Elliott K. Main, MD

Medical Director, CMQCC

Professor of Obstetrics and Gynecology,

Stanford University

Addressing Maternal

Mortality And Severe

Maternal Morbidity (SMM)

Supported by:

California Dept. of Public Health

California Health Care Foundation

Centers for Disease Control (CDC)

Merck for Mothers Project

Yellow Chair Foundation

Reduction of Maternal Mortality is One of the

Greatest Public Health Success Stories of the Last Century

CDC

17.3

In the last 15 years,

US has seen rises in:

Maternal Mortality:

Up 50-70%

Severe Maternal

Morbidity:

Up 100 %

Cesarean Births:

Up 50%

NCHS

From

cdc.gov

1.6%

2X

Search:

Severe

Maternal

Morbidity

Maternal Mortality and Severe MorbidityApproximate distributions, compiled from multiple studies

CauseMortality(1-2 per

10,000)

ICU Admit(1-2 per

1,000)

Severe Morbid

(1-2 per

100)

Thromboembolism 10-15% 5% 2%

Infection 10-15% 5% 5%

Hemorrhage 10-15% 30% 45%

Preeclampsia 10-15% 30% 30%

Cardiac Disease 25-30% 20% 10%

Main et al. Pregnancy-Related

Mortality in California.

Obstet Gynecol 2015

Pre-pregnancy BMI Among Major Causes of Death

Only two

causes had

high rates of

obesity

Cause of Death North Carolina

“Preventable”

California

“Good or strong

chance to alter

the outcome”

United Kingdom

“Substandard

care that had a

major

contribution”

Hemorrhage 93% 70% 44%

Preeclampsia 60% 60% 64%

Sepsis / Infection 43% 50% 46%

DVT / VTE 17% 50% 33%

Cardiomyopathy 22% 29% 25%

AFE 0% 0% 15%

Assessments of Preventability

• California Pregnancy Associated Mortality Reviews– Missed triggers/risk factors: abnormal vital signs, pain,

altered mental status/lack of planning for at risk patients

– Underutilization of key medications and treatments—did not have a plan!

– Difficulties getting physician to the bedside

– “Location of care” issues involving Postpartum, ED and PACU

• University of Illinois Regional Perinatal Network- Failure to identify high-risk status

- Incomplete or inappropriate management

Key Provider Quality Improvement (QI) Opportunities:

Hemorrhage and Preeclampsia

CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report

from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org)

Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with

severity. Am J Obstet Gynecol 2004; 191: 939-44.

Present in >95% of

cases

Present in >90% of

cases

9

◼ Most common preventable causes of

maternal mortality

◼ Far and away the most common causes of

Severe Maternal Morbidity

◼ High rates of provider

“quality improvement opportunities”

Obstetric Hemorrhage and

Preeclampsia: Summary

3 Deadly D’s:

Lost Mothers

Series

Rene Martin,

ProPublica

Renee Montagne,

NPR News

Winner of the

George Polk

Award in

Journalism

(2018)

IMPROVING POPULATION HEALTH OF WOMEN

Maternal Mortality Review Committees

conduct detailed reviews to get complete

and comprehensive data on maternal deaths to prioritize prevention

efforts.

Perinatal Quality Collaboratives

mobilize state or multi-state networks to implement quality

improvement efforts and improve care for mothers and babies.

Alliance for Innovation on Maternal Health moves established

guidelines into practice with a standard

approach to improve safety in maternity care.

MMRCs

PQCsAIM

Zaharatos, CDC, 2018

Identify Issues

CDCCreate Action Steps

HRSA/MCHB

Dissemination Implementation

MCHB / CDC

Community Maternal Health Service Providers and MCH Organizations

● Engagement of public health community programs

● Increase access to care through promotion of collaborative care.

● Engage public voices

Hospitals, Providers, Nurses, Offices,

and Patients

● Create QI Team to implement safety bundles

● Engage wide-range of stakeholders

● Review progress through AIM Data Portal

Perinatal Collaborative: State DPH, Prof Groups Hospital Associations

● Support/coordinate/share hospital QI efforts

● Mobilize state-level resources and partners

● Use state data for outcome metrics

National Pub Health Community, and

Prof Organizations

● Engage/coordinate national partners

● Develop and share resources

● Promote Inter-state relations/sharing

● Support multi-state data platform

AIM Works at National, State, Facility and Community Levels for Implementation

11.1

7.7

10.0

14.6

11.8 11.7

14.0

7.4

7.3

10.9

9.7

11.6

9.2

6.2

16.9

8.9

15.1

13.1

12.19.9

9.9

9.8

13.3

12.7

15.516.9

16.6

19.3

19.9

22.0

0.0

3.0

6.0

9.0

12.0

15.0

18.0

21.0

24.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Maternal Mortality Rate,

California and United States; 1999-2013M

ate

rnal D

eath

s p

er

100,0

00 L

ive B

irth

s

California: ~500,000 annual births, 1/8 of all US births

CA Mortality Review Committee

Key Steps for Improving Care “At Scale”

◼ Linking public health surveillance to actions

◼ Mobilizing a broad range of public and private

partners

◼ Developing a rapid-cycle Maternal Data Center

to support and sustain QI projects

◼ Implementing a series of data-driven large-

scale quality improvement projects

Main etal: Health Affairs 2018; 37:1484-93

CMQCC’s Key Stakeholders/ PartnersState Agencies

◼ CA Department of Public Health, MCAH

◼ Regional Perinatal Programs of California (RPPC)

◼ DHCS: Medi-Cal

◼ Office of Vital Records

◼ Office of Statewide Health Planning and Development (OSHPD)

◼ Covered California

Membership Associations

◼ Hospital Quality Institute (HQI)/California Hospital Association (CHA)

◼ Pacific Business Group on Health (PBGH)

◼ Integrated Healthcare Association (IHA)

Key Medical and Nursing Leaders

◼ UC, Kaiser (N&S), Sutter, Sharp, Dignity Health, Scripps, Providence, Public hospitals

16

Professional Groups (California sections of national organizations)

◼ American College of Obstetrics and Gynecology (ACOG)

◼ Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

◼ American College of Nurse Midwives (ACNM)

◼ American Academy of Family Physicians (AAFP)

Public and Consumer Groups

◼ Consumers’ Union

◼ March of Dimes (MOD)

◼ California HealthCare Foundation (CHCF)

◼ Cal Hospital Compare

◼ Amniotic Fluid Embolism Foundation

Health Plans

◼ Commercial and Managed Medi-Cal Plans

OB Quality/Safety

Project

Performance Measures/ Public

Reporting

Collected Evidence/ QI Tool Kit

Professional Org Leadership

Data-driven QI Collaborative

Hospital Association Joint

Commission

Health Plans (Commercial

and Medicaid)

Purchaser/ Employer

Engagement

Patient + Public EngagementAddress Unit

Culture Issues

Pull As Many Levers as Possible: Collective Impact

Change at Scale Require External Pressures

18

CMQCC Maternal Data Center

Links over 1,000,000 mother/baby records each year!

Maternal Safety Bundles

◼ ReadinessEvery unit—prepare and educate

◼ Recognition & PreventionEvery patient—before event

◼ ResponseEvery Event—team approach

◼ Reporting/Systems LearningEvery unit—systems improvement

Available (with resource links) at: safehealthcareforeverywoman.org

Uniform Structure:

• “Checklist” of items and

practices for every birthing site

• Not a national protocol!!

• Facilities will modify content

based on local resources

What are they?

Hemorrhage Toolkit

>14,000 Downloads to date

CMQCC.org

11.1

7.7

10.0

14.6

11.8 11.7

14.0

7.4

7.3

10.9

9.7

11.6

9.2

6.2

16.9

8.9

15.1

13.1

12.19.9

9.9

9.8

13.3

12.7

15.516.9

16.6

19.3

19.9

22.0

0.0

3.0

6.0

9.0

12.0

15.0

18.0

21.0

24.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Maternal Mortality Rate,

California and United States; 1999-2013M

ate

rnal D

eath

s p

er

100,0

00 L

ive B

irth

s

California: ~500,000 annual births, 1/8 of all US births

CMQCC

CA Mortality Review Committee

Toolkits and Collaboratives

California Quality Improvement Projects

Years Projects

2006 California Pregnancy-Associated Mortality Review established

2008 CMQCC/CDPH OB Hemorrhage Task Force

2009-10 CMQCC Hemorrhage QI collaboratives I and II

2010-11 CMQCC/CDPH Preeclampsia Task Force and QI collaborative

2011 Release of CDPH Maternal Mortality report and education campaign

2011-14HEN/CMQCC/CHA-HQI QI collaborative focused on Hemorrhage and

Preeclampsia

2015-16CMQCC/Merck for Mothers QI collaborative for Reduction of Hemorrhage

and Hypertension (HTN) severe morbidity

2016-19CMQCC QI collaboratives (3 cohorts) for Supporting Vaginal Birth and

Reducing Primary Cesarean Delivery

Preeclampsia

◼ Toolkits and Safety Bundles

CMQCC Preeclampsia Toolkit: 2014

Council on Patient Safety in Women’s Health Safety Bundle: 2017

◼ Early treatment of severe HTN decreases SMM and eclampsia

(Shields, AJOG 2017)

Adoption of CMQCC toolkit at 23 hospitals

◼ Focused on early recognition and treatment, MgS04, PP follow up

Eclampsia decreased by 43%, SMM decreased by 29%

Intensive monitoring of HTN treatment metrics necessary to cause change

(in practice and outcome)

◼ Successful QI requires monitoring, clear metrics

Controlling blood pressure

is the key intervention

to prevent deaths due to stroke

in women with preeclampsia.

“Treat the Damn Blood Pressure!”

Over the last decade, the UK has focused

QI efforts on aggressive treatment of both

systolic and diastolic blood pressure and

has demonstrated a reduction in deaths.

Severe Maternal Hypertension Treated Within 60 Minutes

27

41%

48%51% 53% 55%

60%65% 66%

73%70% 72%

77% 77%73% 72%

76%

82%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline(Oct -

Dec 15)

July-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 June-17 July-17 Aug-17 Sep-17 Oct-17

Proportion of Hospitals with 80% of women treated within 60 min

Percent overall women in collaborative treated within 60 min

13%

Increased 41% to 82%Change per Month, aOR = 1.11, 95% CI 1.10-1.12 P < 0.001

71%

Severe Maternal Hypertension with Severe Maternal Morbidity Reported

28

15%15%

16%

14%

12%

18%

9%

16%

10%

11%

17%

11%

13%

8%

12%

10%

9%

9%

9%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Baseline(Oct -Dec

2015)

May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Pe

rce

nt

of

Wo

me

n w

ith

SM

M

Monthly change, aOR=0.98, 95% CI 0.96-0.99P < 0.004

15% baseline to 9% last quarter41% reduction

*When adjusted for hospital characteristics results were unchanged

Serena Williams’ Story

of Not Being Listened To

Despite history of multiple PE, her doctors and

nurses minimized her PP complaints and refused

a CT scan (later positive for multiple small PE)

Lt. Comdr. Shalon Irving PhD

U.S. Maternal Mortality by Race/Ethnicity

Moaddab A et al. Obstet Gynecol

2018;131:707-12.

Pregnancy-related

Mortality Rates By Race:

New York City

12X

7.0

7.1

26.4

37.2

33.8

41.1

46.1

51.0

41.5

45.7

35.3

32.2

29.0

29.5

27.7

4.9

9.1 7.8

7.6

3.83.2

3.83.74.3

3.9

3.93.1 3.0 3.0

3.8 3.8

4.4

0

10

20

30

40

50

60

1999-

2001

2000-

2002

2001-

2003

2002-

2004

2003-

2005

2004-

2006

2005-

2007

2006-

2008

2007-

2009

2008-

2010

2009-

2011

2010-

2012

2011-

2013

Three-Year Moving Average

0

1

2

3

4

5

6

7

8

9

10White, Non-Hispanic African-American, Non-Hispanic

Hispanic Asian, Non-Hispanic

AA-W Mortality Disparity Ratio

Mate

rnal M

ort

alit

y R

atio

(pe

r 1

00

,000

liv

e b

irth

s)

Morta

lity D

isparity

Ratio

Maternal Mortality Rate, By Race/Ethnicity

Three–Year Moving Averages; 1999-2013California Only Data

California Racial / Ethnic Disparities

Total sample

~3.1million (8 years)

Hispanic/

Latina

Non-

Hispanic

White

Asian/

Pacific

Islander

Non-

Hispanic

Black

American

Indian

Proportion of Births 52% 29% 13% 5.5% 0.3%

Maternal Mortality (per 100,000, 2011-2013)

4.9 7.0 7.8 26.4 n.a.

Severe Maternal

Morbidity (SMM)1.5% 1.2% 1.4% 2.2% 1.9%

Pre-preg. Obesity 27% 17% 8% 30% 35%

Pre-preg. Comorbidity 6% 8% 6% 14% 11%

Maternal Age ≥35 14% 23% 30% 14% 12%

Total Cesarean 33% 33% 33% 38% 34%

Why do black women do

so much worse?

Usual explanation by doctors and nurses

is that black women have more obesity,

more hypertension, more diabetes,

and more social disadvantages…

What If We Looked At B:W Disparity In SMM

Only Among College Graduates?

California linked data: 2010-2015 Q3

Black-White disparity in SMM is

highest among college graduates

(2.2x higher than whites)

Looking At Absolute Rates:

•SMM rate in Black women with

college degrees: 2.4%

•SMM rate in White women without

high school diplomas: 1.6%

And adjusted for age, BMI and other clinical and demographic risk factors…

Educational Attainment

• Rank NYC hospitals by SMM & compare distributions of births

• 65% of whites, 23% of blacks deliver at lowest-SMM tertile hospitals

• If blacks delivered at same hospitals as white… explained 47% of black-white disparity

3 States on the ‘Runway’

How does a state Perinatal Quality Collaborative (PQC) Improve Care and Outcomes?

• Not just a convening of interested stakeholders

• Not just a system of outreach education

Courtesy: Dr. Ann Borders, Medical Director, Illinois Perinatal Quality Collaborative

Successful PQC’s:• Focus on Building Hospital

Capacity to Drive Systems & Culture Change

• Focus on building bridges with Public Health and Communities

AIM Successful AIM:• Focus on Building State

Capacity to Drive Systems & Culture Change

• Focus on building bridges with Public Health and Communities

Successful EXTERNAL Strategies for PQCs to Achieve High Rates (>90%) of Hospital Engagement

Strategy TX CA IL

Legislation encouraging participation

Promotion by DPH /Linkage to Regionalization

Linkage to LOMC program (Levels of Maternal Care)

DSRIP incentives (CMS updated disproportionate care)

News Saturation / Attention

Promotion by State Hospital Association

Health Plan incentives

Cumulative Successes (momentum)

Importance of Timely data

• Data drives hospital (and PQC) QI efforts

• No data: No direction—Are we better ? Are we worse?

• No data: Less effort—easy to put off in face of competing demands

• Benchmarking against like hospitals is powerful

• Current data cuts thru denial: “Our care is great!”

• QI Data is only good if timely: “We are much better than that currently”

• AIM data set tries to give balance to frequency vs burden (cost)

National Safety Bundle Commentary

August 2019

All these Materials Introduce a New Narrative

Key State PQC Opioid Toolkits

MNO-OB Toolkit. *Updated January 2019*

http://www.nnepqin.org/wp-content/uploads/2019/03/Toolkit-for-

Perinatal-Care-of-Women-with-Substance-Use-Disorders_Final-2019.pdf

https://www.acog.org/About-ACOG/ACOG-

Districts/District-II/Opioid-Use-Disorder-in-

Pregnancy?IsMobileSet=false

http://ilpqc.org/?q=MNO-OB

Conclusions

• We know what to do to reduce maternal mortality and morbidity

• It takes collective action of all key stakeholders

• State Perinatal Quality Collaboratives are central but need support

• There are Federal agencies involved but state organizations are critical