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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.
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
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
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