Nevada is believed to have one of the lowest rates of pregnancy-related death in the country.
But that statistic doesn’t tell a complete story.
Something state health officials don’t have is a clear grasp of what caused the deaths that did occur. This means they also don’t know how many of those deaths could have been prevented. And they aren’t sure why Nevada fares so well on pregnancy-related death in spite of other known shortcomings of the health-care system.
A newly formed committee hopes it can shed some light on these oft-overlooked deaths. When they begin meeting this month, the maternal mortality review committee will explore the medical records of pregnant or postpartum women who have died, look for trends, and begin to form policy recommendations designed to keep women safer before, during and after pregnancy.
Maternal mortality is defined by the World Health Organization as dying “while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” Pregnancy-related deaths use the same criteria except broadened to 365 days. Finally, pregnancy-associated deaths are any death of a pregnant or recently pregnant woman, including those whose cause of death is unrelated to pregnancy (ie, a car accident or domestic violence).
America’s Health Rankings ranked Nevada third to last when it comes to pregnancy-related deaths with 14 deaths per 100,000. That’s half the national rate of 29 deaths per 100,000.
However, when it came to women and children’s health overall, Nevada was at the bottom of the pack: ranked 46th of the 50 states. The state has among the lowest physician to population ratios. Similarly, it ranks in the bottom five states when it comes to family medicine, pediatric and obstetrician/gynecological physicians per capita. Women here are more likely to have received late or no prenatal care. Nevada is in the top 12 states when it comes to the percent of women who are uninsured during pregnancy.
The Society of Maternal Fetal Medicine ranks states by four criteria: the existence of a maternal mortality review committee, the establishment of a perinatal quality collaborative, Medicaid expansion and reporting of outcomes data by race. Nevada is currently one of only three states that has met only met one of those benchmarks, Medicaid expansion. (An additional two states have met none of the criteria.)
As he gave a presentation on maternal mortality to the legislative interim committee on health care earlier this month, Dr. Brian Iriye, president of the Society of Maternal Fetal Medicine and managing partner of High Risk Pregnancy Center, expressed uncertainty over the state’s favorable ranking on pregnancy-related deaths.
“It’s unclear why this is happening,” he told the committee. “Is the data incorrect? Possibly.”
A biostatician from the Nevada Department of Health and Human Services told the Current later that the data from the America’s Health Rankings is correct and that best practices are used when it comes to collecting pregnancy-related death data, which comes directly from death certificates filed with the state.
However, as national interest in the topic of maternal mortality has grown, some experts have called into question issues with data and data comparisons. Those issues range from different states asking about deaths over different durations of time, to false positives that aren’t caught without further review, to deaths being misreported because providers don’t see the connections between overlapping medical issues.
“A lot of problems have stemmed from how the definitions have changed over time,” Iriye told the Current. “The whole point is: The data needs to be checked and it’s so imperative that we have this maternal mortality review committee.”
The committee will look at every death individually and ask: Would she have died if she weren’t pregnant?
Iriye is one of the 12 people who’ve been appointed by the head of the Department of Health and Human Services to sit on the committee and ask precisely that question. He says committees in other states have made connections that were previously overlooked.
“In every state that has formed (a maternal mortality review committee), the data that has come out eventually has been different,” he adds. “For example, Texas had a very high rate of maternal mortality, and when they looked back at the data, (almost) 20 percent were due to overdoses.”
Nevada passed over for funding
The United States is the only developed country in the world where maternal mortality rates are rising.
Research has found that 60 percent of these deaths are preventable.
Maternal deaths disproportionately affect American Indian, Alaskan Native and Black women. They are two to three times as likely to die from pregnancy-related causes than white women, according to the CDC.
One analysis by the state of data from 2008 to 2014 found the rate of pregnancy-related deaths among Black women to be twice that of white women: 14 per 100,000 versus 7 per 100,000.
That health equity component was emphasized by Democratic Assemblywoman Daniele Monroe-Moreno when she introduced the bill to create Nevada’s maternal mortality review committee during the 2019 Legislative Session. Lawmakers rushed the passage of the bill in order to meet a May application deadline for a CDC grant to support maternal mortality review committees.
It was an effort that turned out financially fruitless.
In September, the CDC awarded its $43 million to maternal mortality review committees across 25 states. Nevada did not receive any funding, in part because its maternal mortality review committee had not done anything except get authorization from the state to exist.
State officials told the interim committee on health care that the lack of funding presents “a challenge” but that the maternal mortality review committee will be able to proceed as planned without the CDC grant dollars it was hoping to receive. While its members are not compensated for their time, a registered nurse must be trained to extract data in preparation for the committee.
Speaking in absolute numbers, deaths associated with pregnancy are relatively low. It is estimated approximately 700 women die across the country annually. That said, the rates of maternal morbidity — that is the “near miss events” that result in short- or long-term health consequences for women — are significantly higher. Depending on how you define it, maternal morbidity can be 40 to 100 times higher than the mortality rate.
A 2016 report put the rate of severe maternal morbidity in Nevada at 174 per 100,000 for Black, non-Hispanic women and 102 per 100,000 for white, non-Hispanic women.
The maternal mortality review committee is also tasked with reviewing data and information on severe maternal morbidity. Their meetings will not be public due to the sensitive medical information they review, but their findings and policy recommendations will be submitted annually to the legislature.
The first report is expected in April 2021.
In the meantime, health officials in Nevada have already identified things that could improve maternal health overall. This includes expanding the coverage and eligibility thresholds of Nevada Medicaid.
Fifty-eight percent of all births in Nevada in 2018 were covered by Medicaid.
Per federal law, Medicaid must be available for people earning up to 135 percent of the federal poverty level. States have the ability to expand eligibility beyond this. Nevada has, but to a lesser extent than other states. The average eligibility level across the country is 205 percent. Nevada’s is currently 165. Only eight states have a lower eligibility threshold.
It’s estimated that more than a third (35.3 percent) of all Nevada families would fall under the 200 percent threshold.
Medicaid coverage extends to 60 days after delivery. States have the option of expanding coverage to 365 days. Nevada hasn’t done so. According to 2018 data presented by the state to lawmakers, of the 17 women who died within one year of giving birth, 76 percent (13 women) were enrolled in Medicaid. Six of the 13 women who died lost their Medicaid coverage after 60 days.
States also have the option of expanding Medicaid eligibility to “lawfully residing immigrant pregnant women” during their first five years in the country. Nevada has not adopted this coverage option, though it has adopted a similar one for documented immigrant children.
Iriye believes Medicaid expansion combined with other best practices (such as reducing implicit bias by mandating electronic health records and checklists when discussing symptoms and medical issues) could go a long way in improving health outcomes for pregnancy and postpartum women. That has a ripple effect across generations.
“It’s a shame that so little has gone into maternal health,” he adds. “Everything is influenced by the baby and the outcome of the baby, not the mom. We need to get back to thinking about the mom. We need to think about the mom because when you have a healthy mom, you have a healthy baby.”