Maternal Health Issues

Barbara Parker R.N., M.P.H.Division of Women’s and

Infants’ HealthVirginia Department of

HealthOctober 25, 1999

Major Issues Regarding Maternal Health

Maternal MortalityInfant MortalityLow Birth WeightAccess to Care

The 3 leading causes of maternal death in the

United StatesHemorrhage, including

ectopic pregnancyPregnancy-Induced

HypertensionPulmonary Embolism

Reasons for reduction in maternal mortality

Sulfa and antibiotic drugsDecrease infections

secondary to illicit abortionsAvailability of banked bloodSafer surgical procedures,

including Cesarean

The Year 2000 goal (3.3 maternal deaths per

100,000 live births) will not be reached

nationally or in Virginia.

Most obstetric complications which lead to maternal deaths can neither be predicted nor

prevented.

Maternal mortality is not reduced through general

improvement in nutrition, education, or

elevation in social status.

Maternal Deaths by RaceVirginia Residents, 1991-1997

Year Number ofDeaths

Maternal Mortality Ratio

White Black Other Total

1991 3 1.4 8.4 0.0 3.1

1992 6 2.9 12.7 29.5 6.2

1993 4 4.4 4.3 0.0 4.3

1994 6 2.9 18.1 0.0 6.4

1995 4 1.5 14.2 0.0 4.4

1996 3 3.0 0.0 20.8 3.3

1997 4 4.6 0.0 18.9 4.4

Components of maternal death reviews

Investigation of individual maternal death

Multidisciplinary discussion of each case

Recommendations to prevent future deaths

Maternal mortality is reduced by:

Quality intrapartum careAccess to emergency

obstetric care

Infant mortality is a health status variable

which is widely recognized as a measure of a nation’s, as well as a

state’s, maternal and child health status.

The United States ranks 22nd in the world in

infant mortality.

Countries with lower infant mortality rates

than the U.S. have comprehensive medical

care systems that provide virtually all

pregnancy and infant health care visits.

African-American babies are more likely to die in America than their white counterparts when born with the same medical

risks.

Social standing in a community is linked to favorable outcomes in

perinatal care even when access to services

is constant.

Role of men in pregnancy and childbirth:

Encourage reduction of risky behaviors such as smoking, drug and alcohol use

Follow healthy nutrition Promote early and regular prenatal care

Increase assistance with household chores

Observe for complications of pregnancy

Strategies to reduce infant mortality:

Expand Medicaid eligibility

Simplify and shorten eligibility requirements

Provide “wrap-around” services

The improvement in infant mortality rates is

not an indicator that babies are healthier, but

medical technology is enabling sicker babies

to survive.

Resource Mothers - home visiting mentors for pregnant teens and

their familiesBaby Care - case management

services after completion of a “risk assessment” with coordination,

follow-up and monitoringVirginia Healthy Start Initiative - mentoring services for pregnant

women; nutrition services for prenatal patients and infants; male

support services for fathers; and community-based death reviews.

Regionalization of perinatal care was

successful in the 1970s and 1980s by

concentrating the births of very low birth weight infants to the tertiary

centers.

RPCCThe Regional Perinatal Coordinating Councils

(RPCCs) are public/private coalitions charged with the goal to improve the system by which perinatal health care is provided within

Virginia.

Quality of Care

Guidelines for Perinatal Care -ACOG/AAP

Toward Improving the Outcomes of Pregnancy - March of Dimes

National Fetal and Infant Mortality Review

National Fetal-Infant Mortality Review (NFIMR) Program

Established in 1990Public-private partnership

American College of Obstetricians and Gynecologists (ACOG)

Maternal and Child Health BureauMarch of Dimes Birth Defects

Foundation

FIMR is:Community-based, action-

oriented processEarly warning system that

describes health careMethod of continuous quality

improvementMeans to implement core

public health functions

Objectives:

Initiate an interdisciplinary review of fetal and infant death from medical and social records and maternal interview.

Describe significant social, economic, cultural and systems factors that contribute to mortality.

Design and participate in implementing community-based interventions determined from review findings.

Low Weight Births:

7.7% of all Virginia BirthsHas not significantly changed since 1970s

Single most important contributor to infant death

The etiology of preterm labor and premature

birth is unknown.

Low Birth Weight is associated with multiple factors:

Medical Risk Factors High parity Chronic diseases Previous Low Birth Weight infant Genetic factors Multiple gestation Poor weight gain Infection Placental problems Premature rupture of membranes Fetal anomalies Maternal stress

Low Birth Weight (continued)

Demographic Risk Factors Age < 17 years and > 34 years African-American race Low socioeconomic status Unmarried Low education

Behavioral Risk Factors Smoking Poor nutrition Toxic exposures Inadequate prenatal care Substance abuse

Long-term effects of Low Birth Weight

Neurologic disordersLearning disabilitiesDelayed development

Prevention of low birth weight infants is related

to effective family planning.

Efforts to reduce Low Birth Weight are either:

Population-level activitiesIndividual-level strategies

Early and regular use of prenatal care is a strong

predictor of positive pregnancy outcomes.

In 1996, 15.3% of women were uninsured

in Virginia

ConclusionStudies of underlying factors

that contribute to morbidity and mortality are needed

Review of quality of health care and access to care for all women and infants is needed.

Racial/ethnic disparities need to be eliminated.