1. California Maternal Mortality and Pregnancy-Associated Mortality Review Elizabeth Lawton MHS California Department of Public Health Maternal, Child, Adolescent Health Division Empowering Oklahoma’s Women Conference November 13, 2015

2.  The Problem: Maternal Mortality  California Pregnancy-Associated Mortality Review (CA-PAMR)  What did we learn from CA-PAMR?  What other resources were developed?  Strengthened public health programs  Move upstream to preventive, life course model  QI Activities for Maternity Care Providers  Status of Maternal Mortality since 2006  What contributed to the decline?  Next direction of PAMR What This Talk Will Address

3. Maternal Mortality Rate, California and United States; 1999-2006 Maternal Deaths per 100,000 Live Births HP 2020 Objective – 11.4 Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.http://wonder.cdc.govon

4. Maternal Mortality Rates by Age Group, California Residents; 1999-2006 Maternal Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

5. Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2006 Maternal Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

6.  Initiated in 2004-2006 in order to:  Investigate the rise in maternal mortality and the widening racial/ethnic disparity  Identify possible reasons for the rise  Direct policy and programmatic interventions  California Health and Safety Codes give CDPH the broad authority to investigate sources of morbidity and mortality. California Pregnancy-Associated Mortality Review

7. CA-PAMR Project Partners  California Department of Public Health (CDPH), Center for Family Health, Maternal Child and Adolescent Health Division (MCAH)  Public Health Institute (PHI); Sue Holtby MPH and Christy McCain, MPH  California Maternal Quality Care Collaborative (CMQCC); Elliott Main, MD, Christine Morton, PhD  CA-PAMR Committee

8. CA-PAMR Committee Elliott Main, MD, Chair Deirdre Anglin, MD, MPH Conrad Chao, MD Patricia Dailey, MD Maurice Druzin, MD Michael Fassett, MD Elyse Foster, MD Kristi Gabel, RNC-OB, MSN, CNS Dodi Gauthier, MEd, RNC Kimberly Gregory, MD, MPH Afshan Hameed, MD, FACOG, FACC Thomas Kelly, MD Nathana Lurvey, MD Marla Marek, RNC, MSN Larry Newman, MD, FACOG Ed Riley, MD Larry Shields, MD Lucy Van Otterloo, RN, MSN Linda V. Walsh, CNM, PhD, FACNM

9. CA-PAMR Status and Publications  Concluded review of deaths from 2002-2007  Initial CDPH report  ‘Made the Case’ and describes methodology  Findings from review of 2002-2003 maternal deaths  Follow-up report 2016 THE CALIFORNIA PREGNANCY-ASSOCIATED MORTALITY REVIEW (CA-PAMR) Report from 2002-2003 Maternal Death Reviews April 2011

10. ARTICLE in MATERNAL AND CHILD HEALTH JOURNAL California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings Connie Mitchell Elizabeth Lawton Christine Morton Christy McCain Sue Holtby Elliott Main CA-PAMR Status and Publications

11. Key Steps of CA-PAMR Methodology STEP 1: Hospital discharge data linked to birth, death certificates Identifies women who died within one year postpartum from any cause ( Pregnancy-Associated Cohort ) STEP 2: Additional data gathered for each death Coroner Reports, Autopsy Results, and additional information from the Death Certificate (e.g., multiple causes of death, recent surgeries, etc) are obtained STEP 3: Cases selected for CA-PAMR Committee review Documented (ICD-10 obstetric (“O”) code) and suspected pregnancy-related deaths are prioritized for review STEP 4: Medical records abstracted and summarized All available labor and delivery, prenatal, hospitalization, transport, and outpatient and emergency department records are obtained and summarized STEP 5: Cases reviewed by CA-PAMR Committee Committee determines whether the death was pregnancy-related, the cause of death, contributing factors and quality improvement opportunities Source: The California Pregnancy-Associated Mortality Review. Report from 2002-2003 Maternal Deaths. California Department of Public Health, April 2011.

12. CA-PAMR Pregnancy-Related Causes of Death, 2002-2005 (After CA-PAMR case review) Cause of Pregnancy-Related Deaths N (%)Rate (95% CI) Cardiovascular disease49 (23.7)2.3 (1.6-2.9) Cardiomyopathy 33 (15.9) Other cardiovascular16 (7.7) Preeclampsia/eclampsia36 (17.4)1.7 (1.1-2.2) Obstetric hemorrhage20 (9.7)0.9 (0.5-1.3) Deep vein thrombosis/pulmonary embolism20 (9.7)0.9 (0.5-1.3) Amniotic fluid embolism18 (8.7)0.8 (0.5-1.2) All Other Causes (Sepsis, Cerebral vascular accident, Anesthesia complications, Acute fatty liver, etc) 64 (30.9)3.0 (2.3-3.7) TOTAL 2079.7 (8.4-11.0) Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015

13. Risk Factor: Obesity; CA-PAMR 2002-2005 Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015

14. Preventability – or – Chance to Alter Outcome; CA-PAMR 2002-2005 * Significantly more likely to have good-to-strong chance than CVD and AFE deaths **Significantly less likely to have good-to-strong chance than all causes Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015

15. Contributing Factors by Health Care Professionals CA-PAMR 2002-2005 Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015

16. In-Depth Review of Pregnancy-Related Cardiovascular Disease CA-PAMR 2002-2006 (N=64 CVD out of 257 P-R) Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.

17. Key Findings (1): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006 Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.  Racial/Ethnic disparity even more pronounced  African-American women 5.5% of CA births  22% of all pregnancy-related deaths  40% of cardiovascular pregnancy-related deaths  Other risk factors  Obesity, Hypertensive disorders (20%), Substance use (38%), especially stimulants (11%) and alcohol (17%)

18. Key Findings (2): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006 Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.  Time to death from birth or fetal demise  ALL CVD: 9d median, 56d mean, range (0,340d)  CMP: 67d median, 112d mean, range (0,340d)  Timing of CVD diagnosis  Preexisitng disease: 3%  Prenatal period: 8%  At labor and delivery: 65%  Postpartum period: 34%  Postmortem: 48%

19. Key Findings (3): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006 Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.  Presented with Signs and Symptoms of CVD  Prenatal period: 43%  At labor and delivery: 51%  Postpartum period: 80%  Shortness of Breath (61%) and Edema (44%)  52% Identified as Pregnancy-Related on Death Certificate (before case review)  69% Autopsy performed (critical for diagnosis of cardiomyopathy)

20.  Between 2006-2010, CDPH MCAH also:  Invested in Preconception Health Program  Funded local Maternal Health Programs to develop interventions for regional issues  Revamped Black Infant Health Program  Began mapping out more 1 o and 2 o prevention strategies to move MCAH activities upstream  Incorporated the Life Course Model throughout  Developed surveillance capacity to monitor maternal morbidity, including severe maternal morbidity and composite measures. Maternal Public Health Programs and Surveillance Strengthened in California

21. QI Activities for Maternity Care Providers  Translation of CA-PAMR findings into Quality Improvement Activities  California Maternal Quality Care Collaborative  Volunteer Task Force, CA-PAMR Committee members  CDPH MCAH Title V funds  Series of Toolkits to Transform Maternity Care  Hospital Learning Collaboratives  Improve Response and Recognition to:  Obstetric Hemorrhage  Preeclampsia  Cardiovascular Disease  Available – at no cost – at www.CMQCC.org

22. Quality Improvement Toolkits First Version released July 2010

23. Quality Improvement Toolkits First Version released July 2010

24. Quality Improvement Toolkits First Version released July 2010

25. Maternal Mortality Rate, California and United States; 1999-2013 Maternal Deaths per 100,000 Live Births HP 2020 Objective – 11.4 Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.http://wonder.cdc.govon

26.  With this decline, California has achieved and surpassed the Healthy People 2020 objective for maternal mortality of 11.4 deaths per 100,000 live births.  The decline in maternal mortality even continued during 2009 and 2010 when pregnant women were disproportionally impacted by the H1N1 influenza epidemic.  In 2013, the U.S. rates are projected to be nearly three times California’s rates.  California’s maternal mortality rates declined while U.S. maternal mortality rates increased, even though California accounts for one in eight births nationally. Maternal Mortality Decline

27. Maternal Mortality Rates by Age Group, California Residents; 1999-2013 Maternal Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015. a a a b b b c c c d d d

28. Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2013 Maternal Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015. a a a b b b c c c

29. Disparities in Maternal Mortality by Race/Ethnicity, California Residents; 1999-2013 Maternal Deaths per 100,000 Live Births Ratio of African-American to White Maternal Mortality SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00- O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

30.  Mortality rates for African-American women are the lowest they have been since 1999.  In 2011-2013, 26.4 deaths among African-American women per 100,000 live births, half of the peak in 2005-2007.  African-American women continue to have a three- to four-fold higher risk of maternal mortality compared to White women.  African-Americans are disproportionately impacted by negative social determinants of health such as lower wages, access to housing, unsafe environments and racism.  African-American women may have higher rates of underlying health conditions such as hypertension, obesity, and cardiovascular disease that complicate their pregnancies. Maternal Mortality Decline: Racial Disparities Persist (1)

31.  The disparities may also reflect a disparity in health care that can be attributed to differences in health insurance, entry to prenatal care, and access or quality of care.  Finally, the persistent disparity indicates that maternal mortality rates are decreasing proportionally among both African-American and White women. One group is not showing a greater increase or decline, thus the ratio remains steady. Maternal Mortality Decline: Racial Disparities Persist (2)

32. Maternal Mortality Rate (early and late deaths), California Residents; 1999-2013 Maternal Deaths per 100,000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (Early maternal deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) and code O96 is also included when calculating Early and Late Maternal Deaths up to one year postpartum. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

33.  Late maternal deaths did not decline as dramatically  15.2 deaths per 100,000 live births in 2013.  Decline from 2005 peak rate of 19.1 deaths per 100,000 live births  Not as strong as that observed among the early maternal deaths.  Maternal mortality may be shifting to late postpartum deaths as chronic diseases, like cardiovascular disease, play a prominent role in maternal deaths.  This is especially true for peripartum cardiomyopathy, a type of cardiovascular disease unique to pregnancy which typically occurs in the last month of pregnancy through the fifth month postpartum  Consistent with data published by the Centers for Disease Control. Maternal Mortality Decline: Late Maternal Deaths

34. What Contributed to the Decline in Maternal Mortality in California? (1)  We do not fully know what caused the rise in maternal mortality and cannot fully explain what has caused its decline. Some hypotheses for the recent decline include:  Improved attention to the issue of maternal mortality and morbidity by public health officials and maternity care providers through the following activities.  California Pregnancy-Associated Mortality Review (CA-PAMR)  Hospital quality improvement strategies have been developed by Stanford University’s California Maternal Quality Care Collaborative (CMQCC) with funding from CDPH MCAH. To date, CMQCC has developed three quality improvement toolkits and sponsored learning collaboratives for the maternity care community.

35. What Contributed to the Decline in Maternal Mortality in California? (2)  Maternal mortality may be shifting to late postpartum deaths as chronic diseases, like cardiovascular disease, play a prominent role.  The impact of the economic downturn in 2008.  Reduction of the overall California birth rate  Women who gave birth in the last six years may have been healthier and had lower risk pregnancies  Emigration from California due to job loss, cost-of-living, or housing issues  Women may have delayed having children until more economically certain times.  Vital statistics data reporting may be contributing to the apparent decline, either through improvements in identification of pregnancy prior to death or in the coding for causes or timing of death.

36. Next Direction for California and CA-PAMR  Continued analysis of CA-PAMR 1.0 (2002-2007) case reviews  Racial Ethnic Disparities  Congential CVD and Genetic conditions related to CVD  Preeclampsia deaths from stroke  Validation of the death certificate’s ability to identify pregnancy- related deaths  Continued examination of the decline  CA-PAMR 2.0 – investigation of violent and accidental pregnancy- related deaths  Suicides, Homicides, Drug Overdoses  Strengthening Maternal Mental Health capacity at CDPH  Collaboration with CDPH Office of Health Equity  Changes to Vital Statistics forms  Venous Thromboembolism Toolkit

37. Thank you and GOOD LUCK Oklahoma!!! Questions, Comments, Request for Resources: Elizabeth Lawton 916-650-0364; Elizabeth.Lawton@cdph.ca.govElizabeth.Lawton@cdph.ca.gov