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Let’s Make Birthing in Hospitals Better!
Melissa Rodriguez, DMSc, PA-C

May 17, 2022

Have you heard? Maternal mortality rates are increasing in the U.S. We now have the highest maternal mortality rates in all developed countries. The 2020 report from the National Center for Health Statistics, based on data from the National Vital Statistics System, showed that 861 women died due to maternal causes, up to 42 days after the end of pregnancy, with a general maternal mortality rate of 23.8 deaths per 100,000 live births in 2020 (Hoyert, 2022). When stratified by race, non-Hispanic Black women had 55.3 deaths per 100,000 live births, 2.9 times that of non-Hispanic White women. Several medical causes are identified, including cardiac disease, hypertension, hemorrhage, and venous thromboembolism. Social determinants of health also strongly correlate with mortality, as they contribute to preexisting health conditions and why people of color avoid seeking care.

Racism and inadequate access to care further isolate people in need. For instance, maternity care deserts, caused by the increasing number of hospital closures in rural communities, have increased and led to an increase in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year after closure (Kozhimannil et al., 2018). The degree of isolation and lack of services may contribute to maternal mortality in the U.S. and exacerbate the socioeconomic differences within contrasting populations. This phenomenon was highlighted in a study in Louisiana, where those with a lack of maternity care experienced a 91% increase in the risk of death during pregnancy and up to one year postpartum (Wallace et al., 2021). Sadly, even with access, women of color may choose to deliver outside of the hospital due to racism and obstetric birth trauma. We need to improve our services.

Most pregnancies in the U.S. are considered low risk. “High risk” describes a pregnancy with risk to the woman, fetus, or both, increasing the likelihood of a complication, adverse event, or poor outcomes occurring during or after the pregnancy or birth. However, there is always a risk of complications in pregnancy and delivery. The rising number of obese patients, the increasing age at first delivery, the increasing use of fertility treatments, and societal factors play a role in increasing the risk of pregnancy. Women aged 35 or above are at greater risk of maternal mortality, preeclampsia, poor fetal growth, fetal distress, and stillbirth when compared to mothers aged 25-29 (SMFM 2014; Cavazos-Rehg et al., 2015), and this age range accounted for 18% of all births in 2017. Despite this risk, mothers ages 35 and older were more likely to birth at home (23.6%) or at a birth center (18.1%) compared to a hospital birth (17.5%), without available specialty-specific interventions.

Previous cesarean birth also contributes to additional risks for mother and fetus, and the number of cesarean deliveries increased from 5% to 32% over the past 50 years. After a cesarean delivery, women can choose either a repeat cesarean section or vaginal birth after cesarean (VBAC), both of which carry risks. Planned labor increases the risk of maternal infection, surgical injury, and uterine rupture (ACOG, 2019e), particularly if it ends up requiring a repeat cesarean delivery. ACOG recommends a VBAC primarily if it was only one previous cesarean delivery, but concomitant risk factors must be considered, including maternal age, obesity, preexisting health issues, and obstetrical history (Wu, 2019; ACOG, 2019e). Despite this increased risk, VBAC delivery also occurred more frequently at home and in birth center settings (3.4% vs. 2.0%) (NIH, 2020).

Moreover, obesity affects more than one-third of U.S. women aged 20-39 (Hales, 2017). We know that obesity increases the likelihood of developing gestational diabetes or hypertension and creates a greater risk for miscarriage, stillbirth, shoulder dystocia, and spontaneous preterm birth. While the number of “high-risk” pregnancies is not the majority, the loss from lack of preparation could be devastating. Qualified medical providers must provide the most up-to-date care for their patients and be able to pivot to more intensive care as the situation arises.

Maternal care providers, including PAs, need to prioritize a patient’s experience and balance it with individual potential risks. Standardization of obstetric care improves outcomes, particularly by utilizing available obstetric bundles and strategies to reduce the risk of morbidity and mortality. Preference-sensitive decision-making is prioritized when several options are available and should depend on the patient’s cultural and religious beliefs, values, and goals (CMS, 2016). Additionally, preventative care, rather than reactive care, is essential for us to improve maternal health. PAs are educated in the medical model, emphasizing patient communication, prevention, and equitable care. The PA goal is to ensure birthing patients are in good physical and mental health with the appropriate guidance for their birthing experience. PAs staff several labor and delivery units, namely in New York, Illinois, and Massachusetts. Equally, PAs commonly staff ERs, ORs, and primary care, where they will be managing the care of obstetric patients from preconception care until one year postpartum. We need to invest in the robust education and preparation of PAs in obstetrics and gynecology and increase the opportunities for PAs to provide maternal care, both at the local and the legislative level. Furthermore, to address the shortage of preceptor sites for obstetrics and gynecology, we need to increase the number of practicing PAs and their ability to serve as preceptors. I urge this nation to understand the need for maternal healthcare, to keep our families together, strong, and productive, no matter the race or socioeconomic status. Birthing patients need to be supported and PAs are ready to overhaul the maternal health crisis.

References

Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. DOI: https://dx.doi.org/10.15620/cdc:113967.

Kozhimannil, K. B., Hung, P., Henning-Smith, C., Casey, M. M., & Prasad, S. (2018). Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA, 319(12), 12391247.

Wallace, M. et all (2021). Maternity Care Deserts and Pregnancy-Associated Mortality in Louisiana. Women’s Health Issues. 31:2; 122-129

Society for Maternal Fetal Medicine (2014). Advanced Maternal Age and the Risk of Antepartum Stillbirth.

Cavazos-Rehg, P. A., Krauss, M. J., Spitznagel, E. L., Bommarito, K., Madden, T., Olsen, M. A., Subramaniam, H., Peipert, J. F., & Bierut, L. J. (2015). Maternal age and risk of labor and delivery complications. Maternal and child health journal, 19(6), 1202–1211. https://doi.org/10.1007/s10995-014-1624-7

American College of Obstetricians and Gynecologists. Vaginal birth after cesarean delivery: ACOG practice bulletin, 205. Obstetrics and Gynecology. 2019e;133(2):e110–e127.

Wu Y, Kataria Y, Wang Z, Ming WK, Ellervik C. Factors associated with successful vaginal birth after a cesarean section: A systematic review and meta-analysis. BMC Pregnancy and Childbirth. 2019;19(1):360.

Backes EP, Scrimshaw SC. Chapter 3, Epidemiology of Clinical Risks in Pregnancy and Childbirth. Birth Settings in America: Outcomes, Quality, Access, and Choice.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings; Washington (DC): National Academies Press (US); 2020 Feb 6.