Trinity works to reverse alarming trend in U.S. maternal death rate

October 15, 2017


It's a health statistic that would surprise many people — as the infant mortality rate falls in the U.S., the rate of maternal mortality continues to rise.


The U.S. is "the only country outside of Afghanistan and Sudan where the maternal mortality rate is rising," said Dr. Gerald J. Girardi, perinatal medical director for Trinity Health and co-lead of the health system's Perinatal Patient Safety Initiative. "Between 2000 and 2014, there was a 
27 percent increase in maternal mortality."

More women die of pregnancy-related complications in the U.S. than in any other developed nation, and the U.S. now ranks 64th in the world for maternal mortality.

Trinity Health, based in Livonia, Mich., and providing health services in 22 states, is on the national leadership team for the Alliance for Innovation on Maternal Health, a collaboration between the Council on Patient Safety in Women's Health Care and the Health Resources and Services Administration's Maternal and Child Health Bureau, part of the U.S. Department of Health and Human Services.


Susan J. Garpiel, a registered nurse who is director of perinatal clinical practice for Trinity Health and co-lead for the Perinatal Patient Safety Initiative, said some would say there are "only 700" cases of maternal mortality yearly in the U.S., but the rise in the maternal mortality rate is significant and worrisome.

"Pregnancy-related deaths are only part of the picture," she added. "The morbidity rate in pregnant women has risen also. Many women are becoming severely ill and requiring ICU hospitalization, and may have lifelong health problems."

Part of the problem is attributed to the fact that pregnant women in the U.S. are, on average, older, heavier and have more underlying conditions such as diabetes and hypertension than they did in the past. Even so, the Centers for Disease Control and Prevention estimates that at least half of all maternal deaths in the U.S. are preventable.

"It's not just that the women are older; it's how well we are caring for them," Girardi said.

The campaign centers on patient safety bundles developed and promoted by the alliance in 2015 to combat the leading preventable causes of maternal death: obstetric hemorrhage, hypertension/preeclampsia and blood clots. Trinity is also focusing on a fourth area — unnecessary Cesarean-section births.

"People think that C-sections are safe and it's true they are safe, but when you get to the third or fourth there are significant risks to that patient that can lead to infections, blood clots and other complications that can cause maternal death," Garpiel said.


"Data shows that 90 percent of women who have C-sections for their first birth" will continue to have the surgery for all subsequent births, she added.

The patient safety bundles provide "a small, straightforward set of evidence-based information to improve patient outcomes," Girardi said. "The goal is to standardize care and reduce variations."

Each bundle is built around four components:

  • Readiness: This includes having response protocols and a multidisciplinary clinical team ready to implement them. The alliance calls for hospitals to conduct regular unit-based drills, and ensure emergency kits or carts are stocked with necessary medicines and that there is an adequate supply of blood at the ready.
  • Recognition: The patient's risk for complications should be assessed at multiple points before, during and after labor, with a recognition that serious complications can occur in women thought to be at low risk.
  • Response: Every obstetrics unit should have a standard protocol to address potentially life-threatening conditions. It should set out the response to early warning signs and the procedure to escalate the clinical response, as necessary.
  • Reporting: This includes debriefings and formal analysis of a severe maternal event.

Although the alliance initially planned to focus only on the leading preventable causes of maternal death, patient safety bundles also have been developed to deal with maternal depression and anxiety, racial and ethnic disparities in obstetric care and the treatment of pregnant women who have used opioids.

The patient safety bundles, which include interactive e-learning modules that can be used by individuals or in group settings, are available on the alliance's website at

Girardi said Trinity first became involved in the alliance's work in 2015, when the system took on a national improvement challenge focused on reducing obstetric hemorrhages. "Trinity worked hard on this OB initiative, and had significant success in improving patient outcomes," he said.

Trinity placed third in the national competition and was the only nonuniversity center recognized, Girardi added. "We're quite proud of that accomplishment," he said.

The initiative is now part of the standard care at 40 Trinity hospitals in 18 states, Girardi said.

The alliance works primarily through health departments or maternal collaboratives in 11 states — Oklahoma, Maryland, Louisiana, Michigan, Florida, Illinois, Mississippi, New Jersey, North Carolina, Utah and California — and a few multistate hospital systems. Trinity is currently the only Catholic system working with the alliance, known as AIM.

Girardi and Garpiel each have more than 30 years' experience in maternal and child health, and both said similar experiences led them down that career path.

"I thought that I was going to do family medicine, so that I would know families over the years," Girardi said. "But in medical school when I had the opportunity to take part in the delivery process, ... to be at the miracle of birth and part of what is arguably the most important event for that family was beyond description for me."

"If you have children or have attended a birth, the creation energy at that time is the closest to God that you will ever get," Garpiel said.

Both encourage other Catholic hospitals and health systems to get in touch with their state health departments to see if they have considered joining the alliance.

"If you are in one of those 11 AIM states, by all means make the effort to connect with them," Girardi said. "You would benefit from being a part of it."

"You don't have to reinvent the wheel; AIM does provide the road map," Garpiel said.

"Our strength is in working together to build that momentum of change," she added. "It's not something you can accomplish in three months, four months. It takes at least a year for each of these initiatives."


Copyright © 2017 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3490.

Copyright © 2017 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.