1. Preventing Maternal Morbidity
and Mortality In Texas
Definitions of maternal death
World wide data on maternal death
Data on US Maternal death
Maternal morbidity
Reducing maternal death
Role of review committees – state and national
Effective strategies based on most frequent causes of death
AIM program
One hour lecture
Lisa M. Hollier, MD, MPH
Professor, Obstetrics & Gynecology
Baylor College of Medicine

2. Financial Disclosure
Lisa M. Hollier, MD, has no relevant financial relationships with commercial interests to disclose.

3. Acknowledgements Sonia Baeva
Office of Program Decision Support
Department of State Health Services
Members of the Texas Maternal Mortality and Morbidity Task Force

4. Learning Objectives
At the completion of this session, the participants will be able to:
Discuss the most common causes and contributing factors to pregnancy-related death in Texas.
Identify causes of severe maternal morbidity
Implement local solutions to reduce maternal mortality and morbidity

5. Definitions of Maternal Death
CDC / ACOG
pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of pregnancy termination–regardless of the duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Pregnancy-associated mortality is the death of any woman, from any cause, while pregnant or within 1 calendar year of termination of pregnancy, regardless of duration and the site of pregnancy.

6. Reviewing Maternal Death
Texas MMMTF created by Senate Bill 495, 83rd legislature
Multidisciplinary task force within the Department of State Health Services (DSHS)
Tasked to:
study and review cases of pregnancy-related deaths and trends in severe maternal morbidity
determine the feasibility of the task force studying cases of severe maternal morbidity
make recommendations to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas
Approximately 32 states have active committees for the purpose of maternal mortality case review
state-based maternal mortality review can systematically combine reviews of all the deaths in the state
more robust analysis to identify systemic problems
provide a baseline that can be used in monitoring interventions that are implemented

7. Reviewing Maternal Death
Texas MMMTF amended by Senate Bill 17, 85th legislature
study and review:
trends, rates or disparities in pregnancy-related deaths
health conditions and factors that disproportionately affect the most at-risk populations
best practices and programs operating in other states that have reduced rates of pregnancy-related deaths
compare rates of pregnancy-related deaths based on socioeconomic status of the mother
consult with the Perinatal Advisory Council when making recommendations to help reduce the incidence of pregnancy related deaths and severe morbidity in this state
Approximately 32 states have active committees for the purpose of maternal mortality case review
state-based maternal mortality review can systematically combine reviews of all the deaths in the state
more robust analysis to identify systemic problems
provide a baseline that can be used in monitoring interventions that are implemented

8. MMMTF Biennial Report 2018

9. Texas Pregnancy-related Mortality
Leading underlying causes of pregnancy-related death in 2012 identified by the Task Force were:
cardiovascular and coronary conditions
obstetric hemorrhage
infection/sepsis
cardiomyopathy
preeclampsia/eclampsia, mental health conditions, and amniotic fluid embolus
These 4 causes accounted for 76 percent of all pregnancy-related deaths.7,8

10. Maternal Mortality by Race/Ethnicity

11. Preventability of PRM

12. Contributing Factors
Top individual and family level factors contributing to death:
Underlying medical conditions
Cardiovascular conditions, including chronic hypertension
Obesity
Depression
Delay in or failure to seek care or treatment
lack of patient recognition of early warning signs of worsening condition

13. Contributing Factors Top Provider level factors contributing to death:
Failure to recognize high risk maternal health status
failure to refer high risk patients to appropriate care specialties
Failure to recognize and respond to maternal early warning signs
delay in or lack of bedside clinician presence
Delays in diagnosis
Delays in initiation of treatment
Inadequate or ineffective treatment
Lack of effective communication

14. Contributing Factors Top facility level factors included:
Failure to recognize high risk status
Delayed and inadequate response to clinical warning signs
Lack of continuity of care
lack of appropriate hand-off of patients between hospital staff and outpatient providers
impacted by the inability to secure appropriate outpatient care and.
Top systems and community level factors included:
Poor care coordination from the inpatient to outpatient setting
Lack of access to interconception care services and transitional care services.

15. Maternal Deaths 2012-2015 Cause of Death While Pregnant 0-7 Days
SLIDE 5, Dr. Hollier
First, the causes of maternal death were examined along a pregnancy and postpartum timeline.
Maternal deaths were confirmed by matching each woman's death record with a birth or fetal death within 365 days over a four-year period, 2012 through 2015, which supplied sufficient numbers of cases to come up with meaningful interpretations.
These confirmed maternal deaths were then examined by timing and cause of death.
Here are the results of this timeline analysis.
As you see in this table, during 2012 to 2015, CLICK: there were 382 confirmed maternal deaths that occurred within a year following the end of pregnancy.
CLICK: 215 maternal deaths or 56% — the majority — occurred after 60 days postpartum, with CLICK: drug overdose deaths the most common cause of death overall, occurring mostly after 60 days postpartum.
CLICK, CLICK: Hemorrhage and cardiac event were the two most common causes of death while pregnant or within 7 days postpartum — typically deaths that occur during an inpatient hospital stay and are directly related to pregnancy.
But hemorrhage and CLICK: hypertension/eclampsia have been shown to be among the most preventable causes of maternal death.
JUST FOR YOUR INFORMATION
It is true that this records linkage approach cannot capture maternal deaths following an early miscarriage before 20 weeks of gestation.
However, a recent study found that maternal death due to miscarriage is the least frequently occurring out of all possible obstetric causes, and has remained stable over time1.
In fact, the majority of maternal deaths occur in the third trimester and after the end of the pregnancy2-5.
___________
1. Joseph KS, Lisonkova S, Muraca GM, Razaz N, Sabr Y, Mehrabadi A, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:
2. Creanga AA, Syverson C, Seed K, & Callaghan WM. Pregnancy-related mortality in the United States, American College of Obstetricians and Gynecologists 2017;0:1-8.
3. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2003;52(No. SS-2).
4. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to caesarian delivery. Am J Obstet Gynecol 2008;199:36.e1-36.e5.
5. Ronsmans C & Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006;368:
Maternal Deaths
Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
43-60 Days
61+ Days
Post-
partum
Total
Amniotic Embolism 1 9 10
Cardiac Event 2 12 5 27 55
Cerebrovascular Event 8
Drug Overdose 3 7 49 64
Hemorrhage 20
Homicide 32 42
Hypertension/Eclampsia 4 18
Infection/Sepsis 14 11
Pulmonary Embolism 13
Substance Use Sequelae
(e.g., liver cirrhosis)
Suicide 28 33
Other 6 44 63 16 23
215
382

16. Maternal Deaths 2012-2015 Cause of Death While Pregnant 0-7 Days
SLIDE 5, Dr. Hollier
First, the causes of maternal death were examined along a pregnancy and postpartum timeline.
Maternal deaths were confirmed by matching each woman's death record with a birth or fetal death within 365 days over a four-year period, 2012 through 2015, which supplied sufficient numbers of cases to come up with meaningful interpretations.
These confirmed maternal deaths were then examined by timing and cause of death.
Here are the results of this timeline analysis.
As you see in this table, during 2012 to 2015, CLICK: there were 382 confirmed maternal deaths that occurred within a year following the end of pregnancy.
CLICK: 215 maternal deaths or 56% — the majority — occurred after 60 days postpartum, with CLICK: drug overdose deaths the most common cause of death overall, occurring mostly after 60 days postpartum.
CLICK, CLICK: Hemorrhage and cardiac event were the two most common causes of death while pregnant or within 7 days postpartum — typically deaths that occur during an inpatient hospital stay and are directly related to pregnancy.
But hemorrhage and CLICK: hypertension/eclampsia have been shown to be among the most preventable causes of maternal death.
JUST FOR YOUR INFORMATION
It is true that this records linkage approach cannot capture maternal deaths following an early miscarriage before 20 weeks of gestation.
However, a recent study found that maternal death due to miscarriage is the least frequently occurring out of all possible obstetric causes, and has remained stable over time1.
In fact, the majority of maternal deaths occur in the third trimester and after the end of the pregnancy2-5.
___________
1. Joseph KS, Lisonkova S, Muraca GM, Razaz N, Sabr Y, Mehrabadi A, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:
2. Creanga AA, Syverson C, Seed K, & Callaghan WM. Pregnancy-related mortality in the United States, American College of Obstetricians and Gynecologists 2017;0:1-8.
3. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2003;52(No. SS-2).
4. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to caesarian delivery. Am J Obstet Gynecol 2008;199:36.e1-36.e5.
5. Ronsmans C & Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006;368:
Maternal Deaths
Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
43-60 Days
61+ Days
Post-
partum
Total
Amniotic Embolism 1 9 10
Cardiac Event 2 12 5 27 55
Cerebrovascular Event 8
Drug Overdose 3 7 49 64
Hemorrhage 20
Homicide 32 42
Hypertension/Eclampsia 4 18
Infection/Sepsis 14 11
Pulmonary Embolism 13
Substance Use Sequelae
(e.g., liver cirrhosis)
Suicide 28 33
Other 6 44 63 16 23
215
382

17. Maternal Deaths 2012-2015 Cause of Death While Pregnant 0-7 Days
SLIDE 5, Dr. Hollier
First, the causes of maternal death were examined along a pregnancy and postpartum timeline.
Maternal deaths were confirmed by matching each woman's death record with a birth or fetal death within 365 days over a four-year period, 2012 through 2015, which supplied sufficient numbers of cases to come up with meaningful interpretations.
These confirmed maternal deaths were then examined by timing and cause of death.
Here are the results of this timeline analysis.
As you see in this table, during 2012 to 2015, CLICK: there were 382 confirmed maternal deaths that occurred within a year following the end of pregnancy.
CLICK: 215 maternal deaths or 56% — the majority — occurred after 60 days postpartum, with CLICK: drug overdose deaths the most common cause of death overall, occurring mostly after 60 days postpartum.
CLICK, CLICK: Hemorrhage and cardiac event were the two most common causes of death while pregnant or within 7 days postpartum — typically deaths that occur during an inpatient hospital stay and are directly related to pregnancy.
But hemorrhage and CLICK: hypertension/eclampsia have been shown to be among the most preventable causes of maternal death.
JUST FOR YOUR INFORMATION
It is true that this records linkage approach cannot capture maternal deaths following an early miscarriage before 20 weeks of gestation.
However, a recent study found that maternal death due to miscarriage is the least frequently occurring out of all possible obstetric causes, and has remained stable over time1.
In fact, the majority of maternal deaths occur in the third trimester and after the end of the pregnancy2-5.
___________
1. Joseph KS, Lisonkova S, Muraca GM, Razaz N, Sabr Y, Mehrabadi A, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:
2. Creanga AA, Syverson C, Seed K, & Callaghan WM. Pregnancy-related mortality in the United States, American College of Obstetricians and Gynecologists 2017;0:1-8.
3. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2003;52(No. SS-2).
4. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to caesarian delivery. Am J Obstet Gynecol 2008;199:36.e1-36.e5.
5. Ronsmans C & Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006;368:
Maternal Deaths
Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
43-60 Days
61+ Days
Post-
partum
Total
Amniotic Embolism 1 9 10
Cardiac Event 2 12 5 27 55
Cerebrovascular Event 8
Drug Overdose 3 7 49 64
Hemorrhage 20
Homicide 32 42
Hypertension/Eclampsia 4 18
Infection/Sepsis 14 11
Pulmonary Embolism 13
Substance Use Sequelae
(e.g., liver cirrhosis)
Suicide 28 33
Other 6 44 63 16 23
215
382

18. Maternal Deaths 2012-2015 Cause of Death While Pregnant 0-7 Days
SLIDE 5, Dr. Hollier
First, the causes of maternal death were examined along a pregnancy and postpartum timeline.
Maternal deaths were confirmed by matching each woman's death record with a birth or fetal death within 365 days over a four-year period, 2012 through 2015, which supplied sufficient numbers of cases to come up with meaningful interpretations.
These confirmed maternal deaths were then examined by timing and cause of death.
Here are the results of this timeline analysis.
As you see in this table, during 2012 to 2015, CLICK: there were 382 confirmed maternal deaths that occurred within a year following the end of pregnancy.
CLICK: 215 maternal deaths or 56% — the majority — occurred after 60 days postpartum, with CLICK: drug overdose deaths the most common cause of death overall, occurring mostly after 60 days postpartum.
CLICK, CLICK: Hemorrhage and cardiac event were the two most common causes of death while pregnant or within 7 days postpartum — typically deaths that occur during an inpatient hospital stay and are directly related to pregnancy.
But hemorrhage and CLICK: hypertension/eclampsia have been shown to be among the most preventable causes of maternal death.
JUST FOR YOUR INFORMATION
It is true that this records linkage approach cannot capture maternal deaths following an early miscarriage before 20 weeks of gestation.
However, a recent study found that maternal death due to miscarriage is the least frequently occurring out of all possible obstetric causes, and has remained stable over time1.
In fact, the majority of maternal deaths occur in the third trimester and after the end of the pregnancy2-5.
___________
1. Joseph KS, Lisonkova S, Muraca GM, Razaz N, Sabr Y, Mehrabadi A, et al. Factors underlying the temporal increase in maternal mortality in the United States. Obstet Gynecol 2017;129:
2. Creanga AA, Syverson C, Seed K, & Callaghan WM. Pregnancy-related mortality in the United States, American College of Obstetricians and Gynecologists 2017;0:1-8.
3. Centers for Disease Control and Prevention. Surveillance summaries. MMWR 2003;52(No. SS-2).
4. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to caesarian delivery. Am J Obstet Gynecol 2008;199:36.e1-36.e5.
5. Ronsmans C & Graham WJ. Maternal mortality: who, when, where, and why. Lancet 2006;368:
Maternal Deaths
Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
43-60 Days
61+ Days
Post-
partum
Total
Amniotic Embolism 1 9 10
Cardiac Event 2 12 5 27 55
Cerebrovascular Event 8
Drug Overdose 3 7 49 64
Hemorrhage 20
Homicide 32 42
Hypertension/Eclampsia 4 18
Infection/Sepsis 14 11
Pulmonary Embolism 13
Substance Use Sequelae
(e.g., liver cirrhosis)
Suicide 28 33
Other 6 44 63 16 23
215
382

19. Top Causes of Confirmed Death: within 1 Year Following End of Pregnancy
LISA
Here are the leading causes of confirmed maternal death within 1 year following the end of pregnancy for 2012 to (Maternal deaths were confirmed by linking a woman’s death record with a birth or fetal death record within 365 days. Timing of death was determined using a combination of pregnancy status on the death record for death while pregnant, or days elapsed between delivery and death for postpartum maternal death. Cause of death was taken directly from the death record.)
Overall, drug overdose was the most common cause of death, followed by cardiac event, homicide, and suicide. However, drug overdose, homicide, and suicide are all causes of death that are not solely related to pregnancy.

20. Severe Maternal Morbidity
For every woman who dies, about 50 more suffer a severe complication.
Link between maternal mortality, particularly preventable maternal deaths, and severe maternal morbidity
Overall rate of severe maternal morbidity (SMM) increased almost 200%
From 47.6 per 10,000 in 1993–1994 to per 10,000 in 2013–2014
Texas SMM rate is 195 per 10,000 in 2014
These morbidities are a significant burden on women, their families and society in economic, social and personal terms.
Using national data, …….

21. Severe Maternal Morbidity - US
This figure shows the rate of SMM per 10,000 delivery hospitalizations from 1993–2014. Women who received blood transfusions (procedure in which a patient is given donated blood generally in response to excessive bleeding around delivery) account for the greatest fraction of women with SMM. Hence, the SMM rates are shown for women with any indicator of SMM, women who had only transfusion as an indicator, and women who had some indicator other than transfusion.
The overall rate of SMM increased almost 200% over the years, from 47.6 in 1993–1994 to in 2013–2014. This increase has been mostly driven by blood transfusions, which increased from 26.0 in 1993–1994 to in 2013–2014. After excluding blood transfusions, the rate of SMM increased almost 40% over time, from 25.1 in 1993–1994 to 34.3 in 2013–2014.

22. Severe Maternal Morbidity: Top Causes
LISA
Maternal morbidity is what AIM bundles were designed to directly prevent.
Obstetric hemorrhage and hypertension/eclampsia continue to contribute greatly to severe maternal morbidity in Texas, with these two causes having maternal safety bundles for prevention supported by the Alliance for Innovation on Maternal Health or AIM.
_____________
JUST FOR YOUR INFORMATION
UT staff have submitted an abstract titled, Prevalence of Chronic and Pregnancy-Induced Cardiovascular-Related Conditions in Severe Maternal Morbidity in Texas, which they may present/bring-up. Their findings suggest a need to assess the role of chronic cardiovascular conditions in severe maternal morbidity (SMM), especially among older women. The results also suggest that the narrowly defined SMM metric may underestimate the contribution of chronic cardiovascular conditions to severe maternal morbidity (especially hypertension disorders). Hence, their findings, we believe, underscore the importance of addressing hypertension.

23. Obstetric Hemorrhage Rates by Race/Ethnicity (Maternal Morbidity)
LISA
Black women have the highest rates of severe maternal morbidity due to obstetric hemorrhage, followed by Hispanics.
While a very slight decrease in the obstetric hemorrhage rate can be seen between 2012 and 2014, obstetric hemorrhage is still the top cause of severe maternal morbidity in Texas, and thus, has the greatest need for prevention.

24. Rates of Obstetric Hemorrhage by County
LISA
And what about geographically?
Obstetric hemorrhage was estimated based on the number of blood transfusion procedures occurring during obstetric hospitalization – this is the severe maternal morbidity measure the CDC uses as a proxy for hemorrhage.
Here, we used data from the most recent complete 5-year time period available, 2010 to 2014, to have large enough numbers to calculate rates in a majority of Texas counties.
This is the geographic distribution of the rate of obstetric hemorrhage during this time period.
_____________
JUST FOR YOUR INFORMATION
If the audience asks about rates by hospital, feel free to suggest that UT staff could do this once TCHMB votes to implement the AIM bundles, using the Public Use Hospital Discharge file for those counties with higher obstetric hemorrhage rates. There is sufficient evidence here to make that decision.

25. Frequency of Obstetric Hemorrhage by County
LISA
And this is a frequency map, showing the number of obstetric hemorrhage cases by county, for the time period
As would be expected, Harris, Dallas, Bexar, and Tarrant counties (which include the largest cities in Texas) had highest numbers of obstetric hemorrhage cases.
While these counties do not have the highest rates of obstetric hemorrhage, as a whole, hospitals in these counties do see more obstetric hemorrhage cases than hospitals in other counties.

26. MMMTF Recommendations
1. Increase access to health services during the year after pregnancy and throughout the interconception period to improve the health of women, facilitate continuity of care, enable effective care transitions, and promote safe birth spacing. 2. Enhance screening and appropriate referral for maternal risk conditions. 3. Prioritize care coordination and management for pregnant and postpartum women. 4. Promote a culture of safety and high reliability through implementation of best practices in birthing facilities. 5. Identify or develop and implement programs to reduce maternal mortality from cardiovascular and coronary conditions, cardiomyopathy and infection.

27. MMMTF Recommendations
6. Improve postpartum care management and discharge education for patients and families.
7. Increase maternal health programming to target high-risk populations, especially Black women.
8. Initiate public awareness campaigns to promote health enhancing behaviors.
9. Champion integrated care models combining physical and behavioral health services for women and families.
10. Support strategies to improve the maternal death review process.

28. Time Spent in D/C Instruction
Suplee PD. JOGNN 2016;45(6):894–904

29. How Likely to Discuss
Suplee PD. JOGNN 2016;45(6):894–904

30. 2/3 of nurses spent 10 minutes or less in

31. Levels of Maternal Care
In addition to ensuring best practices in hospitals, it is also important to ensure that women receive care in the right place at the right time.
In February 2015, ACOG and Society for Maternal Fetal Medicine (SMFM) developed the document, “Levels of Maternal Care.” This consensus document was endorsed by the American College of Nurse-Midwives and many others.  
The Levels of Maternal Care guidance promotes the development of relationships between institutions with different levels of maternal care. This approach supports pregnant women receiving maternal health care in facilities that best meets their individual needs.
By establishing levels of maternal care, ACOG and SMFM envision achieving: 
Standardized definitions and nomenclature for facilities that provide each level of maternal care
Consistent guidelines according to each level of maternal care for use in quality improvement and health promotion
Geographic distribution of full-service maternal care facilities and systems that promote integration of risk-appropriate antepartum, intrapartum, and postpartum services
The goal is for pregnant women to receive care in facilities that are appropriate to their risk, thereby reducing maternal morbidity and mortality in the United States.
ACOG, Menard et al. Am J Obstet Gynecol 2015, 212 (3),

32. Levels of Maternal Care
Level 4: Comprehensive Care
Level 3: Subspecialty Care
Level 2: Specialty Care
Level 1: Basic Care
Hospital Level of Care Designation for Maternal Care
Need to add the next steps here.
ACOG, Menard et al. Am J Obstet Gynecol 2015, 212 (3),

33. National Agenda to Reduce Maternal Mortality