Maternal Mortality and Morbidity - The Texas Campaign to ......Maternal Mortality and Morbidity Task...

Maternal Mortality and Morbidity TEXAS AND THE RIO GRANDE VALLEY

OverviewHistory of Maternal Health• Brief overview of western maternal health• Key moments and persons

Key Agencies• World• United States• Texas

Maternal Mortality and Morbidity• Top Causes• Contributing Factors• Reduction

History:Antiquity to Middle Ages (BCE to ≈ 1400)

Midwife – the woman who is with women.• The midwife, often referred to as wise woman, was

responsible for the health and wellbeing of women.• Often associated with the birth of babies, but

responsible for a myriad of other women’s health issues.

• Primary goal during delivery was safety of the mother.

From Ostia, now in the Welcome Collection of Medical ObjectsRetrieved from Quatr.us

African-American Midwifery, a History and a Lament, 2017; Goode and Rothman

History:Middle Ages to Enlightenment (≈1400-1700)

Barber Surgeon – is a barber whom also practiced surgery and dentistry.• Barber Surgeons increasingly moved into the realm of

child birth.• Surgical instruments were used by the surgeon for

those deliveries that required more intrusive means and had to be performed by the local Barber Surgeon.

Retrieved from: Medievalist.net

African-American Midwifery, a History and a Lament, 2017; Goode and Rothman

History: Enlightenment to Now (≈1700 onward)

Medical Doctor – is an educated professional who practices medicine, which is concerned with promoting, maintaining, and restoring health.• Rapid advancement in medical education, human

anatomy and physiology, and general scientific knowledge

• Oversight Committees began to govern and assess medical practices

• Bureaus were formed to look into Maternal and Infant Mortality and welfare

Clinical Review, 1843, Lee

Puerperal Fever

Childbed fever• Onset of symptoms: 3 days after childbirth• Rapid Progression with severe abdominal pain, fever, and debility/weakness

Early 19th Century, mortality rates were as high as 25% • Atmospheric toxins• Epidemic constitutions of some women• Putrid air• Solar and magnetic influences

Epidemiology, 5th Ed. Gordis, pg.9

Ignaz Philipp Semmelweis (1818-1865)July 1846 Semmelweis was placed to be in charge of the First Obstetrical Clinic of the Vienna General Hospital (Allgemeine Krankenhaus)

He noticed Clinic One staffed with physicians had a much higher mortality rate (2x higher) than Clinic Two which was staffed by midwifes

Semmelweis conducted an investigation (first hospital-based epidemiologic study)• Determined a pathogen was carried on the hands of physicians• Physicians conducted autopsies on women who died of Puerperal Fever and then delivered babies• Midwives did not conduct autopsies and washed their hands in a chloride of lime solution

• Findings confirmed in 1847

Once handwashing policies were implemented, Clinic One reduced their maternal mortality to that of Clinic Two

1861 publishes a paper – “The Etiology, Concept, and Prophylaxis of Childbed Fever”

Oliver Wendell Holmes Ignaz Philipp Semmelweis: Preventing the Transmission of Puerperal Fever, 2010; Lane, Blum, and Fee

The United States Children’s Bureau

1909 White House Conference on Child Welfare Standards• “social workers, educators, juvenile court judges, labor leaders, and other men and women concerned

with child welfare endorsed the idea of a Federal Children’s Bureau” The Story of the Children’s Bureau

1912 The Children’s Bureau is created with a budget of $25,640• One of the first major investigations was infant and maternal mortality• Discovered the United States had a high maternal mortality rate• Maternal mortality rates had a correlation with poverty• 80% of expectant mothers received no advice or trained care

The Story of the Children’s Bureau: 100 years of serving our nation’s children and families, 2012

The Sheppard-Towner Act

1921 Sheppard-Towner maternity and infancy protection act is passed into law• Provided instruction in hygiene of maternity and infancy • Public health nurses, visiting nurses, consultation centers, literature distribution, and more

• $5,000 would go to each state with an additional $5,000 if the state matched the funds• Administering the program could not exceed $50,000

• The moneys would be channeled through the Children’s Bureau

The Sheppard Towner Act came under fire and lawsuits to overturn the legislation with counter suits following

The law was allowed to expire in 1929, but the accomplishments provided evidence that state and federal programs benefited the population

The Sheppard-Towner Act: Progressivism in the 1920’s, 1969; Lemons

Accomplishments

•183,252 health conferences

•2,978 prenatal care centers established

•3,131,996 home visits by nurses

•22,020,489 pieces of literature were distributed

Maternal death rate 1921: 67.3 per 1,000

1927: 62.3 per 1,000

Most states recognized the importance of the problem and continued the programs

The Sheppard-Towner Act: Progressivism in the 1920’s, 1969; Lemons

Maternal Mortality Study Committees1917- New York Academy of Medicine under G.W. Kosmak suggests a subcommittee to study puerperal fever• Forms, dissolves, and reforms in 1930 as the Committee on Public Health Relations of the New York

Academy of Medicine

1920 – National Committee on Maternal Welfare was established

1930 – Philadelphia County Medical Society established the Maternal Welfare Committee

1935 – “A Maternal Mortality Study in Seven Cities of the Pacific Coast” by T. Floyd Bell is published• Texas establishes a maternal mortality study committee

1948 – The AMA established a Committee on Maternal and Child Care• 1957 – Guide for Maternal Death Studies is published

1968 – 44 states and DC have maternal mortality review committeesAfter Office Hours: History of the maternal mortality study committees in the United States, 1969; Marmol, Scriggins, and Vollman

Reports in Media and Publications

• Poverty• Age• Nutrition• Sepsis• Hemorrhage• Induction• Ethics

Definitions

Maternal Mortality• The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the

duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO)

Pregnancy-related Death• The death of a woman while pregnant or within 1 year of the end of a pregnancy – regardless of the

outcome, 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 (CDC – Pregnancy Mortality Surveillance System)

Definitions

Maternal Morbidity• Physical and psychological conditions that result from or are aggravated by pregnancy and have an

adverse effect on a woman’s health (CDC)

Severe Maternal Morbidity• Unexpected outcomes of labor and delivery that result in significant short or long-term consequences to

a woman’s health (CDC)

World Health Organization (WHO)

Maintains and researches treatment for a variety of infections, co-infections, and health issues women face when pregnant• How to treat a pregnant women when she has a parasitic infection• Types of co-infections based on country of origin

Researches maternal morbidity and creates recommendations for treatment• Causes of maternal morbidity• Partner care and presence in the birthing process• Midwifery

Develops guidelines for treatment in a variety of setting and countries

https://www.who.int/maternal-health/en/

What’s Happening in the World

•830 women die daily from preventable pregnancy and childbirth causes

•Maternal mortality is higher in rural areas than in urban areas

•Having a skilled practitioner before, during, and after childbirth can save the life of the mother and the baby

Major causes of maternal mortality in the world• Sever bleeding• Infections• High blood pressure during pregnancy• Complications from delivery• Unsafe abortions

https://www.who.int/maternal-health/en/

Pregnancy Mortality Surveillance System (PMSS) - CDC

CDC and the American College of Obstetrician and Gynecologist (ACOG) established a national surveillance of pregnancy related deaths in 1986 to better understand the causes of maternal death and to fill gaps in clinical information

The information gathered allows for: • Analysis of trends in maternal mortality over time• Analysis for disparities among populations• Analysis of the causes of maternal death and the risk factors associated with maternal

Disseminate information and data to clinicians and public health professionals to further understanding of maternal death causes to implement actions to prevent them

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm

Trends in pregnancy-related mortality in the US: 1987-2015

National Pregnancy-related Mortality Ratio by age, race-ethnicity, and overall 2011-2013

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744583/

National Pregnancy-related Mortality Ratio by specific cause and cohort years

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744583/

Maternal Morbidity in the United States

Postpartum Depression• 1 in 9 women experience postpartum depression symptoms in the United States• In addition to traditional symptoms PPD sufferers may experience:• Crying more often than usual• Feelings of anger• Withdrawing from loved ones• Feeling numb or disconnected from you baby• Worrying that you will hurt the baby

https://www.cdc.gov/reproductivehealth/depression/index.htm

Severe Maternal Morbidity

Indicators for Severe Maternal Morbidity• Blood transfusion• Acute myocardial infarction/Aneurysm• Acute renal failure• Adult respiratory distress syndrome• Cardiac arrest, fibrillation/ Conversion of cardiac

rhythm• Shock• Ventilation/Temporary tracheostomy• Sepsis• Hysterectomy• Disseminated intravascular coagulation• Air and thrombotic embolism

• Amniotic fluid embolism• Acute congestive heart failure or pulmonary edema• Puerperal cerebrovascular disorders• Heart failure or arrest during surgery or procedure• Eclampsia• Severe anesthesia complications• Sickle cell disease

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm

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1993 1994 1997 1998 2001 2002 2005 2006 2009 2010 2013 2014

Blood Transfusions Without Transfusions

Rates of Severe Maternal Morbidity by Blood Transfusion Status per 10,000 Hospitalizations

Adapted from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm

Hysterectomy DIC

Ventilation/Temp Tracheostomy

Sepsis

Adult Respiratory Distress …

Acute Renal FailureShock

Air/Thrombotic Embolism

Cardiac Arrest, Conversion of …

Acute Myocardial …

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100%

Rates of Severe Maternal Morbidity by Indicator per 10,000 Hospitalizations

Adapted from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm

Maternal Mortality in Texas

• 87% increase in maternal deaths

• 18.3 per 100,000 for years 2006-2010

• 34.2 per 100,000 for years 2011-2015

Theguardian.com

https://www.texastribune.org/2018/01/04/maternal-deaths-are-increasing-texas-probably-not-much-officials-thoug/

Propublica.org

Maternal Mortality and Morbidity Task Force

Established in 2013 (SB495) and implemented in 2015, due to reports of maternal deaths increasing 87% over a five year period

Task Force meets quarterly to review maternal death records• A portion of each meeting is open to the public• The remainder is behind closed doors to protect the health information of individuals (HIPPA)◦ Determines whether the death is pregnancy-related using guidelines established by the CDC

Task Force and DSHS submit a joint report on the finding• No later than September 1 of each even-numbered year• Report shall contain information on trends, disparities, health conditions and factors, best practices of other states with low

maternal deaths, and make recommendations after consulting with the Perinatal Advisory Council

Maternal Mortality and Morbidity Task Force, 2018, DSHS

What we know about maternal mortality in Texas

Black women are most at risk for pregnancy-related death• This gap remained high across all levels of socioeconomic status

Majority of maternal deaths are to women enrolled in Medicaid at time of delivery• Socioeconomic/poverty is a factor

Most pregnancy-related deaths are potentially preventable• Found that at least some chance of death being avoided

Complex interactions contribute to maternal mortality• Personal, provider, systems, facility, and community

Causes of death likelihood are time dependent• Most deaths occur more than 42 days postpartum


Causes of Death

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Drug Over

dose

Cardiac

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Homicid

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Suicid

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Infectio

n/Sepsi

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Cerebrovas

cular

Event

Hemorrh

age

Hyperte

nsion/E

clampsi

a

Pulmon

ary Em

bolism

Amniotic Em

bolism

Substa

nce Use

Squela

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Other Cause

s

Trends in Pregnancy-related Deaths in Texas by Cause 2012-2015


Causes of Death by Pregnancy/Childbirth Time

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70

Drug Over

dose

Cardiac

Event

Homicid

e

Suicid

e

Infectio

n/Sepsi

s

Cerebrovas

cular

Event

Hemorrh

age

Hyperte

nsion/E

clampsi

a

Pulmon

ary Em

bolism

Amniotic Em

bolism

Substa

nce Use

Squela

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Other Cause

s

Trends in Pregnancy-related Deaths in Texas 2012-2015

While Pregnant 0-7 DaysPP 8-42 Days PP 43-60 Days PP 61+ Days PP


Causes of Death for Black Women

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While Pregnant 0-7 Days PP 8-42 Days PP 43-60 Days PP 61+ Days PP Total

Top 5 Causes of Pregnancy-related Deaths among Black Women in Texas by Cause and Timing 2012-2015

Cardiac Event Homicide Hypertension/Eclampsia Drug Overdose Cerobrovascular Event


Factors which contribute to an increased risk of pregnancy-related death

•Unmarried

•Had at high school diploma

•Medicaid

Factors for Black Women

•Married

•Private insurance

•Normal weight


•40 years of age or older

•Late or no prenatal care

•Chronic Health diseases• Pre-pregnancy obesity• Diabetes• Hypertension

•Smoking during pregnancy

•Delivery by Cesarean Section

5 Highest Demographic Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births

Hellerstedt and Hollier, 2018; DSHS Presentation

5 Highest Health Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births


National Maternal Mortality Map 2016 and 2018

Americashealthrankings.org

2016 2018

Maternal Mortality in Texas, 2016, DSHS

Examples of Methods

Maternal Morbidity in Texas

• Texas has approximately 400,000 births annually

• Texas accounts for 10% of all births in the United States

• In 2015, Texas had a Maternal Morbidity Rate of 19.7 per 1,000 deliveries

https://www.kut.org

https://www.hcup-us.ahrq.gov

https://www.uthct.edu

Postpartum Depression

•The prevalence rate of women who experience PPD symptoms in Texas is 13.7%, according to pooled PRAMS data for years 2012-2015

•Depression was the most identified mental health condition that contributed to pregnancy-related death

Some Contributing factors to PPD (not exhaustive)• Stressful life events• Low social support• Pregnancy and birth complications• Preterm birth• Teen mother

HRSA.gov Regional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS

Rate of Diagnosed Pregnancy-related Depression per 1,000 Hospitalizations by Race/Ethnicity: 2014


Leading causes of Severe Maternal Morbidity Rate per 10,000 Hospitalizations 2014

129.8

25.8

20.4

13.97.1

Hemorrhage DIC Cardiac Event Hysterectomy Eclampsia

Adapted from Maternal Mortality and Morbidity Task Force, 2018, DSHS


Obstetric Hemorrhage per 10,000 Hospitalizations by Race/Ethnicity in Texas: 2005-2014 (estimates based on blood transfusions)

Obstetric Hypertension per 10,000 Hospitalization by Race/Ethnicity in Texas: 2005-2014


Public Health Region 11

Major cities in PH Region 11:• Brownsville• Corpus Christi• Edinburgh• Laredo• McAllen

83.7 of the region’s population in 2015 was Hispanic:• Brownsville 93.6%• Laredo 95.2

Median household income:• $22,741-$52,261• 49.1% of female population living below 200% FPL

Regional Analysis of Maternal and Infant Health in Texas, PHR11: 2018, DSHS

Postpartum Depression

•All counties in Public Health Region 11 (except Hidalgo, Kleber, and Nueces) are designated medically underserved• Cameron County and Webb County are partial designations

•Pooled PRAMS data from years 2012-2015 indicate 15.6% of women in PHR 11 reported symptoms of PPD• Highest prevalence of PPD symptoms (along with PHR6/5S)• Hispanic women experienced a higher rate than other women

•Preliminary data from Brownsville’s Maternal and Child Community Health Needs Assessment indicate that mental health is one of the top 3 concerns affecting maternal health

Regional Analysis of Maternal and Infant Health in Texas, PHR11: 2018, DSHS

5 Highest Health Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births


Proportion of Hypertensive Disorders Complicating Pregnancy: 2010-2014(Hypertension, Pre-eclampsia, and Eclampsia)

https://www.arcgis.com/apps/Cascade/index.html?appid=94dcde5a27c74867b090a3b2f3835930

Proportion of Hypertensive Disorders Complicating Pregnancy: 2010-2014(Hypertension, Pre-eclampsia, and Eclampsia)

0.1-10.2%

10.3-14.4% +1 SD

14.5-18.5% +2 SD

18.6- 22.7% +3 SD22.8%+0 cases <100 Deliveries

LaredoCorpus Christi

Brownsville

Rate per 10,000 Hospitalizations


Corpus ChristiLaredo

Brownsville

Obstetric Hemorrhage Public Health Region 11: 2010-2014(blood transfusions)

0.1-118.7

118.8-202.4 +1 SD

Rate per 10,000 Hospitalizations

202.5-286.1 +2 SD

286.2-369.8 +3 SD369.9+0 cases <100 Deliveries


Percent of Live Births to Mothers with No Reported Prenatal Care 2015

https://utsys-pop-health.maps.arcgis.com/apps/MapSeries/index.html?appid=52a1e80ce96f48c985989dd65789eb2e

Percent of Live Births to Mothers who Smoked During Pregnancy 2015


Percent of Live Births to Mothers with Pre-pregnancy Obesity 2015


Recommendations

The Maternal Mortality and Morbidity Task Force have identified 5 domains for improvement• Individual• Family• Provider• Facility• System and Community

Implement safety bundles and protocols• “Hospitals that implemented the hemorrhage safety bundle had an 11.7% decrease in severe maternal

morbidity among all obstetric patients (compared to baseline)”

Hellerstedt and Hollier, 2018; DSHS PresentationMaternal Mortality and Morbidity Task Force, 2018, DSHS

Individual and Family Factors Contributing to Poor Maternal OutcomesUnderlying medical conditions• Delay or failure to seek medical care• Cardiovascular disease• Chronic hypertension

Mental Health• Depression

Failure to recognize early warning signs

Obesity• Increased risk for hypertensive disease• Cardiovascular disease• Preeclampsia


Individual and Family Solutions

Address fundamental social conditions and community-level drivers• Employment, education, language, culture• Adopt health in all policies approach

Build environments that support healthy and active living• Parks, sidewalks, community gardens• Partner and coordinate messaging on benefits of green space

Implement community-based health promotion efforts • Community health workers and outreach efforts to address early warning signs, obesity, hypertension,

chronic illness, and mental health• Case managers to help young and first-time mothers to understand the importance of prenatal care,

good nutrition, and assist in accessing care

Maternal Mortality and Morbidity Task Force, 2018, DSHSRegional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS

Social Conditions as Fundamental Causes, 2010, Phelan et. Al. http://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf

Provider Factors Contributing to Poor Maternal OutcomesInadequate, delayed, or poorly coordinated treatment during pregnancy, delivery, and postpartum• Ineffective treatment• Cesarean section• Labor induction

Failure to recognize early warning signs and high-risk maternal health status• Referral to appropriate care specialist• Lack of bedside clinician presence

Delays, inadequacies, or ineffective treatment of hypertension, hemorrhage, and infection

Prioritizing birth outcome over maternal health status


Provider Solutions

Improve access to care• Extended hours, weekend hours

Support provider capacity to deliver high quality care• Well-woman• Routine Maternity

Promote coordinated systems across the care continuum• Increase knowledge of local resources• Case worker or designated staff to help access resources

Promote web-based modules and round tables to disseminate best practices

Regional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS Maternal Mortality and Morbidity Task Force, 2018, DSHShttp://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf

Facility Factors Contributing to Poor Maternal OutcomesInadequate knowledge, judgement, or performance by facility personnel• Lack in recognizing high risk status• Poor documentation in patient’s chart• Delayed response warning signs of declining health by nursing staff

Lack of recognition of risk factors for hemorrhage• Delayed or no response to warning signs

Continuity of care• Inability to secure outpatient care• Hand-off of patients


Facility SolutionsImprove clinical recognition and response to adverse events• Educate and train medical staff on the early warning signs

Ensure facility readiness for obstetric complications• Hemorrhage safety bundles• Hypertension protocols• Safe reduction of primary cesarean births

Voluntarily participate in organizations which focus on labor and delivery services

Develop posters, quick reference tools, and checklists

Ensure Emergency Department has the necessary training, tools, and staff to hand delivery

Maternal Mortality and Morbidity Task Force, 2018, DSHSHellerstedt and Hollier, 2018; DSHS Presentationhttp://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf

Systems and Community Level Factors Contributing to Poor Maternal OutcomesContinuity of care

Lack of access to interconception care services• Education on birth spacing• Providers to address any underlying health issues

Poor care coordination from inpatient to outpatient• Develop resources for warm hand-off of patient• Follow up to help ensure outpatient care is implemented

Transportation services


System and Community Level SolutionsTalk to local and state politicians on best practices and access to care issues

Strengthen maternal data systems• Build capacity to learn from each maternal death and complication• Use data to monitor performance and outcomes• Apply data from surveys and qualitative sources

Increase value of investment• Create and participate in maternal health partnerships• Disseminate and share what works

http://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf Maternal Mortality and Morbidity Task Force, 2018, DSHS

Remember

•Be innovative and creative

•Make connections and network with similar organizations and providers

•Think outside the box

•Stay dedicated and curious


California Maternal Mortality Rate per 100,000 Live Births: 1999-2013

Thank you!

Referencesa Maternal health resource, & and Planning guide for States.HealtH for every mother

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As Required Chapter, 3 4, Texas Health, Safety Code, & Section, 3. 0.Maternal mortality and morbidity task force and department of state health services joint biennial report

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