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The Lancet article

CDC article, Severe Maternal Morbidity in the United States

Severe Maternal Morbidity (SMM)[edit]
Severe maternal morbidity or SMM, is defined by the CDC as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.” There are nineteen total indicators used by the CDC to help identify SMM, with the most prevalent indicator being a blood transfusion. Other indicators include an acute myocardial infarction ("heart attack"), aneurysm, and kidney failure. All of this identification is done by using ICD-10 codes, which are disease identification codes found in hospital discharge data.

In the United States, severe maternal morbidity has increased over the last several years, impacting greater than 50,000 women in 2014 alone. There is no conclusive reason for this dramatic increase. It is thought that the overall state of health for pregnant women is impacting these rates. For example, complications can derive from underlying chronic medical conditions like diabetes, obesity, HIV/AIDs, and high blood pressure. These underlying conditions are also thought to lead to increased risk of maternal mortality.

Causes[edit]
Factors that increase maternal death can be direct or indirect. In a 2009 article on maternal morbidity, the authors said, that generally, there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or management of the two, and an indirect maternal death,[10] that is a pregnancy-related death in a patient with a preexisting or newly developed health problem unrelated to pregnancy. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or nonobstetrical maternal deaths.

According to a study published in the Lancet which covered the period from 1990 to 2013, the most common causes are postpartum bleeding (15%), complications from unsafe abortion (15%), hypertensive disorders of pregnancy (10%), postpartum infections (8%), and obstructed labour (6%).[5] Other causes include blood clots(3%) and pre-existing conditions (28%).[11] Indirect causes are malaria, anemia,[12] HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it.

According to a 2004 WHO publication, sociodemographic factors such as age, access to resources and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers,[13] especially adolescents aged 15 years or younger.[14] Adolescents have higher risks for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death.[14] Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death.[15]

Public health [edit]
A public health approach to addressing maternal mortality includes gathering information on the scope of the problem, identifying key causes, and implementing interventions, both prior to pregnancy and during pregnancy, to combat those causes.

Public health has a role to play in the analysis of maternal death. One important aspect in the review of maternal death and its causes are Maternal Mortality Review Committees or Boards. The goal of these review committees are to analyze each maternal death and determine its cause. After this analysis, the information can be combined in order to determine specific interventions that could lead to preventing future maternal deaths. These review boards are generally comprehensive in their analysis of maternal deaths, examining details that include mental health factors, public transportation, chronic illnesses, and substance use disorders. All of this information can be combined to give a detailed picture of what is causing maternal mortality and help to determine recommendations to reduce their impact.

Many states within the US are taking Maternal Mortality Review Committees a step further and are collaborating with various professional organizations to improve quality of perinatal care. These teams of organizations form a "perinatal quality collaborative," or PQC, and include state health departments, the state hospital association and clinical professionals such as doctors and nurses. These PQCs can also involve community health organizations, Medicaid representatives, Maternal Mortality Review Committees and patient advocacy groups. By involving all of these major players within maternal health, the goal is to collaborate and determine opportunities to improve quality of care. Through this collaborative effort, PQCs can aim to make impacts on quality both at the direct patient care level and through larger system devices like policy. It is thought that the institution of PQCs in California was the main contributor to the maternal mortality rate decreasing by 50% in the years following. The PQC developed review guides and quality improvement initiatives aimed at the most preventable and prevalent maternal deaths: those due to bleeding and high blood pressure. Success has also been observed with PQCs in Illinois and Florida.

Several interventions prior to pregnancy have been recommended in efforts to reduce maternal mortality. Increasing access to reproductive healthcare services, such as family planning services and safe abortion practices, is recommended in order to prevent unintended pregnancies. Several countries, including India, Brazil, and Mexico, have seen some success in efforts to promote the use of reproductive healthcare services. Other interventions include high quality sex education, which includes pregnancy prevention and sexually-transmitted infection (STI) prevention and treatment. By addressing STIs, this not only reduces perinatal infections, but can also help reduce ectopic pregnancy caused by STIs. Adolescents are between two and five times more likely to suffer from maternal mortality than a female twenty years or older. Access to reproductive services and sex education could make a large impact, specifically on adolescents, who are generally uneducated in regards to carrying a healthy pregnancy. Education level is a strong predictor of maternal health as it gives women the knowledge to seek care when it is needed.

Public health efforts can also intervene during pregnancy to improve maternal outcomes. Areas for intervention have been identified in access to care, public knowledge about signs and symptoms of pregnancy complications, and improving relationships between healthcare professionals and expecting mothers.

Access to care during pregnancy is a significant issue in the face of maternal mortality. "Access" encompasses a wide range of potential difficulties including costs, location of healthcare services, availability of appointments, transportation services, and cultural or language barriers that could inhibit a woman from receiving proper care. For women carrying a pregnancy to term, access to necessary antenatal (prior to delivery) healthcare visits is crucial to ensuring healthy outcomes. These antenatal visits allow for early recognition and treatment of complications, treatment of infections and the opportunity to educate the expecting mother on how to manage her current pregnancy and the health advantages of spacing pregnancies apart. Access to birth at a facility with a skilled healthcare provider present has been associated with safer deliveries and better outcomes. The two areas bearing the largest burden of maternal mortality, Sub-Saharan Africa and South Asia, also had the lowest percentage of births attended by a skilled provider, at just 45% and 41% respectively. Emergency obstetric care is also crucial in preventing maternal mortality by offering services like emergency cesarean sections, blood transfusions, antibiotics for infections and assisted vaginal delivery with forceps for vacuum. In addition to physical barriers that restrict access to healthcare, financial barriers also exist. Close to one out of seven women of child-bearing age have no health insurance. This lack of insurance impacts access to pregnancy prevention, treatment of complications, as well as perinatal care visits.

By increasing public knowledge about pregnancy, including signs of complications that need addressed by a healthcare provider, this will increase the likelihood of an expecting mother to seek help when it is necessary. Higher levels of education have been associated with increased use of contraception and family planning services as well as antenatal care. Addressing complications at the earliest sign of a problem can improve outcomes for expecting mothers, which makes it extremely important for a pregnant woman to be knowledgeable enough to seek healthcare for potential complications. Improving the relationships between patients and the healthcare system as a whole will make it easier for a pregnant woman to feel comfortable seeking help. Good communication between patients and providers, as well as cultural competence of the providers, could also assist in increasing compliance with recommended treatments.

The biggest global policy initiative for maternal health came from the United Nations' Millennium Declaration which created the Millennium Development Goals. In 2012, this evolved at the United Nations Conference on Sustainable Development to become the Sustainable Development Goals (SDGs) with a target year of 2030. The SDGs are comprised of 17 goals that call for global collaboration to tackle a wide variety of recognized problems. Goal 3 is focused on ensuring health and well-being for people of all ages. A specific target is to achieve a global maternal mortality ratio of less than 70 per 100,000 live births. So far, specific progress has been made in births attended by a skilled provider, now at 80% of births worldwide compared with 62% in 2005.