The author’s training in obstetrics began in the 1980s, when assessment of the fetus was mainly through both hands-on maternal physical exam and indirect evaluations of maternal health. In fact, he notes that before the introduction of high-resolution ultrasound imaging and other advances, an obstetrician’s full attention was on the mother. Her health was paramount. However, following technological advances and establishment of routine, safe fetal intervention practices (eg, periumbilical blood sampling), a shift toward the “maternal-fetal dyad” philosophy in obstetric medicine occurred. Over time, the author observed that fetal status became elevated, from that of a passenger of secondary concern to the mother to that of an individual second patient. He notes that fetal interventions became paramount, even if such interventions entailed significant maternal risk. It was this fundamental change that prompted the author to leave maternal-fetal medicine at 47 years old, in order to retrain in anesthesiology and dedicate his work to “Maternal Medicine,” or the focused care of women experiencing medically complicated pregnancies.
Maternal mortality and morbidity rates in the United States have been increasing since 2003, but the author notes that it was in 2010 that a maternity-care crisis became undeniable. Even though US health care expenditures far exceed that of other nations, it still had the highest maternal mortality ratio of any resource-rich country. While changes like the rise in maternal obesity rates and the associated chronic conditions, increasing average maternal age, and changing environmental factors (opioid epidemic, racial divide, etc.) negatively influence the crisis, the author believes that these factors alone cannot fully account for these increasing rates. In fact, Dr Pryde believes that optimization of maternal in-hospital care could reverse these adverse trends. The author cites the California Maternal Quality Care Collaborative project as an example. This collaborative established a statewide maternal care program in 2008, which included creation and deployment of safety bundles, establishment of standardized, evidence-based care, and hands-on training for and dissemination of specialized interdisciplinary teams. Since its implementation of the statewide program, California has seen a remarkable decrease in maternal mortality, contrary to other states in the country.
Consequently, based on the results of the California Maternal Quality Care Collaborative, the author believes that maternal morbidity and mortality can be substantially reduced by striving for nationwide optimization of hospital maternity care. It goes beyond simply having skilled clinicians. He proposes that, in order to achieve success, obstetric units need (1) the formation of teams capable of addressing complex medical and resuscitative aspects of peripartum events at obstetric care facilities; (2) team leaders who coordinate early recognition of maternal crises and appropriately escalate; (3) organization of life-saving treatments and delegation of tasks; (5) an interdisciplinary leadership approach to hospital maternal medicine; and (6) inclusion of the physician anesthesiologist in the care of the maternal patient, specifically an obstetric anesthesiologist. In fact, the author believes that anesthesiology training confers skills that are critical and translatable in obstetric emergencies, including but not limited to establishing emergency intravenous access, expert pharmaceutical titration, cardiopulmonary resuscitation, and more.
Maternal medicine is a high stakes field, involving morally complex decisions and consideration of 2 lives. The interdependence within the maternal-fetal dyad is absolute, and the challenge of maternal medicine is to provide an intervention for both the maternal and fetal patient that does not endanger either party. It is impossible to eliminate all obstetric-related mortality and morbidity. However, with intensification of obstetric anesthesiology manpower, regionalization of maternal care, and proper staffing and coverage of units with maternity rescue-ready clinicians on-site, the author believes that many obstetrical-related catastrophes are avoidable.
Dr Pryde provides a unique perspective on the evolution of maternal medicine over the past 3 decades. As a practicing maternal fetal medicine provider, he witnessed the elevation of fetal status in the “maternal-fetal dyad.” Later in life, he retrained as an obstetric anesthesiologist so he could focus his attention more fully on the maternal medicine component. Through this process he began to recognize, as other providers, organizations, and leaders in health care have recently, that the state of maternal care in the United States is in crisis. Despite spending more money on in-hospital maternal care than other resource-rich countries, the United States has the highest maternal mortality ratio (MMR) of any other developed nation. Between 2000 and 2015, the MMR (per 100,000 livebirths) in the United States rose from 17.5 to 26.4.1 This is in stark contrast to other high-income nations in North America. For example, in Canada, MMR decreased from 7.7 to 7.3 over the same time period. An increasing percentage of parturients have chronic conditions placing them at higher risk of peripartum complications; however, this is ubiquitous in developed countries and cannot solely explain the increasing maternal morbidity and mortality in the United States. Pryde proposes that the problem is complicated by poverty, racial inequities, and the opioid epidemic, issues that are more prevalent in the United States than in other high-resource nations.
The presence of ethnic and racial differences in the management of labor analgesia and cesarean anesthesia has been increasingly highlighted over the last 10 years. In 2007, Glance et al2 demonstrated that black and Hispanic women are significantly less likely to receive labor epidural analgesia than non-Hispanic/white parturients. This difference was present even after adjusting for socioeconomic status and provider differences. In addition, women without private insurance or without higher levels of schooling were less likely to receive labor epidurals than those with private insurance or more years of education, respectively. Such racial disparities have been shown to extend into the obstetric operating room as well. A study looking at 50,974 women undergoing cesarean delivery (CD) between 1999 and 2002 found that African Americans and Hispanics are more likely to receive general anesthesia for CD compared with Caucasians, with adjusted odds ratios of 1.7 and 1.1, respectively.3 A more recent study further supports Butwick et al’s finding, demonstrating that a parturient being of an ethnic or racial minority significantly increases her likelihood of receiving potentially avoidable general anesthesia.4 Interestingly, the percentage of minorities utilizing labor neuraxial analgesia increased during the ten year period they investigated, between 2003-2004 and 2013-2014. The reason for increased general anesthesia use in minorities is not entirely clear but may be in part due to language barriers, provider beliefs, and general mistrust of the medical field.2 Regardless of cause, we can conclude that minority parturients are subsequently, and inadvertently, subject to increased maternal morbidity associated with general anesthesia for CD.4
We are now more aware of the crisis in care that mothers face, so what can we do about it? Pryde rightfully proposes that we are perfectly suited to be leaders in the interdisciplinary care of all parturients. Anesthesiologists by training are highly skilled in many critical life-saving tasks and are masters in resuscitation medicine. These skills are essential for the management of obstetric emergencies and the avoidance of maternal catastrophes. Our background in anesthesiology also provides us with a unique position as interdisciplinary leaders. We can readily transpose the team skills we’ve obtained in the operating room onto the labor and delivery floor. We are in an ideal position to be at the forefront of this team and spearhead multidisciplinary quality and safety initiatives. In addition, we have the potential to be champions for mothers that we recognize to be underserved and misrepresented. As physicians with expertise in pain management and regional anesthesia, we have the opportunity to tailor treatment to the specific needs of opioid-dependent mothers. As clinicians with training in acute care management, we can provide additional information and reassurance in situations where communication barriers may exist. Most importantly, we have an obligation to be ever and increasingly present on labor and delivery units. A current ACOG requirement for centers to achieve level II or higher maternal care is the presence of board-certified anesthesiologists with special training or experience in obstetric anesthesia.5 With the future potential for increased regionalization of maternal care, we can help lead the maternal interdisciplinary force to ensure all centers are at least of level II designation and that these centers are equipped to provide sophisticated, safe and inclusive maternal care.
Comment by Jennifer Fichter, MD and John A. Thomas, MD
1. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015; a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1775–1812.
2. Glance LG, Wissler R, Glantz C, et al. Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007;106:19–25.
3. Butwick AJ, Blumenfeld YJ, Brookfield KF, et al. Racial and ethnic disparities in mode of anesthesia for cesarean delivery. Anesth Analg. 2016;122:472–479.
4. Guglielminotti J, Landau R, Guohua L. Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries. Anesthesiology. 2019;130:912–922.
5. Obstetric Care Consensus No. 2: Levels of maternal care. Obstet Gynecol. 2015;125:502–515.