June 6, 2013

Reducing Maternal Morbidity and Mortality in New York State:

A Consensus Plan

Safe Motherhood Initiative

Global Maternal Health: A Call to Action

THE LANCET, JULY 13, 1985

Maternal Health

MATERNAL MORTALITY—A NEGLECTED TRAGEDY

Where is the M in MCH?

ALLAN ROSENFIELD DEBORAH MAINE

Center for Population and Family Health, Faculty of Medicine, Columbia University, 60 Haven Avenue, New York,

NY 10032, USA

International Movement to Reduce Maternal Mortality

1987, Global Safe Motherhood Conference, Nairobi, Kenya

2000, United Nations' 8 Millennium

Development Goals Target #5: Reduce the maternal mortality ratio ratio by 75% from 1990-2015

World Bank United Nations

United Nations General Assembly. United Nations millennium declaration. A/RES/55/2. New York (NY): United Nations, 2000.

Yearly Rate of Change in Maternal Mortality Ratio,1990–2008

Hogan MC, et al. Lancet 2010.

US Maternal Mortality Ratio: What is the Trend?

Several reports indicate that the maternal mortality ratio in the US is increasing • Maternal mortality ratio rose from 10.0 to 14.5 per

100,000 between 1990 and 2006 • Changes in the National Vital Statistics System may

have improved ascertainment of maternal death

Maternal mortality is NOT DECREASING in the US, despite advancements of modern medicine

Berg CJ et al. Obstet Gynecol 2010, Callaghan WM, Semin Perinatol 2012

9.0

6.5

12.5

10.0

15.0

10.1

17.0

10.9 9.9

16.5 7.6

10.5

20.1

7.1

9.0

9.0

10.3 5.0

10.9

7.8 8.2

12.7

16.0

17.9

11.6

11.0

21.0

10.1

2.6

20.9

14.8

19.0

8.2

12.0

10.9

18.7 7.2 10.3

10.4 8.3

16.5

7.5

4.8

1.2

5.2

2.9

9.2

MATERNAL MORTALITY PER 100,00 LIVEBORN INFANTS

18.9 Source: NLWC from Center for Disease Control and Prevention, National Center for Health Statistics 1999-2006

> 18.0

13.0 -18.0

<13.0

New York State Maternal Mortality Ratios: Deaths per 100,000 live births

Source: NYS DOH Minority Surveillance Report 2012

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

White, non-Hispanic

Black, non-Hispanic

Asian/PacificIslander, non-Hispanic

Hispanic

Pregnancy-Related Deaths by Cause, NYC, 2001-2005

Cause of Death Number Percent

Embolism 28 17.4

Hemorrhage 27 16.8

Pregnancy-induced hypertension 23 14.3

Infection 23 14.3

Cancer 4 2.5

Anesthesia complications 3 1.9

Injury 3 1.9

Other cause of death 50 31.1

Total 161 100

Source: NYC DOH, New York City Maternal Mortality Review Project Team

US Pregnancy-Related Mortality

Source: William Callaghan, CDC., multiple publications

PERC

ENTA

GE

INCR

EASE

New York State Pregnancy-Related Mortality: 2003-2005 and 2007-2009

SMI Data, 2007-9 Triennial Report

N 2003-5 = 33 deaths reviewed by SMI N 2007-9 = 38 deaths reviewed by SMI ~33% of deaths reported by NYS DOH

Opportunities to Reduce Maternal Death

UK triennial “Saving Mothers’ Lives” 2011 report found major substandard care in: 64% of deaths due to hypertensive disease 33% of deaths due to thromboembolism 44% of deaths due to hemorrhage

North Carolina mortality review 1995-1999 40% of maternal deaths preventable

Hospital Corporation of America 2000-2006 27% of maternal deaths preventable

New York State Safe Motherhood Initiative 2008-2009 35% of maternal deaths preventable

Risk Factors For Maternal Mortality in New York City: 2001-2005

Maternal age Women older than 40 were 2.6 times to suffer

maternal death

Obesity 49% of women who died from pregnancy-related

causes were obese

Comorbid conditions 56% of women had a chronic health condition

Racial disparities

Source: NYC DOH MH New York City Maternal Mortality Review Project Team

Strategies to reduce maternal mortality

High risk women: • Timely identification and referral of patients for

appropriate level of care

Causes of Pregnancy-Related Death in the United States, 2006–2008, CDC PMSS

Strategies to reduce maternal mortality

Low risk women: • Comprehensive national effort to educate

all providers on the prevention and treatment of obstetrical complications

Causes of Pregnancy-Related Death in the United States, 2006–2008, CDC PMSS

Interval from End of Pregnancy to Death for Pregnancy Related Deaths, NYC, 2001-2005

Interval Number Percent

Antepartum 26 16.2

0-1 day 54 33.5

2 days – 1 week 27 16.8

>1 week – 1 month 35 21.7

> 1 month – 1 year 16 8.9

Unknown 3 1.9

Total 161 100

Source: NYC DOH, New York City Maternal Mortality Review Project Team

Maternal Early Warning System (MEWS)

Singh et al. Anaesthesia 2012

Obstetric centers should utilize an early warning system to detect abnormal physiologic parameters that precede critical illness Modeled on UK early obstetric warning

system (MEOWS) Research has found these parameters to be

highly sensitive and specific

Maternal Early Warning System (MEWS)

If a pregnant or postpartum patient develops any of the following findings a prompt evaluation by a clinician is required:

Parameter

Systolic BP; mmHg <90 or >160

Diastolic BP; mm Hg >100

Heart rate; beats per minute <50 or >120

Respiratory rate; breaths per minute <10 or >30

Oxygen saturation; % <95

Oliguria <30mL/hr for 2 hours

Maternal agitation, confusion, or unresponsiveness

Source: http://hospitals.nyhealth.gov/

29

25

32

26

9 8 6

0

5

10

15

20

25

30

35

<500 births 501-1000births

1001-2000births

2001-3000births

3001-4000births

4001-5000births

>5000 births

N = 135

NU

MBE

R O

F HO

SPIT

ALS

Birth Volume NYS Hospitals, 2010

The Joint Commission 2010:

Preventing Maternal Death

Calling Attention to Maternal Mortality in the US

Initiatives to decrease maternal mortality • case reporting and review • team training and drills • thromboembolism prophylaxis

Safe Motherhood Initiative

New York State working group met January 2013 41 physicians from 21 hospitals across New

York State Subgroups: Clinical Educational Surgical Research

Reducing Maternal Mortality in New York State

Reducing Maternal Mortality in New York State

SMI Recommendations:

Standardize best practices in 3 areas:

1. Hemorrhage 2. Pre-eclampsia (severe hypertension)

3. Pulmonary Embolism (DVT)

Direct Deaths per Million Maternities by Cause - UK 1994-2008

Saving Mothers’ Lives 2006-2008, National Launch, March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG

The Relevance of Protocols

Statewide protocols for maternal care: •Derived from evidence-based data •Define the standard of care •Minimize variability •Reduce the need to rely on memory •Enhance patient safety •Reduce duplication of effort

SMI CONSENSUS PLAN

Statewide Hospital Enrollment

Hospital adoption of protocols Standardization of care

Development of STANDARDIZED Tool Kits/Bundles

Protocols/Triggers/Drills Checklists/Risk assessment tools

Comprehensive educational plan

HTN/PEC Hemorrhage Thromboembolism

Supported by Merck for Mothers grant ACOG District II Funded for implementation of educational

program Clinical outcomes will be tracked as part of

this initiative

Focus Population • 131 Obstetric Hospitals

– 52 Level 1s – 28 Level 2s – 34 Level 3s – 17 RPCs 75% participation rate – Ob-Gyns; OB nursing, anesthesia, pediatrics, critical

care medicine, cardiology, family practice, midwifery, hospital administration

– Liaison members: all major hospital associations

Year 1: Activities

• Collect / Review hospital protocols in 3 areas • Determine physician/nurse understanding of

the use of 3 protocols • Engage 3-person SMI “teams” from each

hospital ob-gyn, nurse, admin • Financial compensation to hospitals • Develop initial process for data tracking,

collection, & analysis • PR campaign for hospitals as an incentive

Year 2: Activities

• Continued participating hospital education – web conferences – regional teaching days – monthly conference calls

• Hospital staff to standardize data entry processes • Data collection via a private, encrypted web

portal • On-site hospital visits for chart reviews • PR campaign continues

Year 3: Activities

• Review hospital compliance with implementation of new measures

• Conduct rigorous data analysis • PR campaign • Post-initiative KAP survey • Suggested recommendations for further

improvements

National Scalability

• As these 3 “bundles” are developed, validated and integrated into routine care, the facility level cost for project continuation should be marginal.

• Educational materials and protocols may be applicable to, and duplicated in, obstetric settings across the country.

The Gap Between Knowing and Doing

28% - 40% of pregnancy-

related deaths potentially

preventable Clark SL, Am J Obstet Gynecol 2008

Berg CJ, Obstet Gynecol 2005,

Organized Response

“Between the health care we have and the health care we could have

lies not just a gap, but a chasm.”

Crossing the Quality Chasm, IOM, 2001