tools to decrease the rate of cesarean delivery. Financial Disclosure: The authors did not report any potential conflicts of interest.
Megan S. Bradley, MD Elizabeth E. Krans, MD Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh Pennsylvania
committees, we strongly encourage that issues of intimate partner violence, maternal depression, and suicide be addressed seriously as potentially preventable causes of maternal death. Whereas the timely use of uterotonics, anticoagulants, and antibiotics likely can contribute to the prevention of maternal death in specific clinical scenarios, it also is conceivable that a simple screening tool designed to detect maternal depression and perception of physical threat may have similar benefits.
REFERENCES 1. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Matthews TJ. Births: final data for 2011. Natl Vital Stat Rep 2013; 62:1–70. 2. Chazotte C, Cohen WR. Catastrophic complications of previous cesarean section. Am J Obstetrics Gynecol 1990;163:738–42.
Maternal Mortality: Time for National Action To the Editor: As obstetric practitioners committed to the call for “national action” against the rising U.S. maternal mortality rate, as recently outlined by Main and Menard,1 we read with interest their editorial pointing out the common causes of maternal mortality and severe maternal morbidities, the preventable nature of many such unfortunate outcomes, the critical need for standardized approaches to acute hypertension and obstetric hemorrhage management, and the importance of systematic maternal mortality reviews. In discussing the causes of maternal mortality, the authors state: “cardiovascular conditions. including cardiomyopathy have emerged as the number one cause of death....” We wish to point out, however, recent compelling data2 indicating that, sadly, maternal deaths due to homicide and suicide may occur with greater frequency than the common obstetric causes noted in the editorial. Given these data and our own patient-care experiences in these tragic situations, we have advocated universal prenatal and postpartum depression screening, despite a lack of consensus in this regard from the American College of Obstetricians and Gynecologists.3 As the important nationwide initiatives outlined by Main and Menard begin tackling the rising maternal mortality rate through the establishment of case review
362
Letters to the Editor
Financial Disclosure: The authors did not report any potential conflicts of interest.
Jordan H. Perlow, MD Maternal-Fetal Medicine, Banner Good Samaritan Medical Center, Phoenix Perinatal Associates, Phoenix, Arizona Heather Lesmes, MD Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, Phoenix, Arizona
REFERENCES 1. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol 2013;122:735–6. 2. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2011;118:1056–63. 3. Perlow JH, Lesmes H. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2012;119:1274–5.
In Reply: Drs. Perlow and Lesmes raise the very important point that homicide and suicide are significant contributors to pregnancy-associated death, defined by the Centers for Disease Control and Prevention as any death occurring within a year after pregnancy. Cardiac disease, hypertension, thromboembolism, and hemorrhage are the most commonly reported pregnancy-related events. In some circumstances, the line between “pregnancy-associated” and “pregnancy-related” death is blurred. One can argue that a woman’s psycho-
social environment is markedly changed by pregnancy and birth. Worsening depression or increases in intimate partner violence leading to suicide or homicide can be directly related to pregnancy. Maternal deaths, whether due to homicide, suicide, or the more traditional pregnancy-related causes, are equally tragic, potentially preventable, and worthy of national attention. Can screening for depression and intimate partner violence during the prenatal period prevent maternal death? Screening without resources for treatment and referral will have little or no effect on clinical outcomes.1 Patients in need of care for depression face formidable barriers, such as lack of trained providers, psychiatric illness stigmata, lack of insurance coverage for mental health care, and aversion to use of pharmacologic therapy during pregnancy and lactation. There are sensitive, validated tools for screening for depression during the antepartum period,2 but engaging and training providers in evidence-based assessment and treatment remains a challenge, though it is a challenge worth tackling. Studies suggest that screening for intimate partner violence with resources for intervention can decrease recurrent intimate partner violence and improve pregnancy outcomes.3 State maternal mortality reviews are fundamental in the national initiative to improve maternal safety.4 Review of all pregnancy-associated deaths will bring these violence-related deaths to the forefront. Local data should drive safety initiatives through local and state quality collaboratives. Although the first safety bundles that we are endorsing for every hospital in the nation are related to hemorrhage, preeclampsia, and venous thromboembolism prevention, bundles for cardiac disease, sepsis, and perhaps homicide and suicide prevention may follow. The success of the National Partnership for Maternal Safety will depend on the initiative of engaged providers such as Drs. Perlow and Lesmes to identify opportunities and implement strategies for prevention. Financial Disclosure: The authors did not report any potential conflicts of interest.
M. Kathryn Menard, MD, MPH University of North Carolina at Chapel Hill, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Chapel Hill, North Carolina
OBSTETRICS & GYNECOLOGY
Megan S. Bradley, MD Elizabeth E. Krans, MD Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh Pennsylvania
committees, we strongly encourage that issues of intimate partner violence, maternal depression, and suicide be addressed seriously as potentially preventable causes of maternal death. Whereas the timely use of uterotonics, anticoagulants, and antibiotics likely can contribute to the prevention of maternal death in specific clinical scenarios, it also is conceivable that a simple screening tool designed to detect maternal depression and perception of physical threat may have similar benefits.
REFERENCES 1. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Matthews TJ. Births: final data for 2011. Natl Vital Stat Rep 2013; 62:1–70. 2. Chazotte C, Cohen WR. Catastrophic complications of previous cesarean section. Am J Obstetrics Gynecol 1990;163:738–42.
Maternal Mortality: Time for National Action To the Editor: As obstetric practitioners committed to the call for “national action” against the rising U.S. maternal mortality rate, as recently outlined by Main and Menard,1 we read with interest their editorial pointing out the common causes of maternal mortality and severe maternal morbidities, the preventable nature of many such unfortunate outcomes, the critical need for standardized approaches to acute hypertension and obstetric hemorrhage management, and the importance of systematic maternal mortality reviews. In discussing the causes of maternal mortality, the authors state: “cardiovascular conditions. including cardiomyopathy have emerged as the number one cause of death....” We wish to point out, however, recent compelling data2 indicating that, sadly, maternal deaths due to homicide and suicide may occur with greater frequency than the common obstetric causes noted in the editorial. Given these data and our own patient-care experiences in these tragic situations, we have advocated universal prenatal and postpartum depression screening, despite a lack of consensus in this regard from the American College of Obstetricians and Gynecologists.3 As the important nationwide initiatives outlined by Main and Menard begin tackling the rising maternal mortality rate through the establishment of case review
362
Letters to the Editor
Financial Disclosure: The authors did not report any potential conflicts of interest.
Jordan H. Perlow, MD Maternal-Fetal Medicine, Banner Good Samaritan Medical Center, Phoenix Perinatal Associates, Phoenix, Arizona Heather Lesmes, MD Department of Obstetrics and Gynecology, Banner Good Samaritan Medical Center, Phoenix, Arizona
REFERENCES 1. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol 2013;122:735–6. 2. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2011;118:1056–63. 3. Perlow JH, Lesmes H. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2012;119:1274–5.
In Reply: Drs. Perlow and Lesmes raise the very important point that homicide and suicide are significant contributors to pregnancy-associated death, defined by the Centers for Disease Control and Prevention as any death occurring within a year after pregnancy. Cardiac disease, hypertension, thromboembolism, and hemorrhage are the most commonly reported pregnancy-related events. In some circumstances, the line between “pregnancy-associated” and “pregnancy-related” death is blurred. One can argue that a woman’s psycho-
social environment is markedly changed by pregnancy and birth. Worsening depression or increases in intimate partner violence leading to suicide or homicide can be directly related to pregnancy. Maternal deaths, whether due to homicide, suicide, or the more traditional pregnancy-related causes, are equally tragic, potentially preventable, and worthy of national attention. Can screening for depression and intimate partner violence during the prenatal period prevent maternal death? Screening without resources for treatment and referral will have little or no effect on clinical outcomes.1 Patients in need of care for depression face formidable barriers, such as lack of trained providers, psychiatric illness stigmata, lack of insurance coverage for mental health care, and aversion to use of pharmacologic therapy during pregnancy and lactation. There are sensitive, validated tools for screening for depression during the antepartum period,2 but engaging and training providers in evidence-based assessment and treatment remains a challenge, though it is a challenge worth tackling. Studies suggest that screening for intimate partner violence with resources for intervention can decrease recurrent intimate partner violence and improve pregnancy outcomes.3 State maternal mortality reviews are fundamental in the national initiative to improve maternal safety.4 Review of all pregnancy-associated deaths will bring these violence-related deaths to the forefront. Local data should drive safety initiatives through local and state quality collaboratives. Although the first safety bundles that we are endorsing for every hospital in the nation are related to hemorrhage, preeclampsia, and venous thromboembolism prevention, bundles for cardiac disease, sepsis, and perhaps homicide and suicide prevention may follow. The success of the National Partnership for Maternal Safety will depend on the initiative of engaged providers such as Drs. Perlow and Lesmes to identify opportunities and implement strategies for prevention. Financial Disclosure: The authors did not report any potential conflicts of interest.
M. Kathryn Menard, MD, MPH University of North Carolina at Chapel Hill, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Chapel Hill, North Carolina
OBSTETRICS & GYNECOLOGY
