Courtesy Merck
A Momobile manager steps out of her car on her way to a visit with a client.

Two to three women die every day in the U.S. from pregnancy-related complications, according to a new United Nations and World Health Organization report.

Even worse news? The U.S. ranks 47th out of 180 countries for mother mortality rates — last in developed countries. This news comes on the heels of a recent Save the Children report that also ranked the U.S. low among developed countries, adding to the mounting evidence that the U.S. is dropping as a safe place to have a baby.

But the good news is that people are starting to pay attention, says Dr. Priya Agrawal, executive director of Merck for Mothers, a $500 million initiative to put a stop to deaths related to childbirth. The program is innovating ways to save mom — from "Momobile" services that provide home visits to pregnant women, to delivery room protocols for the most common delivery room emergencies, like severe bleeding.

"There is a real lack of awareness — up until now all the attention has been on infant mortality rates," says Agrawal. "Considering that this is not a disease, and that other countries are safe places to deliver, this is unacceptable — especially because most of these cases are preventable."

Problems at home

In her work as an OB/GYN, Agrawal has traveled the world and seen pregnant women who arrive at the hospital to deliver having had little or no prenatal care. The surprising thing, she says, is that she's seeing the same thing in the U.S.

In some low-income neighborhoods, women don't make it to the doctor because they don't have the money or the insurance. Only 50 percent of pregnant women in Camden, New Jersey, which ranks as America's poorest city according to the U.S. Census Bureau, receive first trimester care, she says. This makes it much harder to detect and treat conditions that can lead to a life-threatening childbirth — such as hypertension, diabetes or substance abuse.

For every 100,000 births in Philadelphia, 18 women die, and in Camden it's 30.

"These issues are actually not confined to the developing world. Sadly, there are communities in the United States that face challenges not all that different than those facing women in places like sub-Saharan Africa and South Asia," says Agrawal.

Helping Mom

To address this problem, the Maternity Care Coalition has a home-visiting program called the "Momobile." Underwritten by Merck's program, the Momobile delivers health workers who do in-home visits to help pregnant women navigate the health care system and understand their options.

Has the health care system become so convoluted that people need a dedicated health worker just to map it? For low-income families, the answer is often yes, says JoAnne Fischer, executive director of Maternity Care Coalition in Philadelphia.

Mothers have to find out what health care plans they're eligible for and find a managed care plan and provider that will accept them. Then, they have to find out if they're eligible for food stamps and sign up with that agency. They may also be eligible for help with gas and electric bills. If they have a chronic health problem, like diabetes and hypertension, they may need multiple specialists.

There are resources, but the agencies, paperwork and phone calls pile up fast.

"Meanwhile, some of these people may not have a phone, or they use up all their minutes waiting on hold," she says. "Some have no transportation or child care, and they can't bring their 3-year-old to the appointment."

The Momobile lets the Maternity Care Coalition coordinate care and provide follow-up explanations and education. Text messages between visits provide reminders and encouragement. Childbirth coaches and doulas reduce C-sections, and follow-up visits help with breastfeeding and treatment for postnatal depression. So far, the Momobile has helped over 5,000 women and their families in the Philadelphia area.

"People forget that on the day of birth, a child is born and a mother is born," says Agrawal, who notes that to date, funding and research has largely focused on infant mortality. "This is the first time in 25 years that the MCC has had money to spend just on the mothers."

Emergency plan

It may seem shocking that women die in childbirth in modern American hospital rooms, but it happens. In fact, every year 50,000 women almost die in childbirth or child-birth-related traumas in the U.S.

One of the most deadly problem is hemorrhage — or uncontrolled bleeding — and these deaths or near-deaths are often happening in the hospital, says Dr. Elliott Main.

"It shouldn't happen in this day and age, but it does," he says. Main should know — he's the chairman of the OB/GYN department at the California Pacific Medical Center in San Francisco — one of the largest in the nation with over 6,000 births a year.

Giving birth is something that the body is made to do normally, but things can go wrong — and when they do, they can "spin into danger fast," says Main. Hemorrhaging, or uncontrolled bleeding, usually happens when the placenta doesn't detach properly after birth, or if there is an internal rupture to the uterus, cervix or elsewhere in the birth canal. In these cases, says Main, a woman can bleed out in as little as 10 minutes.

Main is also the director of the California Maternal Quality Care Collaborative (CMQCC), a group of doctors, nurses, public health leaders and lawmakers that are seeking to eliminate maternal deaths and injuries. One of their initiatives is the "O.B. Hemorrhage Tool Kit," which educates doctors and nurses on best practices for hemorrhage emergencies, and a hemorrhage cart, which is ready and supplied with the necessary equipment, such as drugs that help the uterus contract, or uterine balloons that can apply pressure from within and stanch bleeding.

It seems like delivery rooms should be ready for these emergencies, but that's not always the case, says Main. Unlike the ER, where there are standard protocols for emergencies like heart attacks, OB/GYNs operate much more individually, and doctors, nurses, anesthesiologists and surgeons may not all be on the same page when severe bleeding strikes.

"We need to have a plan — as simple as that sounds, that’s not always the case in labor and delivery," says Main. "Unless you've pre-planned some way of coordinating, things can get disorganized."

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Blood transfusions during childbirth have gone up 183 percent over the last five years, according to the U.N report, which indicates that best practices for hemorrhaging are badly needed.

Main and the CMQCC have started rolling out the toolkit throughout California. Overall, California's maternal mortality was 15 percent — the same as the U.S. average; now it's down to 8 percent in California, or cut in half, he says.

The step now is to roll it out nationwide. "This has become a national effort led by physician, nursing and midwife organizations, so I would expect to see some significant changes," says Main.