Talking about death and pregnancy in Texas: a tough discussion

In spring 2017, I attended a cardiology conference in San Antonio to contribute to a discussion about maternal mortality, which is when a mother dies during or shortly after childbirth. The World Health Organization classifies maternal mortality as occurring within 42 days after delivery, while the Centers for Disease Control and Prevention classifies it as death of a mother up to a year after childbirth.

Among resource-rich countries, the United States has the worst maternal death rate at 14 maternal deaths per 100,000 live births. Comparatively, Japan sees 5 deaths and Poland sees just 3 per 100,000 births, according to data from UNICEF.

What really hits home is that Texas has the worst maternal death rate in the country. In Texas, depending on how it is measured, the maternal mortality rate has nearly doubled since 2010. In 2010, there were 18.6 maternal deaths per 100,000 live births. In 2014, the number shot up to 35.8. One could argue that this may be the result of changes in reporting methods, including inaccurate cause of death coding and changes to these codes on women’s death certificates. Nonetheless, it’s something of which to take notice.

Discussions at the conference reinforced a message that surrounds nearly every health care field, from cardiology to neurology: So many deaths and painful conditions could be prevented with appropriate preventive care. And in far too many cases, maternal death falls into that category.

5 leading causes of maternal death in Texas

According to data from the Texas Health and Human Services Maternal Mortality and Morbidity Task Force 2016 Biennial Report, the five leading causes of maternal death are:The first three conditions listed above are chronic medical conditions, and not solely in pregnant women. They require treatment, which means seeing a doctor regularly.

Being pregnant and coping with these conditions increases the risk for maternal complications. Even women who have no medical problems can develop high blood pressure during or shortly after pregnancy. This condition is called preeclampsia. There are far too many stories of women developing the condition, which can escalate quickly into serious complications.

It’s also concerning that death by homicide and suicide account for 12.7 percent of deaths. Clearly we need to focus attention on treatment for mental health conditions and assess our patients’ risk for domestic violence.

Another major contributing factor to maternal risk in Texas may be limited access to optimal care. This can come from barriers to care, such as limited income or lack of public assistance programs. But another concern is inadequate care or even inattention of medical providers to symptoms that present during pregnancy or delivery.

There may be access limitations to subspecialists, such as a cardiologist or neurologist. This may be due to lack of resources in small communities, subspecialists being uncomfortable caring for pregnant patients, or insurance companies declining coverage. Lack of care can lead to symptoms such as severe lethargy, lightheadedness, or palpitations being brushed off as “normal” when in fact there may be a real problem, especially if you have an underlying medical condition such as heart disease or diabetes.

If you feel like something is wrong, or if someone close to you notices that you’re not well, please contact the hospital immediately. Maternal fetal medicine specialists (MFMs) are specially trained to look for these concerns, and we’ll help you access appropriate care to prevent serious complications or decrease your risk.

• Cardiac event: This is a broad category, but it includes conditions such as abnormal heart rhythms (arrhythmias), heart attack (myocardial infarction), and maternal congenital heart disease. Conditions such as arrhythmias and congenital heart disease are not necessarily preventable, but their risks are amplified as the body changes during pregnancy and birth. Having underlying health problems such as Type 2 diabetes and obesity, both of which are treatable and preventable, increases the risk for strain on your heart and having a heart attack.
• Drug overdose: Death from drug overdose in the general population continues to be a problem, especially with recent reports on the heroin epidemic plaguing our country. Drug use must be treated like any other disease or medical problem or it will remain a leading cause of maternal mortality. The majority of deaths in Texas women were due to licit or illicit prescription opioid drugs, according to the report.
• High blood pressure, or hypertension/eclampsia: High blood pressure must be controlled before and during pregnancy. We also take great care to manage blood pressure during labor. If left unmanaged, high blood pressure can lead to heart attack, stroke, seizures and death before, during, and after pregnancy.
• Hemorrhage: Many think of maternal death from hemorrhage as a third world problem. While we have made great gains in the United States, we still have work to do. Bleeding has to be managed aggressively, and it’s imperative to make sure your hospital has an adequate blood blank.
• Sepsis: This also is most frequently thought of as a third world problem given the availability of antibiotics in the United States. However, if infection is not recognized or if treatment is not sought early, sepsis can lead to death.

Seeing a doctor regularly can help improve your health during pregnancy

Women who already are connected to a primary care doctor or Ob/Gyn might be more likely to initiate prenatal care when they discover they’re pregnant. These women have more streamlined access to additional medical care, including management of current chronic diseases or those that develop before, during, or after pregnancy.

But the thousands of Texas women who don’t have established doctor-patient relationships easily can fall through the cracks. We urge you – even if you come in late for prenatal care, even if the first time we see you is at delivery: Ask for help in setting up care following your post-partum visit with your OB. There may be options in your community you aren’t aware of. Your relationship with a primary care doctor should be a partnership aimed at optimizing your health.

We encourage women to maintain and improve their health before, during, and after pregnancy, and connecting with a primary care doctor is a good first step. Your healthy choices cross over to the baby, even after pregnancy. For example, getting control of high blood pressure or diabetes improves organ function, energy levels, and overall health. And when you are healthier, you’re better equipped to care for your new baby.

Women’s and doctors’ roles in turning these numbers around

When a mom’s first interaction with an obstetrician is in labor and delivery rather than in prenatal care, the situation becomes risky for mom and baby. It’s easier on everyone if we know in advance that the mother has risk factors such as diabetes and hypertension.

Women in North Texas can take charge of their health before and during pregnancy in a number of ways:
Of course we’re thinking of your baby’s well-being. But before baby comes, you’re our patient. Your health is a major factor on your baby’s health. It’s up to you and your doctor to work toward a healthier you to be there for the new little one for years to come.

• See a doctor before you get pregnant, or as soon as you find out you’re pregnant, in order to optimize your health. The doctor can help you take charge of risk factors that may cause complications during pregnancy or delivery and help you optimize your medications if needed.
• Learn about your local hospital. Do they have MFMs on staff if a complication arises? How ready is their blood bank to handle emergencies? Are they able to accommodate your special needs if you have diabetes or another chronic condition? Going in to labor and delivery prepared benefits you, your baby, and your care team.
• Ask questions. Never be afraid or embarrassed to ask questions if something seems wrong with your health. You know your body better than anyone else, and you’re your own best advocate.