This Commentary is written by Dr. Michael Lindsay and Dr. Jane Ellis of Emory University School of Medicine
A recent article in a local publication was headlined “Georgia maternal death rate, once ranked worst in the U.S., worse now.” While the problem of maternal mortality is very real – and is of particular concern to us – the article contained key factual inaccuracies regarding 10-year maternal mortality trends in Georgia and painted a distorted picture of the public health efforts that are addressing this crisis.
The article acknowledged that data on Georgia’s maternal mortality “is so bad that no one really knows how high the rate is,’’ and went on to state that the maternal mortality rate (MMR) had increased from 20.5 maternal deaths/100,000 live births in 2006 to 37.2 in 2016. If that were correct, it would mean Georgia has the highest maternal mortality in the country – more than double the national MMR, which was 18.0 in 2014 (according to the CDC).
In truth, neither the public nor the medical community knows the true scope of Georgia’s maternal mortality crisis. Georgia lacks standardized, rigorous reporting and collection of maternal mortality data, so the data reported in the article may be inaccurate. It suffices to say that the situation is grave. But Georgians should know that serious efforts by medical and public health professionals are under way to address this public health crisis, and we urge Georgia’s political leadership to increase their support for this emergency response.
Georgia has not consistently reviewed maternal deaths. Fortunately, formal review was re-instituted in 2013 as a result of a partnership between the Georgia Department of Public Health (GDPH), the Georgia Obstetrical and Gynecological Society, the CDC and other groups.
This multidisciplinary, 35-member Maternal Mortality Review Committee (MMRC) includes physicians, nurses, midwives, public health officials, and epidemiologists.
At quarterly meetings, the MMRC reviews 15 to 20 maternal deaths, summarizes key clinical events preceding each death, determines if the death was pregnancy-related, and assesses whether each death was preventable. Importantly, the MMRC identifies opportunities to prevent deaths by highlighting key factors contributing to maternal mortality.
Let’s now examine the maternal mortality data more critically. The MMR is the annual number of pregnancy-related deaths that occur per 100,000 live births. A death is pregnancy-related if a woman died during pregnancy, at delivery, or during the postpartum period either from a pregnancy complication or an unrelated condition aggravated by pregnancy.
In interpreting Georgia’s MMR, it is essential to understand the two methods used to identify maternal deaths: (1) reviewing checkboxes and (2) matching fetal birth and maternal death certificates. The statistics obtained by these two methods are not always in harmony.
The Online Analytical Statistical Information System (OASIS), the Department of Public Health’s standardized health data repository, generates maternal mortality data using a checkbox on maternal death certificates. This “pregnancy checkbox’’ is designed to record whether the mother was pregnant at the time of death or within one year of death. However, checkbox completion is often prone to error since there is no standardized completion process, and individuals in many cases are not trained to identify and document pregnancy criteria. Furthermore, health care personnel are not required to confirm the accuracy of this entry on the death certificate.
The second approach – studying both fetal birth and maternal death certificates to confirm maternal deaths – is the care identification methodology used by Georgia’s MMRC.
These two approaches to data-gathering have produced strikingly divergent results. For example, in 2012, the first full year of maternal mortality review, the MMRC discovered that 25 percent of maternal deaths reported on OASIS could not be confirmed by the committee or were incorrectly identified as maternal deaths.
With this in mind, it is important to approach the 2016 OASIS data – which is yet to be validated by the MMRC – with a degree of skepticism. The MMR of 37.2, reported in the recent article, was taken directly from OASIS and may well be in error. The rates displayed in OASIS for 2012, 2013, and 2014, for example, are 17.7, 43.6 and 68.6, respectively, while rates for the same three years from the MMRC’s reviews are 19.9, 24.9 and 24.4, respectively.
Efforts are under way to improve the reporting and collection of data, as well as to implement health interventions to prevent maternal mortality. First, training for individuals who complete the pregnancy checkboxes began in 2016. We anticipate that rates computed following this training will be more consistent with rates determined by the MMRC. Second, Georgia is one of 18 states participating in the national Alliance for Innovation in Maternal Care (AIM). This alliance is responsible for development and dissemination of “patient safety bundles,’’ or management plans, to providers and hospitals to reduce maternal deaths. The first bundles introduced in Georgia address obstetric hemorrhage and severe hypertension, which are leading causes of maternal deaths. Implementation of these bundles, under the leadership of the Georgia Perinatal Quality Collaborative (GaPQC), should decrease the risk of maternal morbidity and mortality.
Finally, Georgia is in the early phases of adopting “Maternal Levels of Care’’ as mandated by passage of Georgia House Bill 909 during the 2018 legislative session. Maternal Levels of Care is a national initiative providing for designation of hospitals (Levels I-IV) based on the ability to handle high-risk pregnancies. Higher levels of care provide the expertise and infrastructure to effectively manage pregnancy complications. The goal is to create a statewide system to ensure that women with high-risk pregnancies are managed in appropriate clinical settings, thereby reducing the risk of adverse pregnancy outcomes, including death. Additionally, Georgia has a regionalized system of perinatal care. Each hospital has a designated perinatal center and can transfer a pregnant woman with pregnancy complications to one of these six centers for specialized care.
We acknowledge that Georgia faces many challenges to reduce maternal mortality.
We also realize that opportunities for action exist and that progress is being made to reduce our maternal mortality rate. We believe that the public deserves a balanced portrayal of the facts on this complex public health issue and should be educated about the initiatives that are being pursued to address this problem. Maternal mortality has the potential to touch any Georgian.
We need a sustained effort utilizing a systematic, fact-based approach to positively address the problem and achieve the objective of making childbirth safe for every mother in Georgia.
Dr. Michael Lindsay and Dr. Jane Ellis of Emory University School of Medicine are chair and co-chair, respectively, of the Georgia Maternal Mortality Review Committee