Background A pregnancy question was added to the U.S. standard death certificate in 2003 to improve ascertainment of maternal deaths. The delayed adoption of this question among states led to data incompatibilities, and impeded accurate trend analysis. Our objectives were to develop methods for trend analysis, and to provide an overview of U.S. maternal mortality trends from 2000–2014. Methods This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year-of-adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted, to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions. Results The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington D.C. (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, while Texas had a sudden increase in 2011–2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported. Discussion Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington D.C. increased from 2000–2014, while the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.

Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.

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CONTEXT: Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear. OBJECTIVE: To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting. DATA SOURCES: Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: “neonatal intensive care units,” “racial or ethnic disparities,” and “quality of care.” STUDY SELECTION: English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected. DATA EXTRACTION: Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. RESULTS: Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. LIMITATIONS: Quantitative meta-analysis was not possible because of study heterogeneity. CONCLUSIONS: Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

ObjectiveTo identify how family advocates and clinicians describe disparities in NICU quality of care in narrative accounts.Study designQualitative analysis of a survey requesting disparity stories at the 2016 VON Quality Congress. Accounts (324) were from a sample of RNs (n = 114, 35%), MDs (n = 109, 34%), NNPs (n = 55, 17%), RN other (n = 4, 1%), clinical other (n = 25, 7%), family advocates (n = 16, 5%), and unspecified (n = 1, <1%).ResultsAccounts (324) addressed non-exclusive disparities: 151 (47%) language; 97 (30%) culture or ethnicity; 72 (22%) race; 41 (13%) SES; 28 (8%) drug use; 18 (5%) immigration status or nationality; 16 (4%) sexual orientation or family status; 14 (4%) gender; 10 (3%) disability. We identified three types of disparate care: neglectful care 85 (26%), judgmental care 85 (26%), or systemic barriers to care 139 (44%).ConclusionsNearly all accounts described differential care toward families, suggesting the lack of equitable family-centered care.

Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families’ experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.