Report: 3 factors linked with pregnancy-related deaths
Contributing conditions include behavioral health, substance use, obesity
Sixty-eight Missouri women died while pregnant or within a year of pregnancy in 2018.
The state Department of Health and Senior Services' latest annual pregnancy-associated mortality review, released July 1, looked at the circumstances surrounding the deaths.
The annual report is intended to help the state understand the causes and contributing factors of maternal mortality so Missouri can take steps to prevent future such deaths, according to its dedication.
"Maternal mortality events, those where a mother dies during or shortly after pregnancy, are internationally viewed as an indicator that may be used to judge the overall health of a country, state, or community," the "Missouri Pregnancy-Associated Mortality Review: 2018 Annual Report" executive summary says.
The report looks at women's deaths when they were pregnant or within one year postpartum.
The report identified three factors that contributed to pregnancy-associated deaths - those that occurred within one year of pregnancy due to any cause.
The first - mental health conditions other than substance use disorder - occurred in 46 percent of pregnancy-related deaths that were injury-related. The report points out postpartum depression affects one in seven mothers.
Substance use disorder, the second factor, occurred in 43 percent of injury-related deaths. Of those, 38 percent of the mothers faced unemployment, 31 percent had involvement with Child Protective Services, 31 percent had histories of substance use treatment, 19 percent had been hospitalized for psychiatric treatment, and 16 percent had been involved in domestic violence.
Maternal obesity was found to be a common factor in deaths considered natural. Although 29 percent of Missouri live births in 2018 were to women considered obese, obesity was a factor in 33 percent of pregnancy-related deaths.
The report found 82 percent of pregnancy-related deaths - those occurring from a pregnancy complication, a chain of events initiated by pregnancy or the aggravation of an unrelated condition by the psychological effects of pregnancy - were preventable and had five significant contributing factors. It was common for cases to have multiple contributing factors play roles in the deaths.
The most common contributing factor was classified as "substance use disorder," found in 13.3 percent of the deaths.
"This indicates that the issues in the cases involved a recurrent use of alcohol and/or drugs, causing clinically and functionally significant impairment," the report says. "Many recommendations were identified that tied to an overall area of substance use disorder including addressing patient education, provider screening, referral and treatment practices, standardized practices at facilities, community outreach regarding education and resources, and system-wide telehealth solutions."
Screening failures - putting women at risk for poor clinical outcomes - were the second most frequent contributing factor in the deaths. Classified as "assessment," these failures oftentimes prevented the proper course of treatments to be initiated and played roles in about 12 percent of the deaths.
The report recommends all health care providers perform depression/anxiety screenings and substance use disorder screenings on every patient at every interaction with the patient, throughout the pregnancy and for a year postpartum.
But it's not only important to conduct the screenings to avoid assessment deaths; the health care providers must make referrals to mental health professionals, social workers and treatment programs as appropriate, according to the report.
Even then, the effort may not be enough to prevent some pregnancy-related deaths. The third most common contributing factor in the deaths, classified as "adherence," occurred in 10.8 percent of the deaths. Adherence is when providers identify an issue, but the provider may fail to follow protocols or the patient may fail to comply with them.
The bulk of recommendations concerning adherence had to do with education, particularly for the patients and their families.
Recommendations included targeting preconception health and prenatal health care issues, substance use, mental health and intimate partner violence.
The report continues to demonstrate the need for annual seat belt campaigns. It showed about 28 percent of pregnancy-associated deaths occurred in motor vehicle crashes, second only to poisonings/overdoses (49 percent) in terms of injury-related deaths.
Factors classified as "mental health conditions" and "knowledge" each occurred in about 8.2 percent of the deaths.
While the report recommends screenings for mental health conditions during all interactions, it also found there were "gaps in knowledge regarding treatment of mental health conditions during pregnancy on the part of patients and their families, and providers."
And it recommended the establishment of a perinatal consult center, offering telehealth services for substance use disorder and mental health conditions.
It also recommended providers receive ongoing education on mental health conditions, substance use disorder, and cardiovascular disorders during and after pregnancies.