As a specialist in women’s heart health, Malissa J. Wood, MD, was already well aware of the cardiovascular risks associated with pregnancy.
Even so, she found a deeper dive into the topic “incredibly distressing” as she prepared for her presentation titled “Pregnancy-Associated Myocardial Infarction” at the 2017 American Heart Association’s scientific sessions.
The rate of maternal death in the U.S. is rising while delivery costs remain high, Wood said, and even though physicians know how to prevent some of these cases they are struggling to educate at-risk populations.
According to the World Health Organization (WHO), maternal mortality in the United States nearly tripled from just above 10 deaths per 100,000 live births in 1995 to 28 deaths per 100,000 live births in 2013. The average ratio in low-income regions was 230 deaths per 100,000 births.
Wood gave two possible reasons for the recent mortality increase: a higher prevalence of cardiovascular risk factors such as diabetes and hypertension and the growth of the electronic health record, which could help link post-discharge adverse events to pregnancy. The WHO defines perinatal death as occurring within 42 days after delivery.
“It may be that we’re doing a better job of capturing events related to pregnancy,” said Wood, the co-director of the Corrigan Women’s Heart Health Program at Massachusetts General Hospital.
Wood also presented data showing that in 2012, the average conventional delivery in the U.S. cost $9,775 and the average caesarean section delivery cost $15,041—both figures more than twice as high and up to four times as high as the amounts from Switzerland, France, Chile, the Netherlands, Britain and South Africa. Yet, she said, many countries have lower complication rates and lower death rates than the U.S.
One potential solution, according to Wood, is identifying and educating at-risk populations before pregnancy occurs and actively managing care throughout the process. Women can cut their risk of pregnancy-related complications by focusing on the same lifestyle techniques that prevent cardiovascular disease in the first place: managing blood pressure, eating appropriately and maintaining a healthy weight.
But pregnancy stresses the body and the heart, so it’s even more important to manage these factors if women are considering having a child. Pregnant women carry a threefold risk of heart attack when compared to nonpregnant women. According to the Centers for Disease Control and Prevention, women older than 35 have nearly double the risk of pregnancy-related death and African-American women have three to four times the risk when compared to white women.
Wood estimated 27 percent of pregnancy-related deaths are preventable. She urged women to see doctors if they have symptoms and resist the urge to tough it out or attribute the symptoms to something else.
“I think the preventable deaths are the deaths due to maternal hypertension that’s untreated, the deaths to maternal heart failure that’s undiagnosed,” she said. “Both hypertension and preeclampsia and heart failure in pregnancy are more common in African-Americans, so African-American women should be more aggressively, or at least as aggressively, managed early in their pregnancies and have access to care so that they can have their blood pressures checked and stay on top of their care during their pregnancy. Many women, unfortunately, show up when they’re ready to deliver and they’re very sick and that’s a really difficult situation.”
Wood said the way the U.S. healthcare system is designed may contribute to that issue. Countries that avoid episode-based reimbursement models typically outperform America when it comes to widespread prevention strategies, she said, including for pregnancy-related complications.
“If you charge every time someone gets their blood pressure checked or every time they go to a doctor for a complaint, they’re just not going to go because many people are underinsured or uninsured,” she said. “I think that’s why, in this country, these young patients kind of just show up when they’re ready to deliver and they don’t get prenatal care because they’re afraid of the costs that are going to ensue.”
Of course, healthcare reform is a substantial hurdle and controlled by lawmakers. A major step public health organizations can take right now is educating young women on the cardiac risks associated with pregnancy and the importance of managing those factors.
“I think we need to help young women before they even embark upon starting a family to recognize that being healthy, eating appropriately, having a health body weight, managing their blood pressure—all the same things we talk about in cardiovascular prevention—they really need to take those things seriously so they can have a healthy pregnancy and have a healthy child, because certainly maternal cardiac complications increase the risk of prematurity and fetal risk as well,” Wood said.