Addressing Maternal Mortality Through Cardiovascular Care

CommonSpirit Health has launched several efforts that target cardiovascular care in maternal health.

CommonSpirit Health is stepping up efforts to address cardiovascular disease in maternal health.

In several reports, the United States has the highest maternal mortality rate compared to other developed countries—a report from The Commonwealth Fund found the United States had the worst maternal mortality rate compared to 10 other developed countries. According to a Centers for Disease Control and Prevention (CDC) report, the U.S. maternal mortality rate rose from 20.1 deaths per 100,000 live births in 2019 to 23.8 in 2020. The CDC report highlighted a racial disparity, with the maternal mortality rate for Black women at 55.3 deaths per 100,000 live births, which was nearly three times higher than the rate for White women.

A new report from the CDC shows that the U.S. maternal mortality rate rose 40% from 2020 to 2021.

Addressing cardiovascular disease during pregnancy is crucial to reducing maternal mortality, says Rachel Bond, MD, system director of women's heart health at CommonSpirit. "Cardiovascular death, which is the leading cause of death during pregnancy, is preventable 80% of the time. A lot of that has to do with us communicating with each other and diagnosing these conditions early."

CommonSpirit has established a Maternal Heart Council to educate patients and clinicians about cardiovascular health during and after pregnancy as well as to provide guidance and protocols, she says. "We are getting guidance from both cardiologists who specialize in high-risk pregnancies as well as cardiologists from subspecialty services. So, in the event that we need interventional cardiologists, advanced heart failure cardiologists, or cardiologists who come from other specialties such as electrophysiology where we may have an abnormal heart rhythm, they are incorporated within the Maternal Heart Council. We work collaboratively with the primary obstetrician as well as the maternal fetal medicine provider, who is a high-risk obstetrician."

The Maternal Heart Council is led by physicians and includes advanced practice providers, nurses, and hospital administrators, Bond says. "We all work collaboratively, and the council meets monthly. In addition to the council, on the outskirts of the council, clinicians and nurses meet regularly to actively discuss the day-to-day management of individual patients. So, the council is a broader umbrella, where we are creating guidance on protocols and educational materials that we give to both patients and clinicians. Outside the scope of the council, we as clinicians are meeting regularly and discussing these patients."

Targeting preeclampsia

CommonSpirit has also developed quality improvement toolkits to address preeclampsia, she says. "We know that preeclampsia is an independent risk factor for cardiac disease, which may occur during a pregnancy but can also occur decades after a pregnancy. This is why we like to target preeclampsia because it is a common adverse pregnancy outcome that we are seeing and rates of it are increasing. A lot of that has to do with the fact that women are having children later in life, and we know that anyone who has a baby past the age of 35 is at a slightly higher risk of having preeclampsia. The other reason we are focusing on preeclampsia is that many of these moms are coming into pregnancies with many common risk factors for high blood pressure outside the scope of pregnancy, and preeclampsia impacts blood pressure."

The health system is providing education about preeclampsia, Bond says. "The way from a quality improvement perspective we have been able to tackle preeclampsia is by providing education not only to the patients but also to the clinical staff. The way we have been able to do this successfully for the patients is we have created a 'passport.' That passport goes over signs and symptoms of how preeclampsia may present. It also goes over the common risk factors. In addition, it goes over how to track your blood pressure during pregnancy and after pregnancy. One thing many people do not realize is that when it comes to preeclampsia, it can occur in the post-partum period, usually upto six weeks post-partum."

Providing preeclampsia education to clinicians is pivotal, she says. "The first group of clinicians preeclampsia patients are seeing when they come to the hospital are emergency physicians. So, there is a large value in educating our emergency room providers. One of the questions we have them ask is, 'When was your last pregnancy?' If your last pregnancy was within a year, and you are coming in with signs and symptoms that are concerning for a cardiac condition, it could be related to that pregnancy. We have come a long way in providing education to our emergency medicine providers; and, similarly, we have provided education to our inpatient internal medicine providers—our hospitalists. It is important to highlight that this education is not just in the inpatient setting, it is also in the ambulatory setting. That is where this education has been targeting our obstetricians."

Standardizing care and protocols

Standardizing care and protocols for maternal health is essential, Bond says. "Data has shown that standardizing care and standardizing protocols can ensure that all of our patients are receiving the same level of care. More importantly, standardizing care and standardizing protocols can ensure that patients have access to the most current research and best practices."

Standardizing care and protocols helps address disparities in maternal health, she says. "It is important to highlight the fact that we have a maternal health crisis in the United States, and we know that this crisis disproportionately is affecting women of color and women who come from lower socioeconomic status. Unfortunately, one driver of this situation is there is implicit bias. So, if we remove the potential for implicit bias by standardizing care and creating protocols that are available for anybody regardless of race, ethnicity, or socioeconomic status, our hope is that we will be able to make a change and decrease poor outcomes."

Virtual care for rural patients

To help reach patients who struggle with healthcare access, CommonSpirit is providing virtual care for rural patients, Bond says. "We are targeting rural areas for telemedicine because we know those areas are where we have the majority of maternal care deserts. A maternal care desert is where you have limitations in obstetric care. Not only do they have limitations in obstetric care, but they also have limitations in specialty care such as cardiologists who focus on high-risk pregnancies."

Using telemedicine for patients in rural areas is good for patients and clinicians, she says. "It has been phenomenal because it allows us to reach the patient, it is convenient for the patient, and it can be convenient for clinicians. Through these visits, patients can access all levels of care that they may not already have available in their communities. More importantly, we can work with physicians who are more local to the patient to try to provide them guidance and co-manage patients."