Again this year, a report on maternal mortality details how complex societal issues of rampant obesity, health inequity and the opioid epidemic play roles in keeping Missouri's pregnancy-associated mortality rates high.
The annual Missouri Pregnancy-Associated Mortality Review Board's report, using data from 2017-19, found 75 percent of pregnancy-related deaths were preventable. And, all pregnancy-related deaths due to mental health conditions were determined to be preventable.
By law, the Missouri Department of Health and Senior Services (DHSS) is required to submit a report to the board, which is tasked with looking at the causes and contributing factors associated with maternal mortality and with determining interventions that could prevent the deaths. The report may be viewed at https://health.mo.gov/data/pamr/pdf/2019-annual-report.pdf.
The board looks at demographic factors, including age, race and educational attainment. The board evaluates places of residence, health care insurance coverage, and body mass index. It keeps in mind that correlation does not equal causation, but comparing ratios helps "determine the degree of disparity in health outcomes between each group," the report states.
The report looked at circumstances surrounding 185 women during the time period, who died while pregnant, or within one year of pregnancy. The average was 61 Missouri women who died each of the years. The highest number recorded was 68 in 2018.
The report cautions that the numbers used represent a small portion of the population, thus there is an increased likelihood of results being "Skewed." and some effects may be exaggerated, while others remain hidden. The report also offers a three-year ratio may prevent "skewness."
"While it is vital to analyze these deaths on a yearly basis," the report executive summary states, "the goal of this multi-year report is to provide a more comprehensive representation of maternal mortality in the state."
Among the board's key findings were:
• The greatest proportion of pregnancy-related deaths occurred between 43 days and one year after pregnancy, mental health conditions were the leading cause of pregnancy-related deaths (followed by cardiovascular disease).
• The most common means of fatal injury for pregnancy-related deaths was overdose/poisoning.
• Substance use disorder contributed to 32.7 percent of pregnancy-related deaths.
Seventy percent of deaths were pregnancy-associated, not related (meaning they occurred from any cause during or within one year of pregnancy). The most common cause was poisoning/overdose (33.9 percent), followed by motor vehicle collisions (30.4 percent). The report states substance use disorder contributed to 44.4 percent of pregnancy-associated, not related deaths.
The review board's report recommended four steps the Missouri Legislature could take to lower the amount of maternal mortality.
It recommended the lawmaking body provide funding for a perinatal quality collaborative by 2023. Multiple states have these networks of teams who work together to improve the quality of care for mothers and babies. Several states participate in multi-state networks. For example, California uses a "mentor model" in which 20 pairs of nurse-and-physician mentors, experienced in quality improvement, supported and mentored six-eight hospitals.
The Legislature should establish and fund a statewide prenatal psychiatry access program to aid health care providers in providing evidence-based mental health care including substance use disorder treatment to Missouri women.
It should extend Medicaid coverage to one year postpartum for all conditions (including medical, mental health and substance use disorder), even if the woman did not start treatment prior to delivery. This would help women whose condition is exacerbated by the postpartum period, according to the report.
The report recommends health care providers receive ongoing education regarding screening, referral and treatment of mental health conditions, substance use disorder and cardiovascular disorders during and after pregnancy.
Providers should also perform a full assessment for depression and anxiety, using standardized and validated tools at least once during the perinatal period (as a baseline), once during the comprehensive postpartum visit (and add additional screenings as indicated). Providers should do likewise for substance use disorder. They should make referrals to behavioral health professionals, social workers, community health workers and treatment programs as appropriate, according to the report.
All health care workers should complete trauma-informed care training and implicit bias training at least annually.