SMFM Special Report
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning

https://doi.org/10.1016/j.ajog.2019.12.008Get rights and content

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Background

Evidence presented at the workshop demonstrates that, although safe reproductive health services are needed and beneficial for high-risk women, access is limited and inequitable across the United States and presents the following significant ethical, quality, and safety issues:

  • The maternal mortality ratio in the United States increased from 16.9 maternal deaths per 100,000 live births in 1999 to 26.4 per 100,000 in 2015.2 This increase in mortality was most pronounced among non-Hispanic black

Workshop structure and key findings

Following presentations on reproductive health ethics, disparities, and current policies; risk assessment strategies; components of counseling; and challenges of accessing contraception and abortion, workshop participants joined one of three breakout groups to discuss the following key issues in greater depth and to make preliminary recommendations: (1) assessing risk of maternal morbidity and mortality; (2) counseling women at high risk for pregnancy complications; and (3) training and access

Assessing the risk of maternal morbidity and mortality

A high-risk pregnancy can be defined as a pregnancy in which the woman, fetus, or infant is at significant risk of death or injury. This risk can result from maternal or fetal health conditions or nonmedical, contextual factors in a woman’s life that require additional resources, procedures, or specialized care to optimize outcomes. Maternal health conditions can include preexisting or pregnancy-associated chronic or infectious diseases, substance use or mental health conditions, and past

Counseling content

During prepregnancy counseling, women should be made aware of both maternal and fetal health risks of pregnancy and how to prevent or reduce these risks. These risks can be due to preexisting health conditions, effects of medication use, family or genetic history, or her physical environment.41 If a woman does not desire pregnancy in the next year, counseling about appropriate options for contraception is recommended. The discussion should include information on safety, effectiveness,

Access to reproductive health services

Many complex and interrelated barriers at the institutional, state, and national levels impede training in and provision of reproductive health services for women at high risk of maternal morbidity and mortality. Moreover, other barriers exist at the individual and care team level, such as implicit and explicit bias and discrimination, and religious, moral, or personal objections to abortion and family planning care. These barriers further limit the quality and accessibility of care and

Training for reproductive health services

Access to safe abortion care for all women78,81 and the management and treatment of women at high risk of maternal morbidity and mortality hinges on the availability of sufficient numbers of hospitals and trained physicians who are able to offer abortion care as well as access to MFM and family planning subspecialty care. Routine opt-out training in family planning and abortion-related care, including the performance of D&E procedures, should be formally integrated into all obstetrics and

Acknowledgment

We thank Virginia Andrews, MPH, for all of her work in the development of this manuscript.

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  • Cited by (18)

    • Society for Maternal-Fetal Medicine Special Statement: Postpartum visit checklists for normal pregnancy and complicated pregnancy

      2022, American Journal of Obstetrics and Gynecology
      Citation Excerpt :

      This counseling is particularly important for patients who have experienced previous pregnancy-related complications and those with chronic health conditions.10 Because family planning interventions, including risk assessment and appropriate counseling, can potentially prevent up to 30% of maternal deaths worldwide, prepregnancy care is an important strategy to address the ongoing maternal morbidity and mortality crisis.26,27 For patients who have experienced adverse pregnancy outcomes, specifically early-onset hypertensive disorders, cervical insufficiency, preterm birth before 34 weeks, or fetal growth restriction, prepregnancy counseling focuses heavily on potential morbidity recurrence in a future pregnancy, lifestyle modifications that may reduce obstetrical complications (eg, weight loss, smoking cessation), and interventions that may modify the risk of recurrence (eg, low-dose aspirin or prophylactic cerclage).28,29

    • Differences in postpartum contraceptive choices and patterns following low- and high-risk pregnancy

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      The Khon Kaen University Ethics Committee in Human Research approved this study (HE641240), which was registered with thaiclinicaltrials.org (TCTR20210531001). Using SMFM guidelines, we classified postpartum women as either high-risk or low-risk based on medical or obstetric conditions [9,11]. Medical conditions included chronic or infectious diseases which were pre-existing or associated with pregnancy.

    • The integration of abortion into obstetrician-gynecologists’ practice after comprehensive family planning resident training

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      We also found that actual intention during residency did not correlate with future provision, suggesting the importance of training - all were equally likely to go on to provide abortions, but that fewer than half of graduates provided abortion care, likely due to restrictions. We were surprised that one-quarter of those who said they did not provide abortions because of their subspecialty were maternal fetal medicine (MFM) subspecialists, despite SMFM recommending that all MFM fellows have access to abortion training, many MFM fellows wanting to be trained in abortion care, and many MFM physicians providing abortions [20–22]. Our findings underscore previous studies that highlighted significant institutional [23,24] and logistical barriers that persist [9,25,26] for obstetrician-gynecologists who want to provide abortion care.

    • Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision

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      Citation Excerpt :

      Over the last 9 years, 479 abortion restrictions were enacted in 33 states; in 2020, 236 provisions were introduced to restrict abortion care across the country, and 27 of these provisions were enacted.4–7 The role of the maternal-fetal medicine (MFM) subspecialist in abortion care extends beyond immediate perinatal management of a complex gestation.8 Although studies have found that MFM subspecialists discuss abortion in the setting of fetal anomalies identified during the midtrimester anatomic survey,9,10 little is known about MFM subspecialists’ perceptions about and provision of abortion care for maternal or fetal health conditions.11

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    Corresponding author: The Society for Maternal-Fetal Medicine: Reproductive Health Project for Maternal-Fetal Medicine, [email protected].

    Reprints will not be available.

    All authors and committee members have filed a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication. Any conflicts have been resolved through a process approved by the Executive Board. The Society for Maternal-Fetal Medicine (SMFM) has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    SMFM has adopted the use of the word “woman” (and the pronouns “she” and “her”) to apply to individuals who are assigned female sex at birth, including individuals who identify as men as well as nonbinary individuals who identify as both genders or neither gender. As gender-neutral language continues to evolve in the scientific and medical communities, SMFM will reassess this usage and make appropriate adjustments as necessary.

    All questions or comments regarding the document should be referred to the Reproductive Health Project for Maternal-Fetal Medicine at [email protected].

    The workshop was convened at the 39th Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in Las Vegas, NV, February 11–12, 2019.

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