Maternal deaths in Ga. often preventable, point to broad problems

Upcoming report expected to show a worsening record for the state as more mothers have died since the pandemic began
Precious Andrews plays with her daughter Ryleigh during her lunch break on Friday, February 10, 2023. (Natrice Miller/ Natrice.miller@ajc.com)

Precious Andrews plays with her daughter Ryleigh during her lunch break on Friday, February 10, 2023. (Natrice Miller/ Natrice.miller@ajc.com)

Ky Lindberg worked with other maternal health experts, assembling the latest case files of Georgians who died within months of pregnancy. Looking at death reports, she realized the same thing again and again: the pregnancies had led to the mothers’ deaths. And most of those deaths could have been prevented.

Soon, for the first time since the pandemic, Lindberg and her colleagues on Georgia’s Maternal Mortality Review Committee are expected to release the state’s latest maternal mortality rate. The patients’ details are secret by law, but an early report showed grim numbers.

That report, which summarized the top six causes of maternal mortality in women who are pregnant, delivering or in the year after a birth, found 78 deaths from those causes from 2018 to 2020 — all but two preventable. The full mortality report is expected to include more deaths.

The deaths are a sign of the need for better care of women, and more attention to symptoms that arise in the months after giving birth. And while the number of deaths may be small compared to the overall numbers who give birth, they also signal broad problems in the care that women get that can lead to sickness and hospitalization.

In advance of the release of the full maternal mortality report, the state has disclosed the most common fatal gaps and the committee’s recommended fixes: They want health workers to seek and understand the signs of pregnancy-related heart damage. They want those who care for patients with preeclampsia — a disorder involving high blood pressure in pregnancy — to re-check the patient’s blood pressure three days after they leave the hospital. They want doctors’ offices, hospitals and insurance companies to work together for a patient’s benefit. They want postpartum mental health issues to be caught and treated before they become a crisis.

The pandemic, covered for the first time in the report, worsened the already-existing gaps in care.

There is evidence that suggests that the coronavirus itself posed a special danger for pregnant women, with pregnant women 70% more likely to die from the virus than other women.

But Lindberg and some advocates also see hope. During the same time period the women in the report were dying, the Legislature voted to extend poor mom’s Medicaid health insurance coverage to a full year after giving birth, up from 6 months. With 54% of all births in Georgia covered by Medicaid, the move is expected to make a difference.

But there’s a long way to go.

Georgia has long ranked among the worst states in the nation for maternal mortality, sometimes as the worst, and is currently ranked in the bottom 10.

Seeing a repeating chain of events come alive in patients’ medical records and interviews with next of kin has been “excruciating,” Lindberg said.

Living out the data

Advocates for patients have long maintained that one of the biggest lost opportunities to save a life happens when doctors, nurses or aides don’t take patients’ complaints seriously.

Research suggests that ignoring valid patient complaints especially harms Black patients. Black women are more than twice as likely as white women to die from pregnancy.

Precious Andrews, a Black mother of four, knows that data. She works with Lindberg’s organization, the Healthy Mothers, Healthy Babies Coalition of Georgia, to teach mothers to speak up and advocate for themselves.

Precious Andrews sits with her daughters Bella, 2 (left), nine month old Ryleigh (center), and 12 year old Laila (right) during her lunch break on Friday, February 10, 2023. (Natrice Miller/ Natrice.miller@ajc.com)

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Then, as she brought her fourth child to term last year, she realized she was living out the data.

Twice after Andrews gave birth last April, she returned to the hospital ’s emergency room for obstetric patients with worrying symptoms. On a third occasion, she went to the regular emergency room.

She complained to doctors of swelling in her legs, pain in her chest, headaches, and seeing spots, and nurses measured spikes in her blood pressure. All can be symptoms of preeclampsia, a dangerous, sometimes fatal, blood pressure condition that arises in pregnant women.

Andrews’ doctors admitted her to the hospital on those visits. But Andrews was concerned she had preeclampsia and remembers she got nowhere on that with her doctors: They blamed the leg swelling on the ibuprofen she took for the headache. They blamed the fluid in her lungs on pneumonia, and gave her antibiotics. She recalls they treated her headache as a migraine, even though she said this was different from a migraine.

Seven weeks after delivery, Andrews had another spell with a crushing headache, seeing dots of lights, going numb and watching powerless as her baby slid from her limp arms. She went back to the hospital yet again.

Calling her doctor from the car, Andrews recalls she told her she was too far past her delivery to be seen in the obstetrics ER. “She said, ‘I don’t know what you want us to do,’” Andrews recalled. “They were just like, ‘Go to the ER again, but we’re sure it’s just going to pass.’”

Andrews says that in contrast, the emergency doctors at Piedmont Fayette took her complaints seriously and began a wave of steps to address them including blood pressure medication. She credits them with saving her life.

The doctors noted in the hospital records that the obstetrician had not diagnosed her with postpartum preeclampsia.

Andrews marvels that she is college educated, well insured, and advocates for herself, and still believes she almost died. The research data shows exactly this: The disparity in maternal death rates for Black women cuts across education and class.

She gave birth in the pandemic twice, once in 2020 and once in 2022. And she can see how that made it even worse. Her nurses mentioned the staff shortages. Her doctor forgot a promise to come to her hospital room to discuss test results with her.

Her medical records contain errors, including dating her delivery a month too early and calling her white when she is Black. Most importantly, her doctors, who were independent but allowed to practice at the local hospital, Piedmont Fayette, waved off her dangerous symptoms, Andrews said.

“When I went to the regular ER, they were like, ‘This is not going to pass,’” Andrews said. “Like, you’ll just continue to have this, and you would have probably come in here unconscious or worse.”

As Precious Andrews grew more concerned that doctors were dismissing her complaints of possible preeclampsia, she started keeping records.  Here, her blood pressure with a home monitor is 181/116, extremely high. She went to the hospital. When she got there she told the clinician what the monitor had said.  The clinician wrote in her records that Andrews reported "180's/80's."  (Screenshot courtesy of Precious Andrews)

Credit: (Screenshot courtesy of Precious Andrews)

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Credit: (Screenshot courtesy of Precious Andrews)

Leading causes of maternal death

The upcoming state mortality report is expected to highlight the preventable maternal deaths, pointing to ways health care providers can stop missing opportunities to save lives.

Experts know the leading causes of maternal mortality. For the years 2018 to 2020, the committee found the top causes were, in order: hemorrhage; mental health conditions; cardiomyopathy; cardiovascular or coronary conditions; embolism; and preeclampsia or eclampsia.

Researchers occasionally unearth more as they dig deeper into each death.

To generate better data on each death, Georgia is now beginning to require autopsies of maternal deaths, unless the family objects. Since 2017, the review committee has been interviewing family members of the deceased. Death certificates have an added line asking if a deceased woman had given birth in the year before she died.

Most significantly, experts like Lindberg point out, the Georgia Legislature in 2020 expanded Medicaid coverage for new moms. They now have it from pregnancy until one year after giving birth. That is meant to address the biggest portion of moms who die from pregnancy: Those who die many weeks or months after giving birth, often from problems with the heart or blood that weren’t caught in health checks.

But even with improved systems, many pregnant women don’t get any care because they can’t afford to see a doctor, or don’t have one in their county, or don’t have access to a car. Half of Georgia counties have no OB/GYN.

“Some women show up with no prenatal care,” said Shelmekia Hodo, director of maternal infant health at the March of Dimes in Georgia. “They just show up to deliver their babies.”

Mental health was the second largest cause of death related to pregnancy, the committee found, and it found all those deaths preventable. Large problems can start small, and Georgia has a dearth of mental health workers to help people cope.

Shontel Cargill, shown here at the Georgia Capitol, works to help legislators understand the importance of mental health care for Georgia moms. The pandemic exacerbated mental health problems that often occur for new moms and dads, she says. “And it really showed that our healthcare system was not prepared.” (PHOTO by Arvin Temkar / arvin.temkar@ajc.com)

Credit: arvin.temkar@ajc.com

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Credit: arvin.temkar@ajc.com

“We already have the data that one in seven moms will have experienced postpartum depression, one in 10 dads will experience postpartum depression, one in 10 pregnant people will have depression or anxiety,” said Shontel Cargill, a perinatal family therapist and president of Postpartum Support International. “Those things happen. But when the pandemic happened, it exacerbated all of that. And it really showed that our healthcare system, was not prepared.”

Community workers want patients’ complaints to be respected.

“I think that we’ve got work to do,” said Lindberg. “I think that it’s not enough to continue to talk about it. It’s pretty old to keep asking women to rehash trauma for us to believe them.

“The data is clear. We need to do better. We need to do more and we need to do it now.”


LEADING CAUSES OF MATERNAL DEATH

The state Department of Public Health has released some initial findings from the review of Georgia’s maternal deaths between 2018 and 2020 by the Maternal Mortality Review Committee. These were the top ways in which the committee found pregnancy contributed to the death of someone who was pregnant or had given birth in the previous year.

16 deaths: Hemorrhage. All preventable.

15 deaths: Mental health conditions. All preventable.

13 deaths: Cardiomyopathy (a condition that affects how your heart pumps blood). All preventable.

12 deaths: Cardiovascular and coronary conditions. All preventable.

12 deaths: Embolism (an obstruction in an artery or a blood clot). Ten were preventable.

10 deaths: Preeclampsia and eclampsia. All preventable.

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Credit: Hyosub.Shin@ajc.com

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