Health Policy$ense

Eight Steps to Preventing Pregnancy-Related Mortality in Philadelphia

City's Maternal Mortality Rate is 53% Higher Than National Average

A new report on maternal deaths in Philadelphia sheds light on a persistent problem and recommends concrete, doable steps to reduce pregnancy-related mortality. The 30 members of the Philadelphia Maternal Mortality Review (MMR) team, including LDI Senior Fellows Sindhu Srinivas and coauthor Pooja Mehta identified and reviewed all cases of Philadelphia residents who died within one year of the end of pregnancy from 2010-2012.

They found that 55 women died while pregnant or within one year of the end of pregnancy, during a period when there were approximately 69,000 total pregnancies. Of these 55 deaths, the team determined that 19 were directly related to the pregnancy or childbirth, resulting in a maternal mortality rate of 27.4 per 100,000 live births. This rate is strikingly higher than the national maternal mortality rate of 17.9 deaths per 100,000 live births, and more than twice the Healthy People 2020 goal of 11.4 per 100,000 live births.

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Poor, minority women bear a disproportionate burden of maternal mortality in Philadelphia, as they do nationally. All of the women with pregnancy-related deaths in Philadelphia were poor, and three-quarters were non-Hispanic African Americans.

But to be clear, these women do not seem to be dying from medical mismanagement. The team determined that health care providers or hospitals could have altered the outcome and perhaps prevented the death in only one of the 19 cases. Instead, most of the deaths can be traced to coordination of care, access issues, and systemic inequities in health care and social services resources available to women during their prenatal and postnatal period. The MMR team used the data from the study, along with extensive analysis of gaps in our health systems, social service systems, and community resources, to form a list of eight categories of recommendations, shown below. Taking these concrete steps, according to the MMR team, will help “prevent future maternal deaths, decrease severe maternal morbidity and improve the health and well-being of all area women of childbearing age.”

THE EIGHT STEPS
  1. HEALTH INFORMATION EXCHANGE
    • Implement a comprehensive Health Information Exchange (HIE) system in Philadelphia as soon as possible
    • Make prenatal lab results fully accessible to providers until a comprehensive HIE system is in place
  2. MATERNAL MORBIDITY AND MORTALITY SURVEILLANCE
    • Establish a state-wide Maternal Mortality Review (MMR) process in Pennsylvania
    • Establish a directive to sustain the Philadelphia MMR team
    • Make severe maternal morbidity a reportable event in Pennsylvania
    • Improve autopsy rates and the quality of death certificate completion at local hospitals
  3. PREGNANCY INTENTION AND FAMILY PLANNING
    • Remove financial barriers to inserting long-acting reversible contraception (LARC) for the immediate post-partum period or other inpatient hospital stays
    • Improve general access to long-acting reversible contraception (LARC) in outpatient settings
    • Remove barriers to voluntary post-partum tubal ligations
  4. BEHAVIORAL HEALTH
    • Convene a series of stakeholder meetings to improve coordination of care between prenatal and behavioral health services
    • Develop a city-wide protocol for pregnant and postpartum women on opiate-replacement therapy
    • Include postpartum depression scores in newborn discharge summaries
  5. INTIMATE PARTNER VIOLENCE
    • Support efforts of a coordinated Philadelphia response to the screening, management, and prevention of intimate partner violence (IPV)
    • Offer pregnant and postpartum women both in-person and computer-based options for IPV screening
  6. HOSPITAL & CLINIC-BASED CARE COORDINATION AND SUPPORT SERVICES
    • Increase the number of social work and care coordination staff within hospital/prenatal clinic settings
    • Encourage better communication and referral systems between hospitals and home visiting/community support programs
    • Increase the use and integration of community health workers in prenatal and postpartum care
  7. HOME-BASED CARE COORDINATION AND SUPPORT SERVICES
    • Create a coalition or council among home-based service programs in Philadelphia
    • Develop a unified referral system for home-based prenatal services
    • Create standardized trainings on high-risk prenatal/postpartum scenarios for nurse home visitors
    • Provide more prenatal and postpartum services for women without health insurance
  8. EMERGENCY SERVICES
    • Improve assessment and management of pregnant/postpartum women by first responders and emergency department staff
    • Make rapid HIV tests (and their results) available 24/7 in emergency rooms
    • Distribute 10-year smoke alarms with new baby discharge packages or at post-partum visits