The intricacies of maternal mortality

By Toutou Moussa Diallo, DBA

Executive Summary

The rise in maternal mortality is not acceptable in the United States, nor in the State of New York. The Center for Disease Control and Prevention (2019) defines a pregnancy-related death as the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. This paper focuses on reducing Maternal Mortality (MM) in New York State, starting in New York City. It will discuss some of the contributing factors of this phenomenal rise of MM in the United States and best practices of the scholar practitioner model around the world that healthcare professionals can use to minimize the death rate of mothers. The Scholar Practitioner Model identified the role of a scholar practitioner as, “To advance both theory and practice” (Wasserman & Kram, 2009). This model identifies lessons learned in the field, reflect on them, conceptualize and act upon them and its applicability in the healthcare system in the United States.

Once the United States was the world leader in healthcare and education. Now it is trailing behind some developing countries. Lim et al. 2018 defines human capital as the level of education and health in a population and is considered an important determinant of economic growth. The World Bank calls for measurement and annual reporting of human capital to track and motivate investments in health and education and enhance productivity (Lim et al. 2018). In 1990s, United States of America ranks 6^th , a world leader in healthcare and education, now ranks 27^th (Business Insider, 2020).

This paper will (1) review literatures on causes of maternal death after delivery (vaginal and C-Sections) postpartum care in the United States, (2) provide statistical facts, data collection and utilization, (3) identify gaps between scholars and practitioners interaction, (4) impact of maternal mortality in society (5) Conclude, (6) provide a proposed plan of a local nonprofit, and (7) make recommendations.

Introduction

Postpartum period (whether through vaginal delivery or caesarian section) refers to the first six to eight weeks after childbirth depending on the mother’s health condition. This period is critical because mother’s health is at risk because of tiredness, fatigue, womb healing, and regaining strength. It is a time of transition from carrying a child and taking care of the child, self, husband (if married), and family (Dildy, 2002). This period is where the life of the mother is at risk due to physical and emotional states after delivery. It is even worse when the mother does not have the support in place to care for herself and her child. One may ask, which delivery is the culprit of the rise in maternal death?

Mother experiences womb soreness, tear, and urinary problems after vaginal delivery (Relias.com , 2018). Mother becomes physically and emotionally drained and exhausted. Mother needs plenty of rest, good nutrition, and help during this postpartum period (Milani et al., 2017) A caesarian section is a major surgery. Like any other surgery the body needs time to heal and recover. In the hospital, mother may get help during her three to four days after delivery or longer if there are complications (Deneux-Tharaux et al., 2006). The burden becomes heavier when she returns home to care for herself and her child. If married, her situation may take a downturn, and her condition may worsen (Cheng et al., 2006).

Epidemiology of Postpartum Care

Postpartum care is not well documented and needs serious attention because the health of the mother is threaten and may lead to premature death. Cheng et al. 2006 emphasize that the neglect of postpartum maternal care is seen in the limited number of national health objectives and data collected related to maternal health.

Epidemiology of Vaginal Delivery

There is not enough data to support postpartum care after vaginal and C-Sections, however, there is an increasing awareness of the mother physical and emotional health conditions after vaginal delivery. Health problems associated with vaginal delivery between 8 and 24 weeks postpartum were exhaustion/extreme tiredness, backache, bowel problems, lack of sleep/baby crying, hemorrhoids, perineal pain, excessive/prolonged bleeding, urinary incontinence, mastitis and other urinary problems (Thompson, Roberts, Currie, Ellwood, 2002).

Epidemiology of Caesarian Sections

Between 1970 and 1978 the National Institutes of Health (NIH) examined the reasons for the rise in maternal mortality and found that 30 percent was due to a dystocia (failure to progress in labor and cephalopelvic disproportion), 25 to 30 percent caesarian sections, 10 to 25 percent to breech presentation (the incidence of an infant presenting by the breech at term), and 10 to 15 percent to fetal distress (Sachs, 2018).

Cesarean Sections were implemented to save the lives of the child and the mother, but over the years the practice of C-Sections has been overuse and unnecessary (Sachs, 2018). The first C-Sections was performed by Dr. John Lambert Richmond in 1827 (Sachs, 2018). During that time, C-Sections resulted in high maternal mortality and morbidity because doctors believed that the uterus should not be sutured (Sachs, 2018). Sachs (2018) points out that 6.2 million unnecessary cesareans are performed each year, half in Brazil and China. Unfortunately, the same pattern of unnecessary cesareans are performed in the United States and the rate varies from hospitals to hospitals. According to Hayes & McNeil (2019), 31.9 percent of all births were by cesareans and 25.9 percent of the NTSV (low risk) population had caesarian births. NSTV population are first-time moms with potentially “low-risk” births, single full term baby in the head down position (Hayes & McNeil, 2019). According to Hayes & McNeil (2019), the NSTV caesarian birth rate reached its peak on 2009 at 28.1% and 86.7% of women had a history of a previous caesarian birth. Many hospitals and obstetricians do not allow their patients to give vaginal birth in their facilities because doctors don’t believe that women who previously had a C-Sections cannot give birth vaginally. These repeat cesareans increase long-term complications of placenta accrete (Hayes & McNeil, 2019).

Statistical Facts

In this 21^st Century, statistics on maternal death are staggering and the interaction between scholars and practitioners has been lost. From 2000 to 2014, between 700 and 900 women die each year from complications in pregnancy and childbirth worldwide (WHO, 2019). Another study done by the World Health Organization in 2017 indicates a 38% drop in maternal mortality, about 801 death worldwide. For every woman who dies, approximately 20 others suffer serious injuries, infections, or disability. The United States maternal mortality has increased from 7.2 deaths per 100,000 live births in 1987 to 16.7 deaths per 100,000 liver births in 2016 (Hayes & McNeil, 2019). The World Health Organization (WHO) (2019) describes that four major causes of MM (maternal mortality) are due to complications before and after pregnancy:

severe bleeding (mostly bleeding after childbirth)
infections (usually after childbirth)
high blood pressure during pregnancy (pre-eclampsia and eclampsia)
complications from delivery
unsafe abortion.

United States of America is the World Power, the land of opportunity, and the land of liberty and freedom. Every developed country looks up to the United States of America. With all the money, the best doctors, and healthcare services, and the initiation of the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention Maternal Mortality Study Group, which established the Pregnancy Surveillance System in 1986. Despite all the positive contributors in the United States, the rate of maternal mortality has been rising since 2014.

The United States of America has the worst rate of maternal deaths among developed countries. Though 99 percent of all maternal deaths occur in developing regions, more American women are dying of pregnancy-related complications than any other developed country. Every year in the United States 700 women die from pregnancy delivery complications (CDC 2017). The rate is highest among black women and in rural areas (NPR, 2017). In the United States, maternal death increased by 23.8% deaths between 2000 and 2020 per 100,000 live births (Del, 2018, Center for Disease Control and Prevention, 2020). According to Kheyfets (2022), New York City ranks 30^th in maternal mortality where Black and Latino women die prematurely. Being always last to receive political and social development attention, the rise in maternal mortality in the Bronx is staggering at 32.6% deaths per 100,000 live births (Gibson, 2022).

How was the data collected in the United States?

Each year, CDC requests the 52 reporting areas (50 states, New York City, and Washington DC) to voluntarily send copies of death certificates for all women who died during pregnancy or within 1 year of pregnancy, and copies of the matching birth or fetal death certificates, if they have the ability to perform such record links. All of the information obtained is summarized, and medically trained epidemiologists determine the cause and time of death related to the pregnancy. Causes of death are coded by using a system established in 1986 by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention Maternal Mortality Study Group (CDC, 2020). There is no data in New York State that support postpartum injuries and death.

What is done with the data?

The scholar practitioner model is a well-established model that looks into generating new knowledge and giving research-based knowledge to individuals and organizations to enhance their understanding and effectiveness in the field (Wasserman, Kram, 2009). The scholar practitioner models can help assess some of the contributing factors in the high rise of maternal mortality, such as performance of skilled healthcare workers, shortage of skilled healthcare workers, access and equity in healthcare settings, accountability in providing quality care, and costs.

There are overwhelming research-based evidences that support the lack of knowledge of doctors and nurses in providing quality care during and after delivery. Dr. Debra Bingham, former Vice President of Nursing Research and Education of the Association of Women’s Health, Obstetric and Neonatal Nurses, conducted the survey of the 372 postpartum nurses in 2014. Dr. Bingham found that the educational knowledge was not applied in the field. Some of results are staggering. Many of them were ill-informed about the dangers mothers face after giving birth (Montagne, 2017). Half of the respondents did not know that maternal mortality mostly occur after childbirth. 19 percent of the respondents thought that maternal mortality declined in the United States. 12 percent knew that maternal mortality occurs days after delivery. 24 percent recognized that heart related problems were one of the leading causes of maternal death in the United States. Postpartum education is essential and important because mothers do not see their doctors until after four to six weeks. Some nurses were uncomfortable in providing postpartum complications education to mothers.

One caviar in the effectiveness of providing education to postpartum mothers was the physical and emotional condition of the mother. The survey noted that mothers are exhausted and emotionally charged and physically drained. Nurses did not feel it was the right moment to teach mothers about complications after delivery (Montagne, 2017). Even though, Dr. Bingham stated that there is not enough study on postpartum education, she believes that she needed to do something to change the momentum in her hospital. She started from ground up. After a focus group interview, researchers developed two tools to help nurses to be more effective in educating postpartum mothers: a checklist and script that nurses could follow when instructing new mothers and a one-page handout of post-birth warning signs that mothers could refer to after they returned home, with clear-cut instructions for when to see a doctor or call 911.

These two tools were tested in 4 separate hospitals and were effective in educating both nurses and postpartum mothers. Anecdotes started pouring in a short interval of women coming in with identifiable symptoms similar on the handout. Merck for Mothers spent $500 million dollar to improve maternal health as part of a 10 year plan. Though it is hard to identify who receive funding to do this research since authors do not give funding information in their papers.

Investigative reports were done on four hospitals by National Public Radio and ProPublica, but no action research to document immediate, short or long-term outcomes. There is not enough information about methodologies that can demonstrate and support the scholar practitioner model. The literatures from World Health Organization has enormous information on maternal mortality and a lot of frameworks that are mostly theoretical, but not applicable in the field or have not been tested in the field. Literatures do not show documented action research that support the scholar practitioner model. The most important question is where are healthcare organizations and hospitals in 2020 in their quests of reducing maternal mortality?

In the United States, postpartum care is not well documented and needs serious attention because the health of the mother is threaten and may lead to premature death. Cheng et al. (2006) points out that the neglect of postpartum maternal care is seen in the limited number of national health objectives and data collected related to maternal health. The gap between scholar and practitioner is getting wider and wider in providing quality postpartum care.

Intentional Gaps

Poor maternal health can affect the health and development of a child. Chen et al. 2006 show a longitudinal study that demonstrates that children physical development and emotional states affect their social skills. Despite importance placed on maternal health as Cheng et al. (2006) concur that gaps exist in the availability and scope of maternal postpartum health. Some of the contributing factors as previously stated are availability of services, racial or ethnic disparities, irresponsiveness of state maternal mortality review committees in collecting data related to pregnancy death and providing recommendations for effective interventions (Hayes & McNeil, 2019), hospitals and doctors refusing to allow mothers to deliver vaginally after a C-Sections, and place financial benefit over women’s health.

Maternal Mortality Impact on Society

Millennial Development Goals (MDGs) were instituted by the United Nations member countries to combat the rise in infant mortality, maternal mortality, HIV/AIDS, and malaria in 2000 (United Nations, 2020). The MDGs call for 75% decrease in maternal mortality by the year 2015, which had already passed. Maternal mortality can be reduced if there is a political will to value women as human being and value women’s health as a priority. The utilization of effective collaboration between political leaders, ministry of health, hospitals, academics, and professional health associations can ultimately reduce the high maternal mortality rate in the United States. Shiffman (2011), used a process tracing and case study methodologies to investigate the rise of maternal mortality in Guatemala, Honduras, India, Indonesia, and Nigeria. Shiffman (2011) used two questions for his investigation: to what extent is maternal mortality reduction on the national policy agenda, and what factors have facilitated or obstructed political priority for the cause? Shiffman (2011) collected his data through interviews with officials, observations of implementation sites, government reports and documents, donor agency reports, and published research on safe motherhood. The author conducted 124 interviews and performed 75 with research collaborators (Shiffman, 2011). Interviewees were former ministers and secretaries of health, maternal and child health division heads, officials in other government ministries and agencies, parliamentarians, bilateral donors, multilateral agency representatives, Non-Governmental Organizations officials, and academics. Among his subjects, Honduras was the only country with 40 % decline, but in the remaining four countries, maternal mortality was once again put on the backburner and mothers continue to die prematurely (Shiffman, 2011). Shiffman (2011) changed his method of data collection and interviews because of the unique characteristics in each country. As Dr. Kotter reiterates, scholar practitioner should be willing to use different methods to perform a reality check to validate quality of work and make necessary changes as needed (Kotter, 2015).

Africa is the bedrock of all humanity. Women are the economic driving force of any society. When neglected and put on the backburner, society is doomed to fail. As DaSilva (2018) points out the customer value proposition was the main cause of venture failure. DaSilva (2018) and Wasserman et al. (2009) agree on the importance of putting customers first when designing a new business model. In the case of maternal mortality, politicians should make women’s health a priority. Gulliksen (2017) theorizes on Human Computer Interactions (HCI) and believes that designers and practitioners should design products based on the needs of local people, cultures, traditions, and practices.

Conclusion

The health of a mother is essential for the economic growth of a country and society sustainability. When given proper care a country and society will flourish abundantly because mothers are the one giving birth to all men and women. Kotter (2015) claimed that scholars and practitioners should have these two perspectives: ”See life only as it is and not also as it should be.” Do women need to be validated as part of a society? No woman should die during or after pregnancy. It brings out the inadequacy in the part of political leaders, medical professionals to continue to neglect and putting money first before the health of society backbones. Excessive C-Sections are detrimental to the health of a mother and can lead to premature death. Every mother needs a comprehensive postpartum care away from daily chores and stress. The proposed postpartum care will minimize complications and reduce the number of maternal mortality for years to come.

A Wrap Around Program that Could Save Mother’s life

The New York State Task Force on Maternal Mortality and Disparate Racial Outcomes provided 10 recommendations in April 2018 (Kheyfets, 2022). Progress had been made, however, neither the recommendations nor the steps taken to improve maternal health, for example, breast feeding, newborn care, laws had been passed, data had been collected (Kheyfets, 2022), but the State plan did not include the recovery time during postpartum. Therefore, Grace Leadership Foundation, Inc, a New State 501-C-3 registered nonprofit organization with active United Nations Consultative Status with ECOSOC, believes that postpartum care is crucial to the health of the mother.

On December 2, 2019, Dr. Toutou Moussa Diallo sent letters to New York State political leaders to express her concerns on the rise of maternal mortality in New York City. She communicated with New York State Association of Licensed Midwives, the Black Association of Doulas and some individuals Doulas in Brooklyn, some nurses, Borough Presidents, Council Members, and Community Boards Members. Our original plan was to open Grace Restore Center in Brooklyn. In 2023 with the interest of other health groups and community members, we would like to receive funding to provide 24/7 postpartum home care to mothers in the Bronx.

Our program “Mother First” relates to the quarantine / postpartum confinement. Mother First is a comprehensive and restorative after delivery program that focuses on the whole mother to heal properly and regain strength and the child to receive nurturing love and care. This idea of 40 or more days of rest after delivery has been practiced in Africa since the beginning of times. I have been through this quarantine in Mali after giving birth to my first two children. In the United States, when I gave birth to my last daughter, I became very sick after a week of delivery because not having a support at home. I collapsed with high fever and spent a week in the hospital without knowing who was taking care of my daughter. I got sick because after delivery I had to take care of myself, my newborn, my husband, and home chores. United States does not have the support system that Africa has.

This practice is known in India, and other Asian countries since biblical times. It is not a new thing, but has not been practiced fully in the United States by nonprofit organizations. This practice will save lives and improve the health of mothers and newborns. It is crucial that this quarantine system be available to every mother in the United States. It is the first system to be instituted in the United States of America and starting in the borough of Bronx, New York City by a nonprofit organization.

This postpartum home care model calls for a comprehensive care to both mother and child. Mother will be removed from sexual interferences during the length of the quarantine. It is needed because mother needs to rest and regain strength before returning to a full maternal duty. Mother’s womb needs healing and time to restore to normal condition. Mother with proper living condition will be provided a live-in home attendant for childcare, household chores and assistance with medical appointments. Alternative support will be provided to those with no adequate living condition. Mother First addresses nutrition, primary care, rehabilitation, and any other services needed to strengthen the mother. This quarantine or postpartum confinement has different names around the globe. In the United States, it was called “Maternity Hospitals”.

Mother First will:

reduce the rate of infant and maternal mortality
reduce health disparity among women
increase the number of women who receive quarantine service
keep track of performance and trends in service; and
keep track of women and children who complete quarantine service.

Mother First will improve early access to high-quality healthcare service; access to early childhood education and parental support; give access to nutritious food; provide safe housing and environment; train and hire culturally sensitive healthcare professionals; and celebrate completion of Mother First.

Our program is based on a millennial years old model that we are bringing in the United States. It is not similar to Doulas services. However, it is unique because it focuses on the whole mother to heal properly and regain strength and the child to receive nurturing love and care. We plan to serve 50 to 100 mothers a year.

Recommendations

The health of mothers is precious and needs serious attention from everyone. To see effective societal change in reducing maternal health in the United States, there is a need to:

change policy agenda
reexamine , reevaluate, repurpose medical practices on behalf of women
bring scholars and practitioners to build on, and use existing best practices on collaboration (Bartunek, 2018)
require policy makers to make women’s health a priority
fine hospitals that will perform unnecessary C-Sections
monitor and evaluate healthcare system as Mode2 in England (Bartunek, 2018)
require hospitals to train medical staff on postpartum care
have funding available to nonprofits to provide postpartum care

Hospitals could adjust postpartum services by adapting Abaci & Pershing, 2017 Human Performance Technology (HPT). HPT is designed to improve productivity in organizations by designing and developing effective interventions that are results oriented, comprehensive, and systemic (Abaci, Pershing, 2017). That will save mothers’ lives. Hospitals could also use Abaci

Pershing 2017 three key attributes of action research, which are oriented towards solving practical problems, participative in nature, and utilize systematic in inquiry research reference. Abaci, Pershing (2017), encourage the involvement of graduates students scholar practitioner research so graduates can expand their practices and bring new insights into the effectiveness of organizations. Another important tool that is vastly used in hospitals and could be improved upon in reducing maternal mortality is the utilization of Human Computer Interaction (HCI) (Gulliksen, 2017

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