No More Stalling: We Can Prevent Maternal Deaths

Mother’s Day has passed, but the hard reality of high rates of maternal mortality in the U.S. remains.

UM Health System / Creative Commons

Like low birthweight, maternal mortality is thought of as an indicator of the health and well-being of a nation. The well-being of women and infants determines the health of the next generation and can help predict future public health challenges for families, communities and the health care system.

The frequency of mothers dying has doubled in the U.S. over the last 20 years, making it the worst as compared to every other developed nation. African-American women are three times as likely to die from pregnancy and childbirth as white women.

There is one specific contributor to maternal death that does have a potential solution—but is stalled in implementation.

Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, is a leading cause of maternal morbidity and mortality in the United States. It is an obstetric emergency that occurs in 4 to 6 percent of all deliveries within 24 hours. And its frequency is increasing.

Older maternal age, increased obesity, higher cesarean delivery rate, and more frequent multiple gestations may account for the overall mortality increases. Yet these changes in known risk factors alone do not account for the rising postpartum hemorrhage rates. While some women who experience a postpartum hemorrhage have known risk factors that could be accounted for, many women who do experience this are low risk and are healthy with no known risk factors.

Maternal deaths from postpartum hemorrhage can be prevented. Estimates of the preventability of hemorrhage-related deaths range from 40 to 90 percent. Additionally, more access to high quality care is likely to help reduce maternal deaths, which is also important at a time when national decisions are being made about who will have access to care.

There is a little-known, evidence-based treatment called transexamic acid that has been shown to allow blood to clot more quickly, and which could be broadly applied to prevent excessive blood loss in the context of a postpartum hemorrhage. Transexamic acid, a synthetic derivative of the amino acid lysine, was developed in the 1950s and FDA approved in 1986.

Transexamic acid has been available over-the-counter for years in Europe, marketed for heavy menstrual bleeding. In the United States, Pfizer manufactures the injectable form of transexamic acid called Cyklokapron. The injectable formulation has also been on the World Health Organization’s list of 350 essential medicines since 2011, indicating that it is considered safe, effective and necessary. Side effects are minimal. The cost is less than $2 per dose. However, it is only beginning to be used in the United States, and very rarely at that.

To be sure, it can take between seven and 20 years for evidence-based treatments to be incorporated into medical practice in the U.S.  But this serious lag in use can lead to unnecessary harm and even death. There is a general lack of awareness of the clinical data regarding its use in spite of  numerous studies and Cochrane Reviews supporting the drug’s ability to reduce bleeding. Some report that since this drug will not be a moneymaker for pharmaceutical companies, energies and resources have not been expended to promote its use.

It defies understanding why in the U.S. this problem would persist. The public needs to be aware of this significant risk to women and what can be done to prevent it. The medical community needs to be aware of this evidence-based available treatment and its effectiveness to stem excess bleeding.  Pregnant women and their families need to know to ask their doctor to make sure this drug is available at the hospital when delivering their baby regardless of the existence of risk factors.

It is important to speed the pace of the diffusion of life saving treatments and to use all of the best evidence-based treatments available to prevent the occurrence of harm and save the lives of delivering mothers. By taking these steps we will greatly reduce the frequency of hemorrhage and drive down the U.S. rate of maternal mortality.

It is time to make certain more mothers survive.


Donna Woods, EdM, PhD, is Associate Professor at the Center for Healthcare Studies, Feinberg School of Medicine; The Graduate School Director, the Northwestern Graduate Programs in Healthcare Quality and Patient Safety and Director, the Northwestern Program for Quality and Safety Innovation at Northwestern University. She is also a Public Voices Fellow through The OpEd Project.