FIGURE 1-6 Trends in maternal mortality ratio (per 100,000 live births) by race: United States, 2005-2014. (Data from Moaddab, 2016.) reporting definitely contributes to the rise (MacDorman, 2016b, 2017). In the past, maternal deaths were notoriously underreported (Koonin, 1997). Third, and related to the second explanation, the rate of rise is at least partially due to the revised death certificate and its pregnancy checkbox described earlier (Main, 2015). Fourth, the number of pregnant women with severe chronic health conditions, which place women at higher risk, is greater (Centers for Disease Control and Prevention, 2017a). Finally, the increased proportion of births to women older than 40 years contribute to higher mortality rates (MacDorman, 2017).
Whatever the cause, the apparent sharp rise of the maternal mortality rates has galvanized the obstetrical community to action (Chescheir, 2015). According to Barbieri (2015), the Joint Commission has recommended that birthing centers establish standardized protocols and implement simulation eforts. D' Alton and colleagues (2016) described eforts of a working group to lower morbidity and mortality rates.
Another consideration is the obvious disparity of higher mortality rates among black, Hispanic, and white women as shown in Figure 1-6. Racial disparities translate to health care availability, access, or utilization (Howell, 2016; Moaddab, 2016). And, maternal mortality is disparately high in rural compared with metropolitan areas (Maron, 2017).
Importantly, many of the reported maternal deaths are considered preventable. Berg and colleagues (2005) estimated that this may be up to a third of pregnancy-related deaths in white women and up to half of those in black women. In one evaluation of an insured cohort, 28 percent of 98 maternal deaths were judged preventable (Clark, 2008). hus, although significant progress has been made, further eforts are imperative for obstetrics in the 21 st century.
his serves as another measure to guide prevention eforts. Lowering medical error rates serves to diminish risks for maternal mortality or severe maternal morbidity. The terms near misses or close calls were introduced and defined as unplanned events caused by error that do not result in patient injury but have the potential to do so (Institute for Safe Medication Practices, 2009). hese are much more common than injury events, but for obvious reasons, they are more diicult to identiy and quantiy. Systems designed to encourage reporting have been installed in various institutions and allow focused safety eforts (Clark, 20i12; Main, 2017; Shields, 2017). The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (20 16f) have provided lists of suggested screening topics for this purpose.
Several data systems now measure indicators of unplanned events caused by errors that have injurious potential. This evolution followed inadequacies in the ability of hospitalization coding to reflect the severity of maternal complications. Thus, coding indicators or modifiers are used to allow analysis of serious adverse clinical events (Clark, 2012; King, 2012). Such a system was implemented by the World Health Organization. It has been validated in Brazil and accurately reflects maternal death rates (Souza, 2012). Similar systems are in use in Britain as the UK Obstetric Surveilance System-UKOSS (Knight, 2005,i2008). In the United States, one example is the National Partnership for Maternal Safety (D'Alton, 2016; Main, 2015).