Maternal Deaths – Call for concern for Health Providers

1. Maternal Deaths – Call for concern for Health Providers June Hanke, RN MSN MPH

2. A Human Rights Issue Women have a human right to safe pregnancy and childbirth. Ms. Elisabetta Farina http://www.womencreatelife.org/

3. A Sentinel Event • January of 2010 Joint commission identified maternal mortality as a Sentinel Event • Joint Commission suggested actions • Each case of maternal death needs to be identified, reviewed, and reported in order to develop effective strategies for preventing pregnancy-related mortality and severe morbidity. To this end, The Joint Commission encourages participation by hospital physicians, including obstetrician-gynecologists, in state-level maternal mortality review and collaboration with such review committees in sharing data and records needed for review. The following suggested actions can help hospitals and providers prevent maternal death: Joint Commission Sentinel event Alert January 26, 2010 http://www.jointcommission.org/assets/1/18/SEA_44.PDF

4. Local Collaborative

6. Calculating Maternal Deaths Maternal Mortality - Deaths/100,000 live births during pregnancy or within 42 days of delivery. A ratio not a rate: cannot count total # pregnancies. Pregnancy related ratios are deaths within 1 year. Pregnancy Associated Not related to pregnancy Pregnancy Related OB complications, management, or disease exacerbated by pregnancy Direct OB diseases or management Indirect Preexisting disease aggravated by pregnancy

7. http://www.who.int/gho/maternal_health/en/

8. US MMR 2003-2007

10. Data Source: CDC Wonder Database 2010

11. Data Source: CDC Wonder Data base 2010

13. We need to know WHY to be able to address the causes

14. Why is Maternal Mortality Rising? • Improved vital statistics • Increasing age or increasing prevalence of maternal chronic conditions • Hypertension • Diabetes • Obesity • Social factors • Factors related to health care system & access to quality care

15. Harris County Causes • 2008 • No deaths from Hemorrhage or obstetrical embolism, ectopic pregnancy or abortion. • DVT, Cardiomyopathy. • Mostly can’t determine from coding available. • 33% after 42 days of delivery

16. Other states • New York: 2002-2003 • Embolism • Hemorrhage • Hypertension • Florida: 2009 • 25.9% Infection (87% included Flu like symptoms - 58% NIH1) • 20.7% Hemorrhage • 12.1 Cardiovascular • other

17. HB1133 MMMRB • Legislation proposed by Rep Walle and coauthored by Rep Farrar • Heard in Public Health Committee – failed to received required votes. • Currently in special Study status • Multi disciplinary review board • Information de-identified using HIPPA standards, confidentiality expected, identifies requirements for reporting results. • Review board work is not subject to subpoena or discovery

18. What do we learn from Maternal Mortality Morbidity Review Boards

19. California- leading causes of Pregnancy related death • Before review • 17% Preeclampsia /eclampsia • 15% Hemorrhage • 14% Amniotic Fluid embolism • 7% Sepsis/infection • 6% Venous embolism complications • 41% Other complications • After review • 20% Cardiovascular disease • 15% Preeclampsia / eclampsia • 14% Amniotic Fluid embolism • 10% Obstetrical Hemorrhage • 8% Sepsis / infection California Pregnancy associated mortality review Report from 2002 and 2003 death reviews, April 2011

20. Risk Factors for PRMM Florida 1999-2008 • Being obese class III (morbidly obese) (BMI of 40.0 or +) (RR 9.0). • Not receiving any prenatal care (RR 6.9). • Having a cesarean delivery (RR 4.6). • Being 35 years or older (RR 4.1). • Having less than a high school degree (RR 3.7). • Black race (RR 3.3) • Other risk factor – Chronic Disease

21. Timing of Maternal Deaths • California: • 93 % of deaths within 6 weeks postpartum • Florida: • 17 % prenatal • 6 % L&D • 42% Postpartum not discharged • 35% Postpartum discharged

22. Insurance coverage • California: • Of women who died that were covered by MediCal, 11% died after 42 days. • No deaths occurred after 42 days for women with private insurance.

23. Infant deaths • In California of the 98 pregnancy related deaths – there were 9 fetal deaths and 7 infant deaths. • That is in 16 % of these maternal deaths the baby also died.

24. Maternal Morbidity • Maternal Mortality is a sentinel event for maternal morbidity. • Severe morbidity can effect a woman’s life long wellbeing. • For every one maternal death there are approximately 50 women who experience severe morbidity. • In 2008: • Harris County 1,350 women affected • Texas 4,500 women affected Callaghan, WM, Mackey AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. American J Obstet Gynecol 2008: 199:133e1-133e8.

25. Financial Costs • To family • To community • Financial cost of premature death, 3 – 5 million / woman • To Medical system • Mother’s pregnancy and delivery most expensive condition treated in US hospitals in 2008 • Rising C-Section rate = increased costs • High blood pressure in pregnancy associated with 3.5 days average stay, and average total cost $9,800/stay vs. $5,774 for normal delivery. • California:1996 -2006 PP hemorrhage increased 36% and increased expenditures of $3,277 per woman affected The National Hospital Bill: The Most Expensive Conditions by Payer, 2008, H-CUP Statistical brief #107, March 2011 Agency for Healthcare Research and Quality Rockville MD: The California associated mortality review. Report from 2002-2003 Maternal death reviews April 2011 California Department of Public Health.

26. Cost of MMMRB • An initial budget of $150,000 - $350,000 should be considered to cover staffing, meeting expenses (including travel/meal reimbursement), and database management and data abstraction for mortality review board. Estes, L. (2011). Maternal mortality in texas: 2001-2006 (Doctoral dissertation). Available from Proquest. (3464795)

27. Texas Needs MMMRB • Need Maternal Mortality Morbidity Review Board to understand what the reasons for maternal mortality and morbidity are in Texas • Preventable deaths: 40 - 75 %

28. Changes after Maternal Mortality reviews

29. Why Mothers Die 1997 - 1999, CEMD Intervention !!!

30. Working with the Healthcare Community • NY Maternal Mortality Review Committee • Hemorrhage alert letter • Point of care tools to prevent hemorrhage mortality • Hemorrhage poster • Educational slide sets • Institutional Systemic Approaches to Hemorrhage • Hemorrhage drills • Organized response team for unanticipated blood loss • Ob, Anesthesiology, Blood Bank, Nursing, other staff

31. Poster for Labor and Delivery and Operating Rooms

32. Who supports MMMRB for Texas • The American Congress of Obstetrics and Gynecologists (ACOG) • Texas Association of Obstetricians and Gynecologists (TAOG) • Association of Women, Obstetric and Neonatal Nursing • Childbirth Connections • Association of Texas Midwives • Doctors for Change – Houston • Texas Medical Center – Women’s Health Network • Greater Houston Partnership

33. What are we doing about it nationally? Federal bill HR 894 Maternal Health Accountability Bill of 2011