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Helping Ensure Safe Childbirth in Our Own Backyard: Lessons Learned from Merck for Mothers’ U.S. Efforts

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How did we get here?
Shockingly, the U.S.’s maternal mortality ratio has more than doubled since 1990, even as rates of pregnancy and childbirth complications have declined throughout the developing world. Just as troubling, an additional estimated 60,000 women nearly die from pregnancy or childbirth-related causes each year.

Merck for Mothers is working to reverse this trend and has committed more than $12 million to programs working to improve maternal health by: 1) standardizing approaches to manage obstetric emergencies; 2) supporting maternal mortality review teams to understand the root causes of maternal deaths and develop interventions to tackle these problems; and 3) strengthening community-based efforts to make sure women with chronic conditions receive comprehensive prenatal and primary care.

Our vision is that all women receive the care they need for a healthy pregnancy and safe childbirth. 

What have we learned from our work in maternal health in the US?

Quality improvement requires a culture change. To improve the quality of care in hospitals, all members of the care team need to be involved. Obstetricians, midwives and nurses must be willing to change their individual and collective behavior to create an ethos of safety. This responsibility extends across a hospital because maternity wards depend on support from the blood bank, the intensive care unit and other departments to provide a woman with the care she needs in an emergency. Securing champions from the hospital’s leadership is key to accelerating this culture change.

Quality improvement is possible even in the most challenging clinical settings.  Our partners have developed new evidence-based practices to treat the three leading causes of maternal death in the U.S.: obstetric hemorrhage, hypertension and embolism. Their experience implementing these approaches in more than 300 hospitals in five states has shown that regardless of the type of hospital setting, clinical teams can improve the quality of emergency obstetric care. However, small hospitals, rural facilities and medical centers with fewer resources need extra support to fully implement quality improvement tools.

The postpartum period is severely neglected even though it can be a risky time.  As soon as a woman gives birth, attention shifts from her health to the baby’s needs. Yet, more than 60% of maternal deaths in the U.S. occur after childbirth. Right now, the education that nurses provide about potential postpartum health problems is often very limited and varies from patient to patient because there are no standard discharge guidelines for the care of new mothers. The statistics make clear that before leaving the hospital, women (and their families) should receive information to help them recognize warning signs of a health problem and guidance on what to do.

Better data are needed to understand the root causes of maternal deaths. Currently, only about half of states review maternal deaths, and most of those states do not translate what they learn from the assessment into actions that could prevent deaths from similar causes. In addition, states do not regularly share what they learn about maternal deaths with each other, creating missed opportunities to identify national trends in the causes and contributors to these tragic events and take action to prevent them in the future. 

Chronic disease is compromising women’s health during pregnancy. Increasingly, the problems putting pregnant women at risk for life-threatening complications originate outside the hospital. Many women are entering pregnancy with preexisting, unmanaged health conditions, contributing to the rise in mortality and morbidity. A population health approach is needed to ensure that women with complex health needs are supported and empowered to stay healthy before, during and after childbirth. 

New models of care are needed to help underserved pregnant women.  Pregnant women from communities with limited resources often have a number of competing priorities that make it more difficult to maintain good health and well-being – especially if they have pre-existing health problems. They may have challenges finding adequate housing, healthy food options or mental health services, or other obstacles to securing regular prenatal and primary care. Community health workers can play a pivotal role in linking pregnant women with chronic health conditions like diabetes, hypertension and obesity to services. They can also provide physicians and nurses with insights into factors affecting a woman’s health beyond the exam room. 

What’s Next?

Merck for Mothers’ approach, in collaboration with national and local organizations, is to support the design of innovative programs, test their effectiveness and use evidence-based advocacy for scale up of successful models to reach as many women as possible. In the U.S., we have achieved an early success with quality improvement efforts in five states. In late 2014, the federal government made a commitment to fund an additional eight states to implement the nationally endorsed, evidence-based practices to treat the leading causes of maternal death that resulted from our early investments – paving the way for nationwide expansion over the coming years.
 
We look forward to continuing to share what we learn from our work and contributing solutions that will help reverse the upward trend of maternal mortality in the U.S. and ensure that the four million women who give birth each year have a healthy pregnancy and a safe childbirth.

Dr. Priya Agrawal
Executive Director, Merck for Mothers