High Risk Pregnancy
Pregnancy, while one of the most joyous times in a woman’s life, is also one of the most physically and physiologically stressful times. There is no doubt in anyone’s mind that pregnancy fundamentally changes a woman’s body; some women will gain as much as half of their pre-pregnancy weight during their pregnancies. Others will develop gestational diabetes, pregnancy induced hypertension or, in more severe cases peripartum cardiomyopathy (enlargement of the heart) or kidney failure. During pregnancy, the body increases its blood volume by 50 to better be able to nourish the growing fetus and maintain mama. Most women will “sail” through their pregnancies, labors and deliveries, have healthy children and will “live happily ever after”. Others won’t be so lucky and they or their children will perish from primarily preventable forms of heart disease.
Cardiovascular (heart) disease is a leading cause of death in the United States. A recent article published in Obstetrics and Gynecology reports that researchers in Illinois found that from 2000-2011, nearly 20% of all maternal deaths were heart related, Here is what they found:
- Most of the deaths occurred in the third trimester or within 6 weeks of the post partum period.
- Most of the heart related problems happened in women ages 30-39, while the most severe cases occurred in women over 40.
- Cardiomyopathy (enlarged heart)in pregnancy is a rare cardiac occurrence, is almost exclusively caused by pregnancy and occurs more often in young women, 20-29 years.
- Death from cardiomyopathy is more likely to happen in very young women, less than 20 years old.
- Black women have significantly higher rates of pregnancy related heart disease compared to White or Hispanic women.
- 28% of all of the deaths were potentially preventable.
Yes, you read that last bullet point correctly. Twenty eight percent of the cardiovascular deaths that occurred during or just after pregnancy in the Illinois report were potentially preventable deaths! So what should you, as a Mama on Bedrest do to protect her heart?
- Schedule and maintain your regular prenatal visits. Early detection and early action are the hallmarks of treatment success for any disease, but especially cardiovascular disease during pregnancy.
- Notify your health care provider immediately if you notice any heart palpitations, difficulty breathing, unusual swelling in the hands, feet, face, changes in urine output. Now this may be difficult as you are likely experiencing all of these symptoms as a result of your pregnancy. Suffice it to say that if you have an increase in any of the symptoms or if they suddenly occur where they didn’t previously exist, then consult your health care provider.
- INSIST ON FOLLOW UP AFTER YOU HAVE YOUR BABY!! One of the key points that came out of the points that came out of the Illinois study is that most of the heart disease related deaths occurred after 6 weeks post partum. Many women have their post partum follow up visits with their obstetricians and then don’t return for a year or unless there are other issues. If you had a problem, even a minor problem during your pregnancy, FOLLOW UP FOR UP TO A YEAR POST PARTUM. Many conditions will “flare” with the fluctuation of hormones during the post partum, i.e. get worse, so you want to be closely monitoring for symptoms.
It is imperative that mamas receive comprehensive care of cardiac problems and are fully treated to avoid-or at least mitigate-heart problems in the future. Thankfully not all mamas who have heart problems will die, but many will have life long problems as a result of incomplete care. Be sure to have ongoing follow up and let all subsequent providers know that you experienced heart problems while you were pregnant.
The authors also note that providers must do a better job of
- educating their patients about the signs and symptoms of cardiovascular disease
- referring patients immediately to specialists when problems occur
- continuing to monitor their patients’ conditions well into the post partum period, as long as a year post partum.
As this article clearly states, death from cardiovascular complications is very often preventable. Patients and physicians alike must be aware of the signs and symptoms of cardiovascular disease and both must have a low threshold for seeking evaluation; patients from their obstetricians, physicians from their specialists colleagues. Finally, it is imperative that women who developed cardiovascular symptoms during or just after pregnancy be evaluated for an extended time in the post partum, often up to one year post partum.
What is it like to have a pregnancy related heart problem? Hear a mamas story.
Have you experienced a heart problem during your pregnancy? Please share your story.
If you have more questions, email email@example.com
Mamas on Bedrest: “Widespread Insurance Coverage of Doula Care Would Reduce Costs, Improve Maternal and Infant Health”January 14th, 2016
As we roll into 2016 one thing is certain: We are on the brink of change in the maternity world! At no time in history have there been so many groups and so many initiatives determined to improve maternity care and birth outcomes. Below is a press release put out by two leading maternity advocacy groups, Choices in Childbirth and Childbirth Connection (a program of the National Partnership for Women and Families) to raise awareness not only of the cost benefit of doula care, but also the tremendous benefit doulas provide to mamas and infants in improving birth outcomes. A doula is “a trained birth attendant who provides non-medical emotional, physical and informational support before, during and after childbirth.” Here is more from the press release:
“Widespread coverage of doula care is overdue,” said Michele Giordano, executive director of Choices in Childbirth. “Overwhelming evidence shows that giving women access to doula care improves their health, their infants’ health, and their satisfaction with and experience of care. Women of color and low-income women stand to benefit even more from access to doula care because they are at increased risk for poor maternal and infant outcomes. Now is the time to take concrete steps to ensure that all women can experience the benefits of doula care.”
“Doula care is exactly the kind of value-based, patient-centered care we need to support as we transform our health care system into one that delivers better care and better outcomes at lower cost,” said Debra L. Ness, president of the National Partnership. “By expanding coverage for doula care, decision-makers at all levels and across sectors – federal and state, public and private – have an opportunity to improve maternal and infant health while reducing health care costs.”
The brief provides key recommendations to expand insurance coverage for doula care across the country. They have also provided an informative infographic which also summarized the major points (see below).
- Congress should designate birth doula services as a mandated Medicaid benefit for pregnant women based on evidence that doula support is a cost-effective strategy to improve birth outcomes for women and babies and reduce health disparities, with no known harms.
- The Centers for Medicare & Medicaid Services (CMS) should develop a clear, standardized pathway for establishing reimbursement for doula services, including prenatal and postpartum visits and continuous labor support, in all state Medicaid agencies and Medicaid managed care plans. CMS should provide guidance and technical assistance to states to facilitate this coverage.
- State Medicaid agencies should take advantage of the recent revision of the Preventive Services Rule, 42 CFR §440.130(c), to amend their state plans to cover doula support. States should also include access to doula support in new and existing Delivery System Reform Incentive Payment (DSRIP) waiver programs.
- The U.S. Preventive Services Task Force should determine whether continuous labor support by a trained doula falls within the scope of its work and, if so, should determine whether labor support by a trained doula meets its criteria for recommended preventive services.
- Managed care organizations and other private insurance plans as well as relevant innovative payment and delivery systems with options for enhanced benefits should include support by a trained doula as a covered service.
- State legislatures should mandate private insurance coverage of doula services.
Did you know that September is Infant Mortality Awareness Month?
Globally, The United States spends more on healthcare than any other country. Yet, it has worse birth outcomes than many other countries globally. Despite recent declines in infant mortality, the United States ranked 26th among the 29 Organization for Economic Co-operation and Development (OECD) countries in 2010, behind most European countries as well as Japan, Korea, Israel, Australia, and New Zealand (1). The U.S. infant mortality rate of 6.1 infant deaths per 1,000 live births was more than twice that for Japan and Finland (both 2.3), the countries with the lowest rates. Twenty-one of the 26 OECD countries studied had infant mortality rates below 5.0.
Overall in the United States, white infants die at a rate of 5-6/1000 births and Hispanic infants have a similar infant mortality rate. African American Infants die at a rate of approximately 11.4/1000 births. I’m here in Texas and our infant mortality rate for white and hispanic infants is 5.5/1000 births while it is 11.4/1000 for African American Infants. In Travis County (the Greater Austin Area where I live), African American Infants have an infant mortality rate of 11.5/1000 births, whereas white infants have an infant mortality rate of 3.7/1000 births and Hispanic infants 6/1000 births.(2) What is the cause of this disparity?
Researchers and public health officials have numerous speculations as to why the IMR for African American infants is so poor,
- Delayed initiation of prenatal care among African American women
- Lack of access to quality prenatal care
- Lack of insurance
- Preterm labor/Prematurity
- Low birth weight
- Birth Defect
- Maternal health complications
However Dr. Michael Lu, an obstetrician and gynecologist at the David Geffen School of Medicine at UCLA and a professor in the Department of Community Health Sciences and the Center for Healthier Children, Families and Communities at UCLA School of Public Health has proposed other reasons for the birth outcome disparities. In his groundbreaking research paper “Closing the Black-White Gap in Birth Outcomes: A Life-Course Approach“ (3) Dr Lu and his colleagues point to systemic racism in American culture as the underlying cause of the birth outcome disparities. Lu and his colleagues point out that racism passed down through generations, as well as repeated racial slights in the daily lives of African American women has created an allostatic load of stress on African American women that is affecting their overall health, but in particular, their reproductive health and causing the negative birth outcomes we see in African American women and infants. To address these social determinants of health, Lu and his colleagues propose a 12 point Life-Course approach to closing the racial gap in birth outcomes.
- Provide Inter-conception care for women with prior adverse pregnancy outcomes
- Increase access to preconception care for African American women
- Improve the quality of prenatal care for African American women
- Expand healthcare access over the life course for African American women
- Strengthen father involvement in African American families
- Enhance systems coordination and integration for family support services
- Create reproductive social capital in African American communities
- Invest in community building and urban renewal
- Close the education gap
- Reduce poverty among African American families
- Support working mothers and families
- Undo Racism
Lu and his colleagues have presented an approach that not only address issues surrounding pregnancy and childbearing, but also addresses the social issues affecting African American families and communities. Lu makes some very bold statements, ones that some people may be loathe to accept and even less likely to act upon. But as Lu says in his publication,
“We will not close the Black-White gap in birth outcomes without political will to do so. Political will is the ability to command resources to make things happen (i.e. implement the 12 points).”
As the saying goes, “Where there is a will, there is a way!” The question now becomes do we the American people have the will, the actual desire to close this gap?
MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. National vital statistics reports; vol 63 no 5. Hyattsville, MD: National Center for Health Statistics. 2014.
Austin Travis County Health and Human Services Department. Infant Mortality Rate Causes of Death for Travis County, 2000-2011. Data Source, Center for Health Statistics, Texas Department of State Health Services. Texas Behavioral Risk Factor Surveillance System (BRFSS) 2011-2012
Lu, M.C., MD, MPH, Kotelchuck, M., PhD, MPH, Hogan, V., DrPH, Jones, L., MA, Wright, K., PhD, MPH, Halfon, N., MD, MPH. “Closing The Black-White Gap in Birth Outcomes: A Life-Course Approach” Ethnicity and Disease, Volume 20, Winter 2010.