The Mystery of Maternal Morbidity in the Era of Modern Medicine

The Mystery of Maternal Morbidity in the Era of Modern Medicine

September 14, 2023
By Tania Dawood

The Finding

A recent study published by Dorothy Fink, M.D., et al.,[1] shows that despite the downward trend in maternal mortality throughout recent years, there has been an upward trend in severe maternal morbidity (“SMM”)[2].

The World Health Organization (WHO) defines maternal morbidity as “any health condition attributed to and/or complicating pregnancy, and childbirth that has a negative impact on the woman’s well-being and/or functioning.” WHO defines maternal mortality as the death of a woman from pregnancy-related causes during pregnancy or within 42 days of pregnancy. In other words, Fink’s study documents that, although fewer pregnant patients are dying in the labor and delivery process, more of them are facing delivery-related complications. The study sample encompassed more than 11 million inpatient discharges and showed that the delivery-related in-hospital mortality was found to decrease significantly over a period of 14 years.

The Center for Disease Control defines SMM as "unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health." The most common SMM “condition” noted was associated with blood transfusions, with a prevalence of 108.4 per 10,000 discharges. Others mentioned were disseminated intravascular coagulation, hysterectomy, acute respiratory distress syndrome, acute kidney failure, sepsis, eclampsia, shock, and acute heart failure/pulmonary edema. The prevalence of several of these issues was higher in 2021 than in 2008.

The study’s finding of increased morbidity may seem counterintuitive, given the decrease in maternal deaths; one may expect to see also a decrease in adverse outcomes from health conditions affecting labor and delivery patients.

So, Why Are We Seeing an Upward Trend in SMM?

Per Dr. Fink, SMM is likely increasing due to the overall health of U.S. women giving birth, including increased maternal age, obesity, and pre-existing medical conditions.  At the same time, risk factors for SMM included the mothers being 24 or younger or ages 35 and older, their racial or ethnic minority status, having a cesarean delivery, having Medicaid insurance, and having one or more comorbidities. 

While race and ethnicity factors did not seem significant in overall findings, it was notable that Asian, American Indian and Pacific Islander patients showed the most prominent increase.  The increasing trend of adjusted SMM rates were seen in all racial and ethnic minority groups though.

Dr. Fink’s theory suggests that increases in maternal morbidity have more to do with a labor and delivery patient’s underlying health and related factors, as opposed to any systematic issue in hospitals.  However, it is not clear whether expecting mothers within the last few years truly do operate in poorer health than before.

Why Is This Important for Obstetrical Providers?

The significance of this study is its highlight of trending maternal morbidities. Awareness of the types of underlying issues which have a correlation to maternal morbidities helps clinicians in developing plans to optimize patient care.  It also informs healthcare providers and their risk management and legal teams to manage patient care and litigation risks. In maternal injury cases, understanding potential underlying issues involving comorbidities can aid in establishing a defense where maternal morbidity was not the result of medical malpractice and may have been related to alternative underlying causes.

[1] Dorothy Fink, M.D. is Deputy Assistant Secretary for Women's Health and Director of the Office on Women's Health in the Office of the Assistant Secretary for Health (OASH) at the U.S. Department of Health and Human Services.

[2] Fink, Dorothy.  Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021.  June 22, 2023.  JAMA Netw Open.

Disclaimer: This publication is not intended to provide legal advice but to provide general information on legal matters. Transmission is not intended to create and receipt does not establish an attorney-client relationship. Readers should seek specific legal and/or medical advice before taking any action with respect to matters mentioned in this publication. The attorney responsible for this publication is Tania Dawood. This post constitutes a form of attorney advertising as defined by some state bar associations.