Major maternal health legislation signed into law

January 8, 2019

Two years after its bipartisan introduction, HR 1318 is now law. PLUS: Uterine transplantation from deceased donor results in livebirth. ALSO: Research has shown that route of delivery has an effect on the microbiome of newborns.

Two years after its bipartisan introduction, HR 1318 is now law. The President signed the bill, known as The Preventing Maternal Deaths Act, after the bill’s unanimous passage in both the House of Representatives and the Senate. 

The new law will establish and support Maternal Mortality Review Committees at the state level and provides $12 million a year in new funds for 5 years for states. The committees will be required to review every pregnancy-related death as well as develop recommendations to prevent future deaths. 

The Preventing Maternal Deaths Act was cosponsored by a bipartisan group of Representatives which included Reps. Jaime Herera Beutler (R-WA), John Conyers, Jr. (D-MI), Ryan A. Costello (R-PA), and Diana DeGette (D-CO). It was first introduced to the House in March 2017 but remain stalled in committee despite having over 190 cosponsors. 

The legislation has been a top priority of the American College of Obstetricians and Gynecologists (ACOG), which praised the House for passing the bill in mid-December. In a statement, ACOG President, Lisa Hollier, MD, MPH said, “The passage of the Preventing Maternal Deaths Act has been a long-held goal for ACOG and is a crucial step to reversing our country’s rising maternal mortality rate. No more pregnant and postpartum women should die from preventable causes.” 

Several more maternal health-related bills have been introduced or passed, including the recently passed, Improving Access to Maternity Care Act, which will reduce chronic shortages of maternity care providers in certain parts of the country. The Ending Maternal Mortality Act of 2018 (HR 5761) directs the Secretary of Health and Human Services to submit a national plan to Congress to reduce the rate of maternal mortality on a biennial basis. It was introduced in May 2018 but has stalled. Outside of Washington, six states have passed bills in the past year to establish or strengthen their own maternal mortality review panels. 

While maternal mortality rates have steadily decreased among the world’s developed nations, the United States has seen its rates increase with wide disparities among different races. The Centers for Disease Control (CDC) reports that pregnancy-related deaths rose from 7.2 per 100,000 in 1987 to 18 per 100,000 in 2014. In 2014, the rate was 12.4 pregnancy-related deaths among white women and 17.8 deaths among women of color. While the bulk of this increase is due to increased ascertainment, the CDC contends that 60% of these deaths are preventable.

While the maternal mortality issue is complex, several causes of death have been identified including cardiovascular diseases, infection, hemorrhage, thrombotic pulmonary embolism, and hypertensive disorders. Socioeconomic factors, such as lack of access to care, increased age of mothers, and rising rates of obesity, have also been identified as contributing factors.

Uterine transplantation from deceased donor results in livebirth

In September 2013 in Sweden, the first birth following uterine transplantation from a living donor was recorded. A new report in The Lancet has documented another milestone in treatment for uterine infertility: the first successful live birth after uterine transplantation from a deceased donor. 

The patient, a 32-year-old woman with congenital uterine absence, underwent the transplantation in Hospital das Clínicas, University of São Paulo, Brazil. She had been diagnosed with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and presented with uterine agenesis, but no cardiac, renal, or bone structure dysfunctions. 

The donor was a 45-year-old woman who had three vaginal deliveries and no signs of sexual disease. Her cause of death was Fischer 4 subarachnoid hemorrhage. 

Surgical time from iliac and pelvic vessel preparation to uterus implantation was 2 hours. Immunosuppression followed the Swedish protocol including 1 intraoperative methylprednisolone and 1.5 mg/kg of thymoglobulin as induction therapy. It was continued via tacrolimus and mycophenolate mofetil (MMF) until 5 months post-transplantation, when MMF was replaced by azathioprine. Menstruation first occurred at 37 days post-transplantation and was regular (every 26-32 days) thereafter. 

Prior to transplantation, the patient underwent in vitro fertilization, which yielded 16 eggs obtained from a single cycle that produced eight good-quality blastocysts for cryopreservation. At that time, Doppler ultrasound, regular menses and no signs of rejection indicated to the authors of the report that the organ remained in good condition. 

The woman’s pregnancy proceeded normally until Week 32, when she presented with signs of pyelonephritis and was treated with ceftriaxone as an inpatient for 10 days. At 35 weeks and 3 days, the patient underwent cesarean delivery, which was in line with the protocol used by the Swedish transplant team. During delivery, the transplanted uterus was removed and the patient’s vaginal orifice was closed. 

The newborn weighed 2550 g and measured 45 cm in length. Her Apgar scores were 9 at 1 minute, 10 at 5 minutes and 10 at 10 minutes. At 7 months and 20 days, when the authors wrote the article, the baby continued to breastfeed and had normal growth parameters. 

The authors believe that the success of this transplant from a deceased donor and the ensuing live birth expands the options for childbirth among women with infertility attributable to uterine factors.  While the Swedish study demonstrated success with assisted reproduction and uterine transplantation, the requirement for a live donor is a major limitation and, as such, donors are in short supply.  

Uterine transplantation is still considered experimental by many countries, but the authors believe that this recent success shows that the procedure is promising. Future studies, they said, should continue to expand upon the existing research to improve and refine the technique so that women with uterine factor infertility can have the option of a healthy pregnancy.

Cesarean delivery and the neonatal microbiome

Research has shown that route of delivery has an effect on the microbiome of newborns. A new study conducted in Europe shows that cesarean delivery may prevent mother-to-child transmission of some microbial strains during a key point in immune system development. 

The findings, published in Nature Communications, are from an analysis of the earliest gut microbial community structures and functions in 33 neonates, half of whom were born via cesarean delivery and half vaginally. The authors used 16S rRNA gene amplicon sequencing and high-resolution metagenomics for the research.

Stool samples were collected from the infants at ≤ 24 hours, 3 days, and 5 days postpartum. The microbiome in them was compared with those in samples from stool and vaginal swabs taken from their mothers less than 2 hours before delivery.

The authors said they found that cesarean delivery prevents certain bacteria that ordinarily interact with an infant’s immune system from being passed from mother to child. Levels of TNF-αand IL-18 were higher in the feces from the vaginally delivered neonates than in those born via cesarean, as were levels in neonatal blood plasma.  

The microbial composition between the two groups of infants differed most strongly on Day 3 postpartum. The earliest gut microbiome in the infants born via vaginal delivery also had higher immunostimulatory potential than the microbiome in the infants born via cesarean. 

Their results, the researchers said, “support that cesarean delivery disrupts mother-to-neonate transmission of specific microbial strains, linked functional repertoires and immune-stimulatory potential during a critical window for neonatal immune system priming.” They believe the bacterial colonizer-immune system link, with other factors, may explain why infants born via cesarean are statistically more prone to develop allergies, chronic inflammatory diseases and metabolic diseases. Further investigation is warranted, said the authors, of ways to replace the maternal bacterial strains that are lacking in babies born via cesarean.