Most deaths among pregnant women are preventable. Should Nashville implement a vision zero plan?
Pregnant women and new mothers die in our city for reasons that are mostly preventable. In fact, national and state numbers regularly show that close to 80 percent of maternal mortality deaths are preventable. Should and can Nashville implement a vision zero action plan to prevent these deaths?
The most useful data to evaluate trends in maternal mortality is at the state level. Compared to other states, Tennessee’s maternal mortality rate is actually rather high. The Tennessee Department of Health released a Maternal Mortality report to the General Assembly last October, which examined the latest available data from 2021. It showed that 134 Tennessee women died during or within one year of pregnancy that year and trends are getting worse (even prior to COVID-19, which significantly increased maternal mortality).
The report distinguished between pregnancy-related deaths (53 women); COVID-19 related deaths (22 women); and pregnancy-associated, but not related deaths (63 women). A whopping 79 percent of these deaths were considered preventable, according to the state report. When viewing the state report, it needs to be read with care as it jumps between 2021 data and 2017-2021 data, leaving the impression of inconsistent data reporting, especially in the executive summary.
Another key finding in the report shows clear racial disparity with African American women at higher risk of maternal mortality. For example, between 2017 and 2021, a total of 166 Tennessee women died from pregnancy-related causes. Per the report, Non-Hispanic Black women were more than twice as likely to die compared to Non-Hispanic White women.
Tennessee ranks third in the country when comparing national maternal mortality between states from 2019 to 2021, according to KFF (an independent research arm that grew out of the Kaiser Family Foundation).
Considering that a majority of these deaths are preventable, NashvilleHealth released a statement in 2022 that the maternal mortality rate in Nashville — the healthcare capital of the United States — is unacceptable. NashvilleHealth is a local collaborative movement founded by Dr. Bill Frist, with a focus on improving Nashville’s most critical health challenges.
The Metro Public Health Department shared the following local data, which represents the timeframe from 2018-2021 for pregnancy-related deaths and compares it to Nashville peer cities. Their source data stems from CDC’s Wonder database, a system for disseminating public health data and information.
- Davidson County: 18
- Mecklenburg County: 11
- Austin (Travis, Hays, and Williamson Counties): 13
A Tennessee Maternal Mortality Review Committee, established by a 2016 law, examines each death and assists with recommending measures to prevent them. These recommendations to Tennessee lawmakers were summarized in the report to the General Assembly and are copied here verbatim.
Policy recommendations for pregnancy-related deaths:
- COVID-19 was the leading cause of pregnancy-related deaths in 2021. The COVID-19 vaccine should be offered to all pregnant women and providers should be educated and aware of the improved outcomes for pregnant patients with the use of ECMO (extracorporeal membrane oxygenation, or ECMO, is an advanced form of life support targeted at the heart and lungs).
- One in four pregnancy-related deaths had co-occurring mental health and substance use disorder contributing to the death. The State should improve access to and availability of mental healthcare providers and find ways to promote an increase in the mental healthcare workforce. Treatment should be offered to all women with a substance use disorder.
- Hemorrhage was the leading cause of death among women who died on the day of delivery. Facilities should require providers to maintain competencies in managing obstetric hemorrhage and offer training and education on pregnancy and postpartum complications.
Policy recommendations for pregnancy-associated, but not related deaths:
- Acute overdose was the leading cause of pregnancy-associated, but not related deaths. Naloxone should be provided to all households with known substance use disorder and a substance use history. Providers should ensure outpatient treatment for pregnant women and provide education and resources to their family members who also have a substance use disorder to establish a sober living environment.
- Deaths relating to violence were one of the leading causes of pregnancy-associated, but not related deaths that occurred 43-365 days after delivery. Providers should screen all women for domestic violence during every medical visit, especially at prenatal care appointments.
- Lack of prenatal care was a contributing factor in pregnancy-associated, but not related deaths. The State should improve access to prenatal care with increased enrollment in presumptive eligibility to ensure the proper treatment, resources, and screenings during their pregnancy.
Data reports and recommendations like these are imperative to make a preventable problem visible. The Metro Public Health Department (MPHD) is working with several community partners and the state to implement programs that assist women during and after their pregnancy. One such program is called Firefly, located at the Vanderbilt Center for Women’s Health and focuses on improving care for pregnant and postpartum women suffering from opioid use disorder. Nashville Strong Babies is housed at MPHD and provides tiered case management assistance for pregnant, post-partum and parenting families. Tennessee Family Doula Services offer labor and postpartum support and accompanies mothers through the process of childbirth. Doulas are women employed to provide guidance and support to a pregnant woman and/or to a mother of a new baby. They typically do not have formal obstetric training.
Programs like these help, but D’Yuanna Allen, MPHD’s assistant bureau director for Population Health, said maternal mortality prevention efforts should also focus on the social determinants of health including housing needs.
“We can design the best clinical interventions. We can design the best community-based interventions, but until we are able to address the social determinants of health, we will continue to see deaths that shouldn’t be,” Allen said.
Social determinants of health, according to the Centers for Disease Control (CDC), are the “nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”
The following are examples of social determinants of health:
- Safe housing, transportation, and neighborhoods;
- Racism, discrimination, and violence;
- Education, job opportunities, and income;
- Access to nutritious foods and physical activity opportunities;
- Polluted air and water; and
- Language and literacy skills.
Allen, a staunch housing advocate who sits on the community’s Homelessness Planning Council, believes that addressing housing insecurity is a huge factor in decreasing maternal mortality, infant mortality, and health-related complications for mother and child.
Looking at the actual number of maternal deaths, of which close to 80 percent are preventable, Nashville should be devising an action plan to eliminate preventable deaths for mothers and even add infant mortality.
After all, we do have a five-year action plan the Mayor’s Office released in 2022 to prevent traffic deaths called “Vision Zero – Safe Streets in Nashville.” Vision Zero calculated that based on data going back to 2014, on an average year, 360 people who drive, 75 people who walk, and eight people who bike are severely injured or killed on Nashville’s streets.
Nationwide, Nashville ranks 24th in traffic deaths per 100,000 residents. In 2019, Nashville had a fatality rate of 14.5 people (per 100,000), which compared to Austin’s fatality rate of 9.3 people and Charlotte’s rate of 8.2 people. Vision Zero clearly finds these injuries and deaths preventable and unacceptable.
Our city can do something similar and prevent most deaths among mothers and infants. While I have not covered infant deaths in this column, it may be worth addressing it together with maternal mortality — if Nashville policymakers are inclined to do so.
Political arguments in opposition to this suggestion may claim that the numbers are so low that they don’t warrant an action plan. And that instead we should double down and focus on the current approaches through existing programs to address the issue.
However, so far, we have clearly not done enough yet to stop preventable deaths and decrease our maternal mortality rate to practically zero. And it’s not for a lack of trying from the health sector.
If well done, community plans do more than just create programs and interventions. Most action plans are intended to generate policy that outline how communities can improve collaboration across sectors, and they rally political will to solve a specific problem, which can result in potential funding if necessary. The key to an effective plan, however, is to work it rather than shelve it.