Documenting root causes of Philadelphia’s high maternal mortality rate

     Philadelphia obstetrical experts say new moms need better, immediate access to long-lasting birth control, such as the IUD. (<a href=“http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=143448833307715060000&searchterm=IUD&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=174197693Photo via ShutterStock) " title="ssiudx1200" width="640" height="360"/>

    Philadelphia obstetrical experts say new moms need better, immediate access to long-lasting birth control, such as the IUD. (Photo via ShutterStock)

    Philadelphia first began tracking the deaths of new mothers and pregnant women in the 1930s when illegal abortion, blood infections and excessive bleeding were the leading killers.

    What kills women in the first year after a pregnancy has changed dramatically since then. Today chronic disease, drug addiction, mental health problems and domestic violence lead the list, according to the new report.

    Pooja Mehta, an obstetrician-gynecologist at Penn Medicine, says the review team made a string of recommendations to address those issues.

     

    “Systems of care needing to be more seamless, needing for there to be good communication between emergency rooms, prenatal clinics and hospitals,” said Mehta, a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania.

    “The surprising findings for many people was that so many of these tragic deaths were related to social-economic status,” said perinatologist Jason Baxter, a specialist in high-risk pregnancies at Thomas Jefferson University.

    Not surprised

    Baxter says when he suspects that a patient is at risk for domestic violence, for example, he knows there are in-hospital social workers and resources available. But he worries that too few patient get help beyond the hospital once they return home and to their neighborhood.

    Now that the experts know what’s killing new moms in Philadelphia, the report details steps that could bridge the gap between community services, traditional health care and social services, Baxter said.

    The Maternity Care Coalition is working with a local initiative called Merck for Mothers that is testing new ways to share information across agencies, said Bette Begleiter, deputy executive director for the coalition.

    Mehta said it’s especially important for a woman to have a “medical home” during a vulnerable time such as pregnancy so her care is coordinated by a team that has a holist view of her life and health.

    The Philadelphia Maternal Mortality Reviewed team analyzed 55 deaths.

    “Only one out of the 55 deaths within those three-year period was something that this committee felt was possibly preventable, could be altered by better obstetrical or maternal care,” said Arnold Cohen, a maternal-fetal medicine specialist at Einstein Medical Center.

    Cohen said many of the social and societal issues that are killing women in Philadelphia are beyond the immediate control of physicians, midwives, nurses and other obstetrical-care providers.

    Between 1997 and 2008, 19 obstetrical units closed across southeastern Pennsylvania. For years, health advocates have complained about the shortage of places for women to give birth across the region, but Cohen says — for him — the new report suggests that women get good care at the six OB units that remain.

    Still Philadelphia lags behind other parts of the country. The review team calculated a pregnancy-related death rate of 27.4 per 100,000 births.

    “Using that same methodology on a much bigger level, the maternal mortality rate for the country was most recently estimate to be 17, it seems like the rate here in Philadelphia with the surveillance tools we have is significantly higher than the national maternal mortality rate,” Mehta said.

    “The death of a pregnant woman, or a mother, we know impacts a whole family, impacts children but also represents experiences of women — people of reproductive age in general — with the pregnancy being one of the events in a life course that may bring someone to the health system and alerts the health system to ongoing issues,” she said.

    Mehta said after working with the committee, it’s clear that post-partum women need better access to birth control and family planning services so they can plan to conceive at the right, safest times.

    An unplanned or undesired pregnancy can exacerbate certain health conditions — such as high blood pressure and diabetes, and that puts women at risk, she said.

    Long-acting reversible contraception such as the intrauterine device or implant can cost $600 to $800.

    Cohen says may doctors want to offer women those options in the hospital immediately after a birth, but private insurance and the Medicaid plans in Pennsylvania won’t pay for the birth control if it is implanted during the same ‘episode of care’ as a birth.

    Cohen and other physician and have lobbied lawmakers and insurance companies in Harrisburg.

    “Unfortunately none of them have changed their policies yet,” he said.

    The IUD or implant are typically covered by Medicaid and private insurance during a future visit.

    “But many women don’t come back for post-partum visits or family planning,” Cohen said. Compliance is problem, he said.

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