Spotlight Article

Spotlight

Shocking Maternal Mortality in Colorado  

Colorado is one of 49 states and the District of Columbia that saw a jump in maternal deaths in the past quarter century, bucking worldwide trends that saw a 44% decrease over the same period. How did this happen?  And how can we reverse course to prevent these tragic deaths?

Maternal death rates around the world are falling – a 44% decrease in the 25 years from 1990 to 2015, according to a report from the World Health Organization last year. That’s thanks in large part to gains in developing countries where death rates are much higher than in the developed world.

However, a recent editorial in the New York Times brought into sharp focus a rising maternal death rate in the US, a 26% jump in just 14 years.

The Times cited a research study published earlier this month in the journal Obstetrics and Gynecology that’s been causing a stir with its findings on state-to-state maternal deaths.  According to the study, there were increases in maternal death rate in 49 states and the District of Columbia from 2000 to 2014. Standing out among the states was Texas, which saw its maternal death rate more than double just since 2000.

California was the only state with a decline in maternal death rate, by about 30% over the same period.

Possible explanations cited for rising maternal deaths in Texas and nationwide were the inequity in the American health care system, including racial disparities in health care, the opioid epidemic, and defunding of women’s health services in 2011 in Texas that coincided with a spike in maternal deaths.

That got us to wondering at CORCRC. Where does Colorado stack up? We found that death rates are rising here, as everywhere else in the country, and the pace may be accelerating.  

It’s hard to assess the scope of the problem

In Texas, the increase in maternal deaths was not gradual: instead, death rates were pretty steady until 2010, when they suddenly jumped by almost 50% within a year, and continued increasing more gradually after that, according to the study released a few weeks ago.

Remarkably, the response from public health officials was slow, despite this epidemic of maternal deaths in Texas. Better data reporting, investigation, better oversight would almost certainly have made a difference, according to a recent task force report. Annual reporting rather than biannual reporting may have quickened the response time.

But the story of Colorado’s maternal deaths is less clear cut. That’s because maternal deaths in the developed world are so rare that they number in the single digits many years in smaller states like Colorado. This makes accurate, high quality data and timely, complete reporting critical for being able to identify trends.

To have more power to detect mortality trends, it makes sense to combine maternal mortality data across states. This can get complicated in a hurry, though, because state death certificates have historically been a patchwork of slightly different definitions of relationship of death to pregnancy status, making the data hard to compare against other states or countries.3 The US is the only developed country in the world that does not have a single, standard death reporting system.

This confusion was supposed to be rectified by a revised US standard death certificate recommended for adoption by the states in 2003. The new death certificate has a set of specific pregnancy-related questions aligned with international standards, to improve tracking of maternal deaths.

But only 4 states actually adopted the recommended changes by 2003. Colorado was one of the last holdouts to make the switch, in July 2015. This was likely due to lack of funding, says a source in the state records office.

Colorado maternal mortality up at least 25%

In the study that’s been raising the alarm in Texas, Colorado maternal death data were analyzed in combination with 7 other lower-population states to increase statistical power. All the states had no pregnancy question on their death certificates. In the years 2000-2014, maternal deaths in these 8 states rose by almost 25%, mirroring the national average of just over 26% increase.

This is good news and bad news. The good news is that Colorado, when grouped with 7 other states, doesn’t stick out with exceptionally high increases in mortality. Also, we were well below the national average with 10.8 deaths per 100,000 live births in 2014 versus 23.8 nationwide. This maternal death rate is more comparable to Western European countries like Great Britain, with a death rate of 10.4 per 100,000 live births.

The bad news: a 25% increase in maternal deaths is shockingly bad in a country that spends more on health care per capita by far than any developed country. What’s more, since there was no pregnancy question on the death certificate in Colorado and the other states in this analysis, the fact that maternal death rates appear to be half the national rate may, in part, reflect less complete data. The true maternal death rate could be higher than the analysis indicates.

Also, this analysis of 8 geographically far-flung states, related only by our method of maternal death reporting, is not exactly telling us about Colorado maternal health. What do we have in common with Alaska, Hawaii, North Carolina, Massachusetts, West Virginia, and Wisconsin?

A publicly available dataset maintained by the Colorado Department of Public Health and Environment (CDPHE) has compiled causes of death from residents of Colorado based on death certificates, from 1999 to 2015. A CORCRC analysis of maternal death rates by year in Colorado gives cause for concern.

In the years 1999 to 2015, there were between 0 to 16 Colorado residents who died of pregnancy complications every year, with a total of 120 maternal deaths in the 16 year period.

Maternal death rates vary a lot each year in the state, since maternal mortality is rare. Rates average about 8 deaths per 100,000 from 1999-2012. But then in the years 2013 and 2014, the numbers spike to 23 and 24 maternal deaths per 100,000 live births. This was about three times the rate in the preceding year, 2012, and well above any preceding year. The unusually high death rates decreased in 2015, to 15 deaths per 100,000 live births.

Women of color were more likely to have died than white women. Although African Americans make up less than 5% of the Colorado population, 13% of women who who died from 1999-2015 were black.

maternal-deaths-co-2

Source: CoHID birth and death data, accessed September 14, 2016.

The spike in 2013-2014 might not reflect a huge public health crisis looming, because the numbers of events are relatively small, making the spike possible by chance, statistically speaking. And fortunately, the level apparently decreased in 2015. Nevertheless, this spike in death rates in 2013-2014 among Colorado residents translated to about 10 deaths more per year than in 2012. That’s 20 families who tragically lost a beloved mother, sister, wife, far too soon.

Why are maternal deaths increasing and what can be done?

Preliminary results from a 2012 study found that the number one cause of maternal deaths was suicide or drug overdose.  Opioid use is increasing in Colorado, as it is across the country, and this is likely to be a significant factor in the increasing deaths. Continuing coverage by the Denver Post has shone a light on the enormous magnitude of the opioid epidemic – more deaths from opioids occur in the state than traffic fatalities. Officials revealed plans in late September to deal with the continuing opioid crisis that did not specifically address pregnant or postpartum women.

The Maternal and Child Health (MCH) division of CDPHE lists better mental health treatment, and substance abuse prevention and treatment for pregnant and postpartum women, as two of its  top 10 list of priorities for 2016-2020 to improve maternal health.

MCH oversees a review committee that evaluates every reported maternal death in the state. The committee is composed of a panel of licensed maternal health care providers. Its purpose is to understand maternal deaths that occur in the state to improve maternal care, but the committee’s recommendations are not binding, and it is unfunded by the state.

The lag time for reviews by the committee is currently 3 years, so that means they are just now reviewing 2013 data, the first year of the spike in maternal deaths. This lag is intentional due to concerns by committee members that their findings could be used as evidence in pending lawsuits. Legislation was unsuccessfully pursued last session to prevent subpoena of committees findings, to address this concern of committee members, an MCH spokesperson said.

Low-cost, accessible, pre- and post-natal health care to vulnerable populations is critical to address these tragic deaths. MCH is studying how to provide better access to at-risk populations, with results forthcoming in the American Journal of Obstetrics & Gynecology.

“Across the country, we’ve seen over and over that when barriers to access are put in place, people experience a delay in getting the care they need, such as regular health care screenings, pregnancy tests, and birth control – all  of which may be a part of preventing maternal mortality,” says Whitney Phillips, spokesperson for Planned Parenthood of the Rocky Mountains, an important provider of women’s health services in the state.

The 2010 Affordable Care Act, or Obamacare, has brought the number of uninsured Coloradans to historic lows, 6.7% in 2015 down from a high of 16% in 2011. Yet the most vulnerable populations are the likeliest to be uninsured, meaning they receive inadequate or non-existent care.

More community-based outreach to the highest risk pregnant and postpartum women, cutting the 3-year delay in state review of these deaths, and annual reporting requirements may be important first steps to address this issue. “[T]here is always more that could be done to address these issues that so significantly impact the health and well being of Colorado’s women, children and families,” says Rachel Hutson, Director of the Children, Youth and Families Branch at CDPHE.

Although there are no easy answers to the increasing maternal deaths in Colorado and across the country, we owe it to families across the state to get to the bottom of this rising public health concern.

 

Gwen Murphy, PhD, is a freelance medical writer who has been a enthusiastic supporter and volunteer for women’s health for two decades. To learn more or to contact Gwen, visit her website, http://www.murphymedicalwriting.com, her blog,www.gwenmurphy.wordpress.com, or email info@murphymedicalwriting.com.