranial hemorrhage in women with hypertensive crisis, and postpartum hemorrhage (PPH). The current study presents its 6-year observation and clinical results of these measures as well as examines the issue of predictability of maternal death. The Hospital Corporation of America encompasses 110 maternal/newborn facilities in 21 states. After a review of maternal deaths that occurred during 2000 to 2006, three patient safety programs were developed to reduce such deaths. These programs included use of intraoperative and postoperative pneumatic compression devices in women having cesarean delivery (CD); protocols for prompt recognition and treatment of hypertensive crisis and preeclampsia-related PE; as well as protocols for obtaining assistance and replacing fluid, blood, and components for PPH. After introduction of these protocols, a review was conducted of deaths that occurred in 2007 to 2012. With the use of a hypothetical ideal medical system, the maximum possible effect of an ideal system of maternal transport and availability of specialized referral centers on maternal mortality rates was determined. During 2000 to 2006, a total of 95 maternal deaths occurred among 1,461,270 births (6.5/100,000). During 2007 to 2012, a total of 81 maternal deaths occurred among 1,256,020 deliveries (6.4/100,000 births). However, when causes of death were examined during 2007 to 2012 and compared with those in 2000 to 2006, there was a statistically significant decline in the rates of fatal postcesarean PE (7 vs 1 or 0.5/100,000 vs 0.07/100,000; P = 0.038) and maternal mortality from hypertensive etiology (15 vs 3 or 1/100,000 vs 0.2/100,000; P = 0.02). Rates of death from other causes did not change. Of the entire 176 deaths during 12 years, 99 women (56%) had no significant risk factors of the ultimate cause of death at the initial examination; 32 women (18%) had known, terminal, or end-stage disease or cardiac arrest. On admission, 45 patients (26%) had known risk factors of the ultimate cause of death, but 76% of these women were admitted to a specialized center. Only 12 maternal deaths (7%) would have been prevented with an ideal system of risk identification and transport to specialized centers, even assuming that all women with common conditions were transported to specialized centers. Sixty-eight (84%) and 13 deaths (16%) were associated with CD and vaginal birth, respectively (P < 0.001). Thirty of the CD-associated deaths were perimortem procedures; 35 deaths were related to the indication for CD and were unrelated causally to the route of delivery. Only 3 deaths were potentially related causally to CD, 1 each from surgically induced bleeding, pulmonary hypertension, and PE after CD. Disease-specific protocols can reduce maternal death due to hypertensive disease and postoperative PE. Annually in the United States, 2 to 6 women die because of CD. Reducing deaths from PPH should be a priority for preventing maternal deaths in the future.