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

A Human Rights Issue Women have a human right to safe pregnancy and childbirth. Ms. Elisabetta Farina

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,

Local Collaborative

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 Related OB complications, management, or disease exacerbated by pregnancy Pregnancy Associated Not related to pregnancy Direct OB diseases or management Indirect Preexisting disease aggravated by pregnancy Calculating Maternal Deaths

US MMR

Data Source: CDC Wonder Database 2010

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

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

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

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

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

What do we learn from Maternal Mortality Morbidity Review Boards

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

Risk Factors for PRMM Florida 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

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

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.

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.

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, American J Obstet Gynecol 2008: 199:133e1-133e8.

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: 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 Maternal death reviews April 2011 California Department of Public Health.

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: (Doctoral dissertation). Available from Proquest. ( )

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

Changes after Maternal Mortality reviews

Why Mothers Die , CEMD Intervention !!!

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 30

31 Poster for Labor and Delivery and Operating Rooms

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

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