SMFM Special ReportReproductive 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
Section snippets
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.
References (96)
- et al.
Side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy
Womens Health Issues
(2016) - et al.
Disparities in family planning
Am J Obstet Gynecol
(2010) - et al.
Assessing preventability of maternal mortality in Illinois: 2002–2012
Am J Obstet Gynecol
(2014) - et al.
A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery
Am J Obstet Gynecol
(2019) - et al.
Temporal and external validation of the fullPIERS model for the prediction of adverse maternal outcomes in women with pre-eclampsia
Pregnancy Hypertens
(2019) - et al.
Pregnant women's perspectives on decision-making when a fetal malformation is detected by ultrasound examination
Sex Reprod Healthc
(2013) - et al.
Decision satisfaction among women choosing a method of pregnancy termination in the setting of fetal anomalies and other pregnancy complications: a qualitative study
Patient Educ Couns
(2018) - et al.
Effect of counseling quality on anxiety, grief, and coping after second-trimester abortion for pregnancy complications
Contraception
(2018) - et al.
Preferences for decision-making about contraception and general health care among reproductive age women at an abortion clinic
Patient Educ Couns
(2010) - et al.
The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample
Patient Educ Couns
(2010)
An exploration of perceived contraceptive coercion at the time of abortion
Contraception
Decision aid tools to support women's decision making in pregnancy and birth: a systematic review and meta-analysis
Soc Sci Med
Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention
Contraception
Radical or routine? Nurse practitioners, nurse-midwives, and physician assistants as abortion providers
Reprod Health Matters
Abortion care policies and enforcement in US obstetrics and gynecology teaching hospitals: a national survey
Contraception
Society for Maternal-Fetal Medicine (SMFM) consult series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications
Am J Obstet Gynecol
The importance of access to comprehensive reproductive health care, including abortion: a statement from women's health professional organizations
Am J Obstet Gynecol
Putting abortion pills into women's hands: realizing the full potential of medical abortion
Contraception
Abortion training in US obstetrics and gynecology residency programs
Am J Obstet Gynecol
Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs
Am J Obstet Gynecol
The benefits of family planning training: a 10-year review of the Ryan Residency Training Program
Contraception
Predictors of abortion provision among practicing obstetrician-gynecologists: a national survey
Am J Obstet Gynecol
Society for maternal-fetal medicine (SMFM) special report: the maternal-fetal medicine subspecialists' role within a health care system
Am J Obstet Gynecol
Dilation and evacuation training in maternal-fetal medicine fellowships
Am J Obstet Gynecol
Racial injustice and family planning: an open letter to our community
Contraception
Abortion incidence and service availability in the United States, 2017
Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
Lancet
Health care disparity and pregnancy-related mortality in the United States, 2005–2014
Obstet Gynecol
Saving mothers' lives: transforming strategy into action: report of the Maternal Health Working Group 2012. Global Health Policy
State Medicaid coverage of medically necessary abortions and severe maternal morbidity and maternal mortality
Obstet Gynecol
Abortion-related mortality in the United States: 1998–2010
Obstet Gynecol
Women's mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study
JAMA Psychiatry
Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States
Am J Public Health
Contraceptive use among women with nedical conditions in a nationwide privately insured population
Obstet Gynecol
Association Between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States
JAMA
The Obstetrician–Gynecologist Workforce in the United States
Maternal-fetal medicine workforce in the United States
Am J Perinatol
Assessing the safety and quality of abortion care in the United States
Early abortion bans: which states have passed them?
Conspiracy beliefs about birth control: barriers to pregnancy prevention among African Americans of reproductive age
Health Educ Behav
Under the shadow of Tuskegee: African Americans and health care
Am J Public Health
Intersections of ethnicity and social class in provider advice regarding reproductive health
Am J Public Health
African American women and family planning services: perceptions of discrimination
Womens Health
Medicaid pregnancy termination funding and racial disparities in congenital anomaly-related infant deaths
Obstet Gynecol
Paid maternity leave in the United States: associations with maternal and infant health
Matern Child Health J
Reducing disparities in severe maternal morbidity and mortality
Clin Obstet Gynecol
Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends
Acta Obstet Gynecol Scand
Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013-2017
MMWR Morb Mortal Wkly Rep
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 GynecologyCitation 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
2022, ContraceptionCitation Excerpt :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
2021, ContraceptionCitation Excerpt :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
2021, American Journal of Obstetrics and GynecologyCitation 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
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.