Arkansas’ strategy to reduce maternal deaths

Women in the United States are more likely to die from childbirth or pregnancy-related causes than women in all other developed countries, according to the Centers for Disease Control and Prevention. More than 700 American women die each year due to pregnancy and childbirth-related complications. Arkansas has 35 maternal deaths per 100,000 live births; the national average is 20 deaths per 100,000 live births. The leading causes of maternal death are hemorrhage, heart problems, blood clots, infection and pre-existing chronic conditions.

Maternal deaths are increasing, but serious illness (morbidity) related to pregnancy and childbirth is increasing even faster. Each year more than 60,000 new mothers have serious or life-threatening complications – physical and/or mental – for up to a year after giving birth. Even healthy new mothers are at risk for these complications. The most common preventable errors include uncontrolled high blood pressure, fluid retention (edema) with preeclampsia, insufficient attention to vital signs and hemorrhage following C-section births.

From 1993 to 2014, the serious complication rate more than doubled. New mothers needing resuscitation from heart failure increased by 175 percent; endotracheal breathing tubes and sepsis infection treatment both increased 75 percent. C-section births have increased from less than 5 percent in the 1960s to 33 percent in 2016 – twice the rate in European countries. C-sections increase serious complication risks in subsequent pregnancies. Inducing labor has more than doubled since 2000, leading to prolonged labor and increasing hemorrhage risk.

The causes appear to be a combination of factors including inadequate access to care, pre-existing chronic conditions and increased use of drugs, tobacco and alcohol. Complications also increase with age. Women over age 35 are twice as likely to die of pregnancy complications as women aged 20 to 24.

The risk of pregnancy-related deaths for black women is almost four times higher than for white or Hispanic women. It takes billions of dollars a year to provide care – treating just one complication – preeclampsia – exceeds $1 billion annually.

Prior to 2003, Arkansas women could only access specialty obstetrical care in the state’s urban centers. Rural physicians often referred high-risk patients to urban hospitals staffed with maternal-fetal medicine and genetic specialists. But many patients could not afford to travel or did not seek the specialty care they needed.

In 2003, the state’s health leaders crafted a successful solution with the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), a high-risk obstetrical telemedicine program. By bringing expertise to rural providers, local co-management of high-risk pregnancies became possible.

Through telemedicine, the ANGELS team can provide a variety of experts statewide and is available at 57 health department units and 23 hospitals or clinics. ANGELS has helped reduce neonatal and post-neonatal deaths, increased the percentage of deliveries in neonatal intensive care-equipped hospitals and significantly decreased the rate of postpartum complications. In 2015, ANGELS diverted emergency visits that represented $1.2 million in cost savings.

The second part of Arkansas’ strategy to reduce maternal deaths and illness began in 2017 in hospitals providing obstetric services. Implementation of maternal safety bundles provided action plans for treatment of major causes of death and illness.

AFMC’s Medicaid Quality Improvement team is educating new mothers about post-delivery warning signs. The postpartum period is a critical time to ensure women and their newborns are healthy. It is important for women, family members and health professionals to understand warning signs that can lead to maternal death. Teaching women to recognize potentially life-threatening signs of post-birth complications can save lives.

The Arkansas General Assembly and Gov. Hutchinson addressed maternal deaths this year by establishing a maternal mortality review committee that will collect and analyze data to pinpoint the causes of maternal death. The committee will also develop strategies to prevent maternal deaths.

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Editor’s note: AFMC CEO Ray Hanley and Michelle Murtha, RN, are the authors of this guest commentary. The opinions expressed are those of the authors.