By Robert Fulton
California Health Report
Yolanda Serrano eagerly anticipates the arrival of her first child. The 22-year-old is due to give birth to her baby boy this month, and has regular checkups with her obstetrician at the Institute for Maternal Fetal Health, a collaboration between Children’s Hospital and the University of Southern California at Hollywood Presbyterian Medical Center in Los Angeles.
Doctors diagnosed Serrano with hyperthyroidism at the age of 12, and she treats the condition through a combination of diet and medication. Serrano’s thyroid levels are under control, and though they may increase after giving birth, there should be no complications to her or her child because of the condition.
“Now it’s just a matter of me continuing that diet, not trying to eat fast food as much,” said Serrano, a South Los Angeles resident studying criminal justice at East Los Angeles College.
Serrano is proactively maintaining her health during her pregnancy, a strategy experts think may be key to improving maternal mortality rates.
A recent report from the California Health Care Foundation shows that the maternal mortality rate in California has increased significantly since the late 1990s. Furthermore, the same report shows a wide disparity in maternal mortality between African American women and the rest of the population.
“A Mixed Bag: Clinical Quality in California,” authored by health care consultant Jennifer Joynt, is part of the CHCF’s California Health Care Almanac. Joynt is also the project manager Almanac.
According to the report, the maternal mortality rate in California more than doubled from 1999 to 2006 before declining in recent years. The rate was 7.7 deaths per 100,000 live births in 1999 and 11.6 in 2009. The national rate rose from 9.9 deaths per 100,000 live births in 1999 to 12.7 in 2007. African American women in California were nearly four times as likely to die from childbirth, suffering 41.1 deaths per 100,000 live births over a three year moving average from 2007 to 2009.
“The number of mothers dying during birth is still pretty small, but it is concerning that it’s been going up,” Joynt said.
“A Mixed Bag” doesn’t give specific reasons for the increase in maternal mortality, nor does it offer solutions. But the report, health care providers and officials offer insight as to possible causes for the increase. These include changes in the way maternal mortality has been reported; access to quality pre-natal care; an increase in the number of women having children later in life; an increase in the number of women with chronic diseases such as obesity, hypertension and diabetes; and an increase in artificial reproduction methods and Cesarean sections.
The California Pregnancy-Associated Mortality Review, published in April 2011, states that improved data reporting may account for approximately a third of the increase in the maternal mortality rate. However, this does not explain the entire increase, nor the ethnic disparities in the maternal mortality rate.
Sara Twogood and Alyssa Wittenberg, obstetricians/gynecologists with the Institute for Maternal Fetal Health and assistant professors of clinical obstetrics and gynecology at the USC Keck School of Medicine, point to the impact of chronic diseases and poor health on expectant and postpartum mothers.
Expectant mothers with chronic diseases such as diabetes, hypertension and obesity are at greater risks for complications relating to childbirth; and expectant mothers who are obese are at risk for gestational diabetes, gestational hypertension and preeclampsia. Obesity can lead to a hypercoagulable state, which can lead to blood clots, pulmonary embolism, stroke and heart attack. “A Mixed Bag” shows that one in five California mothers with a recent live birth was obese prior to pregnancy, 12 percent had diabetes and 10 percent had hypertension.
“If you’re dealing with a patient who has multiple chronic diseases, they’re a lot likely to have issues during their labor course or post-partum complications, things like that,” Wittenberg said.
Twogood added that an increase in artificial reproductive technology such as invitro fertilization could lead to increases in morbidity and possibly mortality; and that women are getting pregnant later in life. According to “A Mixed Bag,” women age 40 and older suffered maternal mortality at a rate of 41.8 deaths per 100,000 live births from 2007 to 2009.
“With increased age you’re at an increased risk for multiple health problems before and during pregnancy, like high blood pressure, diabetes,” Twogood said.
Another factor in increased maternal mortality may be an increase in Cesarean sections. Live births by Caesarean rose 40 percent in California from 2000 to 2010, according to the California Health Care Foundation report.
“If you think about the main reasons that would lead to mortality in a pregnant woman, pulmonary embolism is huge, and so is hemorrhage,” Wittenberg said. “And both of those things you’re at higher risk of after caesarean delivery.”
The disparities between African American women and the rest of population in relation to maternal mortality are difficult to explain, but professionals believe that the population is more susceptible to the potential causes of maternal mortality, such as lack of access to quality prenatal care and chronic disease.
“In general we don’t really know, but there’s a lot of theorized reasons as to why,” said Dr. Diana Ramos, Director of Reproductive Health of Maternal, Child, and Adolescent Health Programs for the Los Angeles County Department of Health, and an associate professor at the USC Keck School of Medicine.
While the increase in the maternal mortality in California since 1999 is alarming, successful steps have been taken to lower the rate in recent years.
According to the California Department of Public health, the maternal mortality rate for all women in California dropped to 9.2 deaths per 100,000 live births in 2010, and to 33.8 for African American women during a three year moving average from 2008 to 2010. While the numbers are still higher than they were in the late ‘90s, and the disparity remains, the declining numbers are a positive sign.
Dr. Shabbir Ahmad is the Director of the California Department of Public Health Center of Family Health’s Maternal, Child and Adolescent Health Program. He credits various programs implemented in recent years for the continuing decrease in maternal mortality, such as a partnership with the California Maternal Quality Care Collaborative. Toolkits created include looking at how to reduce non-medically necessary inductions and how to respond to hemorrhaging.
“I am hopeful as we move forward we’ll be seeing a better result,” Ahmad said. “My main concern is how we can reduce the gap between African Americans and other ethnic groups.”
The Los Angeles County Maternal Care Quality Improvement Project Implementation Guide was designed to provide public health departments with a guide to decrease obstetric hemorrhage.
“We took advantage of the electronic platform in which to disseminate all of the information and subsequent data has shown that there’s decrease in blood product transfusion in those hospitals that actually implemented it,” Ramos said.
The Institute for Maternal Fetal Health treats expectant mothers with a fetal anomaly. Patients receive top obstetrician care through USC and then Children’s Hospital steps in with care for the baby.
Wittenberg and Twogood see the key to the maternal mortality rate continuing to decline laying in better overall health.
“If patients are healthier before pregnancy, then the likelihood of having complications is a lot less,” Wittenberg said.