Maternal Mortality - Healthy Start Coalition of Miami-Dade...Maternal Mortality: Death of a woman...

Our Practice Is Our Passion

Maternal Mortality: What Can a Perinatal Quality Collaborative Do?

William M. Sappenfield, MD, MPH, CPHProfessor & Director

Florida Perinatal Quality CollaborativeThe Chiles Center


Conflicts of Interest

1. No reportable conflicts

2. Contract/Grant funding from:• Florida Department of Health

• Centers for Disease Control and Prevention

• American Congress of Obstetrics & Gynecology

2


Learning Objectives

1. Describe the current maternal mortality crisis in the United States and Florida.

2. Summarize why maternal mortality reviews are necessary to address the crisis in the U.S. and Florida.

3. Explain how maternal mortality findings can effectively guide and direct prevention efforts in Florida.

3


Max Roser and Hannah Ritchie (2019) - "Maternal Mortality". Published online at OurWorldInData.org.Retrieved from: 'https://ourworldindata.org/maternal-mortality' [Online Resource]


Maternal Mortality, Developed Countries, 1990-2015

Source: National Geographic, December 2018


Trends in pregnancy-related mortality in the United States: 1987-2015

Source: CDC Pregnancy Mortality Surveillance System

Death Certificate Revision


Maternal Mortality by US States, 2011-15

05

101520253035404550

Mater

nal D

eaths

Per

100,0

00 Li

ve B

irths

FL 36th

US

Source: America’s Health Rankings, United Health Care

What is the Difference Between

Maternal Mortality

Pregnancy-Related Mortality

&

?10


Definitions

Maternal Mortality: 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.

Pregnancy-Associated Mortality: Death of a woman, from any cause, while she is pregnant or within one year of pregnancy.

Pregnancy-Related Mortality: Death of a woman which resulted from:1) complications of the pregnancy;2) the chain of events initiated by pregnancy, leading to death; or3) aggravation of an unrelated condition by effects of the

pregnancy, resulting in death.


Identification of Maternal MortalityBased on Death Certificates

Starting with ICD-9, switched coding from limiting to one year to 42 days.


Identification of Maternal MortalityBased on Death Certificates and ICD-10


Stage 1: Identification of Pregnancy-Associated Deathsand Selection of PAMR Cases

MATERNAL DEATH CERTIFICATES

MATCHING BIRTHCERTIFICATES

MATCHING FETALDEATH CERTIFICATES

MATCHING HS PRENATAL SCREEN

UNDUPLICATED POOL OF PREGNANCY-

ASSOCIATED DEATHS

------------------------------------SORTED BY M.D. REVIEW----------------------------------PREGNANCY- RELATED | POSSIBLY PREGNANCY-RELATED | NOT PREGNANCY- RELATED

PREGNANCY-RELATED

ALL CASES

POSSIBLY PREGNANCY-RELATEDNOT PREGNANCY- RELATED

ICD 10 PREGNANCY √ BOX

RANDOM SELECTION

In Florida, how does PAMR’s

Maternal Mortality

Pregnancy-Related Mortality

Compare to ‘CHARTS’

?16

Accuracy of Maternal Death Reporting From Death Certificates

Florida 2006-2009

Pregnancy-Related Death (PAMR)Yes No Total

Maternal Death (Vitals)

Yes 104 62 166

No 60 13,498 13,558

Total 164 13,560 13,724

17


Florida 2006-2009



Yes 104 62 166

No 60 13,498 13,558

Total 164 13,560 13,724

Sensitivity = 63% = 104 / 16418


Florida 2006-2009



Yes 104 62 166

No 60 13,498 13,558

Total 164 13,560 13,724

Predictive Value Positive 63% = 104 / 166 19

0

10

20

30

40

50

60

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Rat

ios

per 1

00,0

00 L

ive

Birt

hsFigure 2. Florida Pregnancy-Related Mortality

(PAMR) and Maternal Mortality Ratios (CHARTS) Florida 2006-2016

PRMR MMR

1121

05

101520253035404550

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths

3-year Pregnancy-Related Mortality Ratios by Race/Ethnicity, Florida, 1999-2017

All (w/ 2017) White (w/ 2017) Hispanic (w/2017) Black (w/ 2017)

Difference between two time periods p<0.0522


0% 5% 10% 15% 20% 25%

AnesthesiaAmniotic fluid…

UnknownCerebrovascular…Cardiomyopathy

Thrombotic embolismCardiovascular

OtherHypertensive disorder

InfectionHemorrhage

Percentage of Deaths

Distribution of Pregnancy-Related Causes of Death Florida (2008-2017)

Source: CDC website and FDOH data request


0% 5% 10% 15% 20% 25%

AnesthesiaAmniotic fluid…

UnknownCerebrovascular…Cardiomyopathy

Thrombotic embolismCardiovascular

OtherHypertensive disorder

InfectionHemorrhage

Percentage of Deaths

Distribution of Pregnancy-Related Causes of Death United States (2011-2015) and Florida (2008-2017)

FloridaUnited States

Source: CDC website and FDOH data request

00.5

11.5

22.5

33.5

44.5

5

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths

3-year Pregnancy-Related Mortality Ratios by Cause of Death, Florida, 1999-2017

Hemorrhage Hypertensive Infection Ammniotic Embolism

Time trend from 1999-2017 p<0.0525

00.5

11.5

22.5

33.5

44.5

5

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths



Time trend from 1999-2017 p<0.0526

00.5

11.5

22.5

33.5

44.5

5

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths




00.5

11.5

22.5

33.5

44.5

5

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths


Cerebrovascular Cardiovascular Other Causes Cardiomyopathy

28

05

101520253035404550

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths

3-year Pregnancy-Related Mortality Ratios by Race/Ethnicity, Florida, 1999-2017

All (w/ 2017) White (w/ 2017) Hispanic (w/2017) Black (w/ 2017)


What Do We Learn From Reviews?

30


0% 20% 40% 60% 80% 100%

Percent of Deaths

Good Some

Preventable Pregnancy-Related DeathsFlorida, 2017

68%

Urgent Maternal Mortality Messages

00.5

11.5

22.5

33.5

44.5

5

1999-2001 2002-2004 2005-2007 20008-2010 2011-2013 2014-2016/7

Per 1

00,0

00 li

ve b

irths


Hemorrhage Hypertensive Cardiomyopathy

Infection Ammniotic Embolism

36

Obstetric Hemorrhage Initiative—OHI

37


OHI Initiative Hospitals

• 31 Florida hospitals• 4 North Carolina hospitals

38


Key OHI QI ElementsReadiness• Develop an Obstetric Hemorrhage Protocol• Develop a Massive Transfusion Protocol • Construct an OB Hemorrhage Cart• Ensure Availability of Medications and EquipmentRecognition• Antepartum Risk Assessment• Quantification of Blood Loss• Active Management of the Third Stage of LaborResponse• Perform Interdisciplinary Hemorrhage Drills• Debrief after OB Hemorrhage Events

39


Percent of Hospitals Assessing for Risk of Obstetric Hemorrhage at Birth Admission

40

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

75 to 100% ofwomenassessed

1 to 74% ofwomenassessed

No womenassessed


Percent of Vaginal Deliveries Where Blood Loss Was Quantified

41

4% 8% 9%14%

21% 22%32% 32%

38%44%

49% 47% 45% 46%52% 55%

61% 62%

0%10%20%30%40%50%60%70%80%90%

100%

Perc

ent a

chie

ved

Month

Hypertension in Pregnancy Initiative—HIP

42

43

HIP Initiative Hospitals

32 Florida hospitals1 Colombia hospital

44

Hypertension Patient Safety BundleReadiness

Every unitRecognition / Prevention

Every patientResponse

Every case of severe hypertension/preeclampsiaReporting / Systems Learning

Every unit


Percent of Women by Hospital with Persistent New-Onset Severe HTN Who Were Treated <1 hr

20%

48% 47%

67%71%

67%

90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline Q1-16 Q2-16 Q3-16 Q4-16 Q1-17 Apr-17

Per

cent

of W

omen

Goal

Max. Value

75th Percentile

Min. Value

25th Percentile

Median


Percent of Hospitals meeting HIP Structural Measures

46

48%

97%

40%

94%

8%

70%

12%

61%

8%

97%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2015 (n=32)

Hypertension policies & procedures

EHR integration

Patient, family, staff support

Multidisciplinary case reviews

Hypertension discharge education

June 2017 (n=32)

PROVIDE 2.0Extend, Enhance & Expand

47


NTSV Cesarean RatesU.S. States, 2017

26.0

31.0

0

5

10

15

20

25

30

35

40

Utah

South

Dak

otaIda

hoNe

w Me

xico

Alas

kaVe

rmon

tAr

izona

Hawa

iiW

yomi

ngCo

lorad

oW

iscon

sinNo

rth D

akota

Oreg

onW

ashin

gton

North

Car

olina

Indian

aMi

nnes

otaMi

ssou

riKa

nsas

Maine

Monta

naIow

aOh

ioCa

liforn

iaOk

lahom

aDe

lawar

eNe

bras

kaIlli

nois

New

Hamp

shire

Rhod

e Isla

ndMa

ssac

huse

ttsPe

nnsy

lvania

Unite

d Stat

es6

Virg

inia

Arka

nsas

Mich

igan

Tenn

esse

eSo

uth C

aroli

naW

est V

irgini

aGe

orgia

Alab

ama

Conn

ectic

utMa

rylan

dKe

ntuck

yTe

xas

Neva

daDi

strict

of C

olumb

iaNe

w Yo

rkNe

w Je

rsey

Louis

iana

Miss

issipp

iFlo

rida

48Source: NCHS (2017) Final Birth Data 2017

FLUS

HP 2020 Goal—23.9%

Cesarean: Maternal RisksLong Term &

Subsequent Births1/100 to 1/1000• Abnormal placentation

(previas and accretas)• Uterine rupture• Surgical adhesions• Bladder surgical injury• Bowel surgical injury• Bowel obstruction

AcuteCommon:• Longer hospital stay• Increased pain and fatigue• Postpartum hemorrhage

(transfusions ~2%)• Slower return to normal

activity and productivity• Delayed or difficult

breastfeeding

1/100 to 1/1000• Anesthesia complications• Wound infection• Deep vein thrombosis

49

We perform over 160,000 Cesareans every year in California

And, we perform over 81,000 Cesareans every year in Florida!


Pregnancy-Related Mortality Rate Due to Hemorrhage Excluding Ectopic by Prior Cesarean Status

Florida, 1999 to 2017

0.00.51.01.52.02.53.03.54.04.55.0

1999-01 2002-04 2005-07 2008-10 2011-13 2014-17

Deat

hs P

er 1

00,0

00 L

ive

Birt

hs

Birth Year

All DeathsAll Deaths Without Ectopics


Percent of Live Births Delivered by Cesarean and Repeat Cesarean, or with Prior Cesarean, Florida, 1999-2017

25.5%

31.1%36.0% 37.8% 38.0% 37.3%

11.1% 11.8% 12.4% 13.5% 14.7% 15.3%

0%

10%

20%

30%

40%

50%

1999-01 2002-04 2005-07 2008-10 2011-13 2014-17

Perc

ent o

f Liv

e Bi

rths

Birth Year

C/SBirths with Prior C/S




0

2

4

6

8

10

12

14

1999-01 2002-04 2005-07 2008-10 2011-13 2014-17

Deat

hs P

er 1

00,0

00 L

ive

Birt

hs

Birth Year

No Prior CesareanFirst Birth




1.5

5.3

1.1

6.7

11.6

8.8

0

2

4

6

8

10

12

14

1999-01 2002-04 2005-07 2008-10 2011-13 2014-17

Deat

hs P

er 1

00,0

00 L

ive

Birt

hs

Birth Year

Prior CesareanNo Prior CesareanFirst Birth

Our Practice Is Our Passion54

0%

10%

20%

30%

40%

50%

60%

70%

80%

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101

105

109

113

Range: 13.37—59.8%Median: 28.7%Mean: 29.9%

2018 NTSV Cesarean Rates, 115 FL Hospitals

Source: FL Vital Records, 2018

National Target =23.9%

Joint Commission Reporting >30.0%

55

Provide 1.0/2.042 Hospitals

56

Provide 2.034 Hospitals


FPQC Initiative Resources

Online Tool BoxAlgorithms, Sample protocols, Maternal education

tools, Slide sets, etc.

Custom, Personalized webcam, phone, or on-site Consultations & Grand

Rounds Education

Monthly and Quarterly QI Data Reports

Educational sessions,

videos, and resources

Project-wide in-person

collaboration meetings

Monthly e-mail Bulletins

Technical Assistance

from FPQC staff, state

Clinical Advisors, and National

Experts

Monthly Collaboration

Calls with hospitals

state-wide

57

59

Bishop's Score CalculationParameter 0 1 2 3Dilation (cm) 0 1 - 2 3 - 4 5 - 6Effacement, % 0 - 30 40 - 50 60 - 70 80Station (-3 to +3) - 3 -2 -1, 0 +1Consistency Firm Medium SoftPosition Posterior Middle AnteriorACOG Patient Safety Checklist No. 5; December, 2011

≥≥

Cervical ripening

Mechanical (foleybulb or Cook ripeningcatheter)

Prostaglandin(prostaglandin E2 ormisoprostol with orwithout mechanical)

Repeat if unfavorable

Consider cesarean delivery forfailed induction of labor when:

Latent labor (< 6 cm) exceeds 24 hoursand preferably

At least 12 - 18 hours of oxytocinadministration following amniotomy

(Maternal-fetal conditions permitting)

If labor does notoccur and

delivery indicated

Favorable Cervix(Bishop's score)

Nulliparity 8Multiparity 6

≥≥

Induction of labor algorithm(adapted from Obstetric Care Consensus. Safe Prevention of the Primary Cesarean Delivery.

March, 2014. Number 1)

Bishop's scoreunfavorable after at

least 2 ripeningattempts, consider

either:

Trial ofoxytocin

Consider discharge home if:

Contractions are minimal intensityIntact fetal membranesStable maternal and fetal condition

Reschedule within 24 to 48 hours, if needed

Choice 2

Choice 1

Nulliparous Multiparous(informational only)

Early labor (3to 6 cm)

Median 3.9 h Median 2.295% 17.7 h 95% 10.7 h

Consider cesarean delivery for active labor arrestwhen at least 6 cm and:

4 hours: no cervical change & adequate contractions,6 hours: no cervical change & inadeqate contractions

(Maternal-fetal conditions permitting)Zhang Obstet Gynecol 2010;116:1281-7 and Spong

Obstet Gynecol 2012;120:1181-93)

YesNo

Oxytocin induction

Titrate slowly usinglowest effective doseto achieve regularcontractions andcervical change

Consider amniotomywhen labor progressesslower than 95% (seebox for normal labor)

Maternal or fetal indications fordelivery

(ACOG Committee Opinion, No. 560, 2013)

As per ACOG recommendations,perform induction of labor before 41

weeks when a maternal or fetalindication exists. When none exists,

proceed with a favorable cervical exam.Obstetric Issues

Premature rupture of membranes

Pregnancy at or beyond 41 weeks

Pregnancy between 39 and 41 weeks

with favorable cervixMaternal Issues

Essential hypertension

Diabetes mellitus

Gestational HypertensionFetal Issues

Growth restriction, singleton or multiple

Multiple gestation

OligohydramniosThis is a simplified table adapted for this

algorithm. Please see accompanyingcompanion checklist for additional

indications for delivery.

Informational only, focus isnulliparous patient


Quality ImprovementThe Framework for QI

60

What are we trying to accomplish?

How will we know that a change is an

improvement?

What change can we make that will result

in improvement?

Associates in Process Improvement: Model for Improvement

Plan Do

Act Study

Our Practice Is Our Passion61

Enro

llmen

t

PROVIDE Baseline

NON-PROVIDE Baseline


Conclusions

• U.S. and Florida are having a maternal mortality crisis: High rates and no improving.

• There are better ways in the US to measure maternal mortality.

• State pregnancy mortality reviews provide valuable information in reducing mortality and morbidity.

• Quality of health care contributes to these deaths.• State-wide quality improvement initiatives can assist

in reducing mortality and morbidity.


Save the Date: April 16-17, TampaFPQC 2020 Conference• Reducing Cesarean Deliveries – Elliott Main, MD

Clinical Professor, Obstetrics & Gynecology-Maternal Fetal Medicine, Stanford University; Medical Director, California Maternal Quality Care Collaborative

• Antibiotic Stewardship – Martin J. McCaffrey, MDProfessor, University of North Carolina; Director, Perinatal Quality Collaborative of North Carolina

• Shared Decision-Making in Perinatal Care – Neel Shah, MD, MPP, FACOG

Assistant Professor, Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School; Director, Delivery Decisions Initiative

For More Information, go to www.fpqc.org

http://www.fpqc.org/

Maternal Mortality - Healthy Start Coalition of Miami-Dade...Maternal Mortality: Death of a woman...

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