By JESSICA HARPER
BALTIMORE (April 26, 2011) — When an overweight, pregnant stroke survivor saw Dr. Pedro Arrabal for a check-up earlier this year, the doctor had a bad feeling about her fate.
"She was counseled about all her risks and decided to take the risks," said Arrabal, a high-risk pregnancy specialist at Sinai Hospital in Baltimore. "We got her through the pregnancy, and delivered her somewhat early."
Though the patient did well postpartum, Arrabal said, her good fortune would be short-lived.
"She ended up, four months after delivery, being found dead," he said. Though she survived a stroke, the combination of the strain of pregnancy and an underlying heart condition likely led to her death.
This case is typical of what Maryland high-risk obstetricians are seeing in the state: expectant and new mothers losing their lives to preventable complications like obesity, substance abuse or lack of prenatal care. In some cases, two or all three of these factors intertwine to complicate a pregnancy.
These trends are pushing Maryland's maternal death rate past the national average, according to a 2010 report compiled by the Maryland Health Department's Maternal Mortality Review Program. The national maternal death rate for 2003-2007 averaged 15.8 maternal deaths per 100,000 live births. For that same period, the report notes, Maryland's rate was 20.5.
The World Health Organization defines maternal mortality as, "the death of a woman while pregnant or within 42 days of conclusion of pregnancy."
Maternal mortality cases generally fall into one of two categories, according to the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists: pregnancy-associated death, meaning death of an expectant or new mother from a cause unrelated to her pregnancy, or pregnancy-related death, meaning the death of an expectant or new mother from a cause related to or worsened by her pregnancy.
Dr. Kevin Ferentz, director of clinical operations at the University of Maryland School of Medicine, said the state's high maternal death rate is linked to Baltimore being the heroin capital of the U.S. and the absence of programs to help pregnant addicts.
"There are very few services available to women who are abusing substances to go for care in Baltimore," said Ferentz, who heads the Department of Family Medicine.
"At the university, we don't have anything special for women who are abusing substances while pregnant."
Ferentz said this dilemma runs statewide.
"If we don't have that service in Baltimore, there's a very good chance those services don't exist in more rural areas of the state," he said.
Arrabal, director of the Division of Maternal Fetal Medicine at Sinai, also sees expectant and new mothers with drug problems. Substance abuse, he said, sometimes determines whether pregnant women seek prenatal care.
"Part of the issue, especially with the women who do have a drug history is that they might be afraid of the repercussions of getting prenatal care," he said.
The chief repercussion, he said, is getting social services involved, and particularly the fear their child will be taken away from them.
Prenatal care, the doctors said, is critically important. Yet women who have been pregnant before, are usually less likely to seek it, Ferentz said.
"That's because they got through their first pregnancy and they know what to expect and (think) everything will be OK," he said.
Also contributing to a mother's poor outcome from pregnancy are heart problems, exacerbated by obesity.
"If you see in the report, one of the things that was associated with poor outcomes was the lack of prenatal care which, to a certain extent, is almost inexcusable in a state like Maryland," Arrabal said.
Heart problems, too, are a concern, Arrabal said, a condition, he said, often exacerbated by obesity.
"You've got to remember that pregnancy is a significant stress to a woman's heart," he said.
A pregnant woman's heart pumps 50 percent harder than when she's not with-child, he said, and her blood volume increases by 50 percent.
With heart disease, Arrabal said, a woman can feel fairly well early in the pregnancy, but that quickly changes once cardiac demands increase and her body begins to deteriorate.
"By then, it may be too late for us to make a significant impact," said Arrabal. "So, for instance, pregnancy termination may not help the situation at that point if they are far enough along."
Members of The Maryland State Medical Society served on the Maternal Mortality Review Committee and helped compile the 2010 report. MedChi is doing what it can to help end maternal deaths in the state, said Executive Director Gene Ransom III.
"We spend a lot of time and energy on it. We track numbers and have been writing the reviews," he said.
The problem "calls out for solutions," Ransom said, and he thinks it's time for policy makers to look at it. Like Arrabal, he sees the high rate as inexcusable.
"Maryland is one of the wealthiest states," he said. "We shouldn't be an outlier in maternal mortality."
Both Arrabal and Ferentz are taking steps to end maternal mortality on their turf.
At the university, Ferentz and other physicians give expectant mothers a book called "What To Expect When You're Expecting," by Heidi Murkoff and Sharon Mazel.
"All women get that book," he said. The university has also instituted a house call program for pregnant patients.
"We're trying very hard to go out at least once during each pregnancy to assess the environment that the patient lives in and to help the mom bond with the physician who is going to be delivering the baby," he said.
Sinai Hospital is seeing an increasing number of undocumented women ineligible for insurance through the state. Arrabal, a native of Cuba, speaks fluent Spanish, as does another high-risk obstetrician. Sinai Hospital pays for a translating assistance service that includes languages more obscure than Spanish.
And both doctors are seeing more pregnant patients over age 40. Arrabal recently saw a 51-year-old expectant mother.
"For multiple reasons, it is easier now for the older woman to get pregnant," Arrabal said. Older women, statistically, are less likely to become pregnant due to menopause or other factors. Fertility aids like donor eggs can help, Arrabal said, but the woman must be sure she is healthy enough to get pregnant.
While troubling, maternal mortality is still a pretty rare occurrence, the physicians said. "If you look at the statistics, you're talking about a denominator of 100,000," said Arrabal. "There are lots of good outcomes."
Ferentz agreed.
"Luckily the numbers, while frightening, are actually still very low," he said. "Fifty-some-odd people die in a year, given the tens of thousands of babies that are born every year."
Ferentz has yet to lose a patient to maternal mortality, and he said he would never think of trading his chosen profession for another.
"Delivering a baby is the best thing I do," he said.
"I have no intention of stopping doing deliveries until I'm too old to be able to do them or retire," Ferentz said.