Maternal mortality: causes and concerns from an OB hospitalist

By Dr. Rakhi Dimino on August 23rd, 2017

As a mom and an OBGYN, it hit me hard to learn that maternal mortality was higher in the United States than other developed nations. In the labor and delivery unit, I can vividly remember women who flirted with death and survived. One bled so profusely after birth that we heard the blood hit the ground. One mother sat straight up and said she was dying before she collapsed with an embolism. But we have read about other pregnant women who have died at home from a brain hemorrhage or from postpartum suicide. The birth of a baby should be one of the most normal events that a woman’s body endures, and even with access to modern medicine, we have not been able to decrease the maternal mortality rate in the U.S. for the last 25 years. Instead, it has actually increased. My home state of Texas leads the nation in the number of women who die during or shortly after delivery. Unfortunately, this is not a simple problem to solve, and there are many contributing factors.

The rise of chronic diseases
Although our knowledge of the birthing process has grown in the last quarter century, the profiles of women having babies has changed. Obesity, chronic hypertension, heart disease, and diabetes are all more common now than 20 years ago. The number of women delaying childbirth until their mid to late 30s or even their 40s has increased as well. As we increase in age, the prevalence of these same chronic medical problems increases even further. With improvements in fertility treatments, women who have previous medical conditions, such as cancer, are now able to pursue pregnancy. These baseline medical problems all increase the risk of maternal mortality.

Lack of access
But it’s not just that our bodies might be different from women having babies a few decades ago. Prenatal, delivery, and postpartum access to healthcare is lacking in large swaths across the country. As more and more rural hospitals close their labor and delivery units due to cost constraints, and the shortage of OBGYNs continues to grow, many women either go without care or must travel hours to get to a hospital with appropriate access to care. In most obstetrical emergencies, such as hemorrhage, stroke, embolism, and heart disease, minutes matter. There is no time for hours. Adding to distance challenges are astounding racial disparities. Black women are nearly three and a half times more likely to die from pregnancy related conditions than white women. Foreign-born women also have a higher maternal mortality rate. This begs us to look at access to pregnancy care as a key factor.

Issues in medical reimbursement
The way physicians often receive reimbursement might contribute to the problem as well. When physicians are reimbursed by the number of patients seen, time is money. In some clinics, one physician will see more than 40 pregnant patients in one office day. There is simply no time to listen to all of a patient’s concerns or adequately counsel them about which symptoms they should seek medical attention for. There is no reimbursement for any extra visits including screening of postpartum pre-eclampsia and depression about one week after delivery. This poor combination of potentially inadequate counseling and poor follow-up screens can contribute to missed early warning signs.

High C-section rate
As many have pointed out before, our high C-section rate likely contributes to maternal mortality as well. No one will argue that some C-sections are necessary. But many physicians do not offer a trial of labor after a previous C-section because most hospitals require a physician to be immediately available during the entire labor for safety reasons. It does not make economic sense for a physician to cancel an entire office day to be immediately present for one laboring patient. And yet each subsequent C-section leads to an increase of a life-threatening complications. At times, physicians are choosing what makes economic sense over what is best for the individual patient.

So what’s going to solve this issue? It won’t be physicians alone. It will take a collaboration of OB physicians, family physicians, OB anesthesiologists, nurse midwives, doulas, mother-baby nurses, hospital administrators, public health officials, lawmakers, and patients with their families. We must work as a village to build a safety net of support around our pregnant mothers, not just during pregnancy but after birth as well. Our team must realize that more intervention during childbirth is not always better, but a good support system is critical to decrease maternal mortality. As a team, we must be prepared to not only react to an emergent condition quickly, but also to predict and prevent one before it happens.

To build our maternal safety net, we must start thinking outside the box. Can we leverage technology and apps to monitor women at home who live remotely from a maternity hospital? Can we have doulas provide emotional support during labor and in the weeks to come, calling for help when concerning physical and mental symptoms arise? Can we decrease physician visits in low-risk women, and allow high risk patients to spend more time with physicians? Can midwives manage most low-risk prenatal and delivery care that could decrease our C-section rate while saving high-risk management for physicians? Could an inpatient OB hospitalist team be the glue that sticks this team together? None of these are new or impossible ideas, but they take good collaboration to maximize their usefulness.

The ability to study the causes of maternal mortality in detail is very important to solving this crisis. We cannot stop there. We must start building our collaborative support system. We must all be willing to work together and be a part of the solution to prevent the loss our mothers.


This blog provides general information and discussion about healthcare-related subjects. The content and linked materials provided are not intended and should not be construed as medical advice. If the reader is an expectant mother with a medical concern, she should consult with an appropriately licensed physician or healthcare provider.

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