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 http://www.womencreatelife.org/

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

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 AssociatedNot related to pregnancy

DirectOB diseases or

management

Indirect Preexisting disease aggravated by pregnancy

Calculating Maternal Deaths

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

US MMR 2003-2007

Data Source: CDC Wonder Database 2010

Data Source: CDC Wonder Data base 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: 2002-2003

– 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 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

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, 1991-2003. 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: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.

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)

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 %

Changes after Maternal Mortality reviews

Why Mothers Die 1997 - 1999, CEMD

Intervention !!!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

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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