Maternal mortality panel finds 70 percent of Alabama pregnancy deaths preventable; urges Medicaid expansion

Nearly 70 percent of pregnancy-related deaths of Alabama women were preventable in 2016, according to the state’s first report on maternal mortality since officials began collecting data last year. 

The report also recommended that Alabama expand Medicaid, calling a failure to do so “an underlying, yet significant factor” impacting the maternal deaths covered in the report. 

Earlier this year, Alabama allocated nearly a half–million dollars to examine why Alabama women die from pregnancy-related or associated conditions.  

Funding for the state’s Maternal Mortality Review Committee came last year after Reckon and AL.com highlighted the state’s failure to address maternal death and after intensive lobbying by state medical and nonprofit organizations. In 2017, the latest year for which data was available, Alabama recorded its highest-ever number of deaths related to childbirth and pregnancy complications. 

“Alabama is working hard to make change,” said Britta Cedergren, associate director of postpartum care with the Alabama March of Dimes, one of the organizations that pushed for full funding of the committee. “Change is slow, but change is happening and that change starts with improved data.”  

The committee published its first report this month, including data-based recommendations for improving the health of Alabama’s mothers. The committee comprises around 25 doctors, nurses, public health officials, social workers and other healthcare professionals under the umbrella of the Alabama Department of Public Health. Dr. Rachel Sinkey, a maternal and fetal medicine specialist and professor at the University of Alabama at Birmingham, chairs the committee. 

The report covers 36 maternal deaths in Alabama in 2016. The committee looked at two types of maternal death: pregnancy-associated, which is a death occurring during or within one year of pregnancy from a cause not related to pregnancy; and pregnancy-related, which is a death occurring during or within one year of pregnancy from a pregnancy complication or other events aggravated by the pregnancy. 

Of the deaths the committee reviewed, 47% were determined to be pregnancy-associated, 36% were pregnancy-related and the remaining six were unable to be categorized. These are percentages similar to those found by review committees in Tennessee and Georgia. 

A few of the report’s most notable findings: 

1. Nearly 70% of the deaths were preventable  

In most cases, investigators found that if “reasonable changes” had been made, there was a chance the mothers’ deaths could have been prevented. 

2. Who were the 36 women?

More than half of the mothers were white, and about a quarter were black, approximately corresponding to racial demographics in the state. More than half of the women had a high school diploma or less. Eighty percent lived in metropolitan areas, even though only about 59% of Alabama births occur in those areas. About two-thirds of the women used Medicaid as their primary insurance for prenatal care, a higher percentage than the state as a whole. Medicaid covers about half of all births statewide. 

3. Mental health and substance use disorders contributed to nearly half of the deaths  

Mental health was a key contributor in 42% of the deaths, and substance use disorders in 47% of the deaths. Five of the deaths were suicides.

The report’s authors pointed to the small number of in-patient beds available for pregnant patients who have substance use disorders.  

“Punitive measures for pregnant women with mental health and substance use disorders must be eliminated,” the report’s authors said, “in order to create an environment that encourages them to seek assistance during pregnancy. 

In recent years, Alabama has led the nation in charging pregnant women with felonies for exposing their fetuses to controlled substances, thanks to the state’s chemical endangerment law. 

“Out of fear of negative consequences (e.g. incarceration or losing custody of children), women avoid getting appropriate care, which leads to missed opportunities for treatment of both the mother and baby.” 

4. Two-thirds of all deaths occurred several weeks or months after childbirth

Even though these deaths are connected with pregnancy, most of them happened 43 days to one year after childbirth. 

This is important to note, the report’s authors point out, because Alabama Medicaid terminates coverage six weeks after childbirth.. Women left uninsured after those six weeks may not be able to afford medical care for potentially life-threatening physical or mental health issues that arose from their pregnancy.  

Alabama is one of 14 states that has not expanded Medicaid. 

“Healthcare coverage remains a significant issue in addressing maternal mortality,” the report’s authors said. “Medicaid expansion up to one year postpartum and improved reimbursement for providers could improve the healthcare women receive, as a majority of the deaths reviewed occurred 43 to 365 days after the end of pregnancy.” 

In Georgia, another state that did not expand Medicaid, lawmakers voted this year to extend postpartum Medicaid coverage to six months after the birth. A similar bill was presented in the Alabama legislature earlier this year by Rep. Laura Hall, D-Huntsville, but it died in committee. 

5. Cardiovascular-related conditions were the leading underlying causes in pregnancy-related deaths

Among pregnancy-related deaths, heart diseases like cardiomyopathy and cardiovascular/coronary conditions were leading causes, followed by hemorrhage, amniotic fluid embolism, blood disorders, infection, mental health conditions and preeclampsia/eclampsia. 

The report noted its investigators were hampered in determining contributing factors to some deaths because autopsies were performed on only half of the deaths they reviewed. 

6. The health care system, provider and facilities were identified as contributing factors in the deaths

Some deaths had several contributing factors. Patient-related factors like substance–use disorders or delay–of–care were cited most often. System failures like a lack of care coordination or access to care followed close behind, as well as provider-related problems like clinical skill or inappropriate assessment. 

“It is important to note that while patient/family factors were the most frequently identified,” said the report’s authors, “implementation of prevention strategies are most often at system, facility, provider and community levels.” 

The report calls on legislators, state health departments and other initiatives to use the data to better provide for Alabama mothers, particularly when it comes to health insurance, mental health and substance use disorders. 

Moving forward, the committee plans to continue reviewing the state’s maternal deaths. If funding allows, the committee could broaden its scope, as other states’ committees have done, to collect data on pregnancy-related conditions and illnesses that threaten mothers’ lives.  

“All efforts must be employed to mobilize our collective expertise and technological advances to save the mothers of Alabama,” the report’s authors concluded. “They are most deserving of the best that medical, social, and technological sciences and community support have to offer.” 

Read the full report here.