Transcript Maternal Mortality: What are the causes???

Maternal Deaths – Call for concern
for Health Providers
June Hanke, RN MSN MPH
A Human Rights Issue
Women have a human right to safe
pregnancy and childbirth.
Ms. Elisabetta Farina http://www.womencreatelife.org/
A Sentinel Event
• January of 2010 Joint commission
identified maternal mortality as a Sentinel
Event
• Joint Commission suggested actions
• Each case of maternal death needs to be identified, reviewed, and
reported in order to develop effective strategies for preventing pregnancyrelated mortality and severe morbidity. To this end, The Joint
Commission encourages participation by hospital physicians, including
obstetrician-gynecologists, in state-level maternal mortality review and
collaboration with such review committees in sharing data and records
needed for review. The following suggested actions can help hospitals
and providers prevent maternal death:
Joint Commission Sentinel event Alert January 26, 2010 http://www.jointcommission.org/assets/1/18/SEA_44.PDF
Local Collaborative
Calculating Maternal Deaths
Maternal Mortality - Deaths/100,000 live births during pregnancy
or within 42 days of delivery. A ratio not a rate: cannot count
total # pregnancies. Pregnancy related ratios are deaths within 1
year.
Pregnancy
Associated
Pregnancy
Related OB
complications,
management, or
disease exacerbated
by pregnancy
Direct
OB diseases or
management
Not related to pregnancy
Indirect
Preexisting disease
aggravated by pregnancy
http://www.who.int/gho/maternal_health/en/
US MMR 2003-2007
Data Source: CDC Wonder Database 2010
Data Source: CDC Wonder Data base 2010
We need to know WHY to be able to address the causes
Why is Maternal Mortality Rising?
• Improved vital statistics
• Increasing age or increasing prevalence of
maternal chronic conditions
– Hypertension
– Diabetes
– Obesity
• Social factors
• Factors related to health care system &
access to quality care
Harris County Causes
• 2008
– No deaths from Hemorrhage or obstetrical
embolism, ectopic pregnancy or abortion.
– DVT, Cardiomyopathy.
– Mostly can’t determine from coding available.
– 33% after 42 days of delivery
Other states
• New York: 2002-2003
– Embolism
– Hemorrhage
– Hypertension
• Florida: 2009
– 25.9% Infection (87%
included Flu like
symptoms - 58% NIH1)
– 20.7% Hemorrhage
– 12.1 Cardiovascular
– other
HB1133 MMMRB
• Legislation proposed by Rep Walle and
coauthored by Rep Farrar
• Heard in Public Health Committee – failed to
received required votes.
• Currently in special Study status
• Multi disciplinary review board
• Information de-identified using HIPPA
standards, confidentiality expected, identifies
requirements for reporting results.
• Review board work is not subject to subpoena
or discovery
What do we learn from Maternal Mortality Morbidity Review
Boards
California- leading causes of Pregnancy
related death
•Before review
– 17% Preeclampsia
/eclampsia
– 15% Hemorrhage
– 14% Amniotic Fluid
embolism
– 7% Sepsis/infection
– 6% Venous embolism
complications
– 41% Other
complications
• After review
– 20% Cardiovascular
disease
– 15% Preeclampsia /
eclampsia
– 14% Amniotic Fluid
embolism
– 10% Obstetrical
Hemorrhage
– 8% Sepsis / infection
California Pregnancy associated mortality review Report from 2002 and 2003 death reviews, April 2011
Risk Factors for PRMM
Florida 1999-2008
• Being obese class III (morbidly obese) (BMI
of 40.0 or +) (RR 9.0).
• Not receiving any prenatal care (RR 6.9).
• Having a cesarean delivery (RR 4.6).
• Being 35 years or older (RR 4.1).
• Having less than a high school degree (RR
3.7).
• Black race (RR 3.3)
• Other risk factor – Chronic Disease
Timing of Maternal Deaths
• California:
– 93 % of deaths within 6 weeks postpartum
• Florida:
– 17 % prenatal
– 6 % L&D
– 42% Postpartum not discharged
– 35% Postpartum discharged
Insurance coverage
• California:
– Of women who died that were covered by
MediCal, 11% died after 42 days.
– No deaths occurred after 42 days for women
with private insurance.
Infant deaths
• In California of the 98 pregnancy related
deaths – there were 9 fetal deaths and 7
infant deaths.
• That is in 16 % of these maternal deaths
the baby also died.
Maternal Morbidity
• Maternal Mortality is a sentinel event for
maternal morbidity.
• Severe morbidity can effect a woman’s life
long wellbeing.
• For every one maternal death there are
approximately 50 women who experience
severe morbidity.
• In 2008:
– Harris County 1,350 women affected
– Texas 4,500 women affected
Callaghan, WM, Mackey AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 19912003. American J Obstet Gynecol 2008: 199:133e1-133e8.
Financial Costs
• To family
• To community
– Financial cost of premature death, 3 – 5 million / woman
• To Medical system
– Mother’s pregnancy and delivery most expensive condition
treated in US hospitals in 2008
– Rising C-Section rate = increased costs
– High blood pressure in pregnancy associated with 3.5 days
average stay, and average total cost $9,800/stay vs. $5,774
for normal delivery.
– California:1996 -2006 PP hemorrhage increased 36% and
increased expenditures of $3,277 per woman affected
The National Hospital Bill: The Most Expensive Conditions by Payer, 2008, H-CUP Statistical brief #107, March 2011 Agency for Healthcare Research and Quality
Rockville MD: The California associated mortality review. Report from 2002-2003 Maternal death reviews April 2011 California Department of Public Health.
Cost of MMMRB
• An initial budget of $150,000 - $350,000
should be considered to cover staffing,
meeting expenses (including travel/meal
reimbursement), and database
management and data abstraction for
mortality review board.
Estes, L. (2011). Maternal mortality in texas: 2001-2006 (Doctoral dissertation). Available from Proquest. (3464795)
Texas Needs MMMRB
• Need Maternal Mortality Morbidity Review
Board to understand what the reasons for
maternal mortality and morbidity are in
Texas
• Preventable deaths: 40 - 75 %
Changes after Maternal Mortality reviews
Why Mothers Die 1997 - 1999, CEMD
Working with the Healthcare Community
• NY Maternal Mortality Review Committee
• Hemorrhage alert letter
• Point of care tools to prevent hemorrhage
mortality
•
• Hemorrhage poster
• Educational slide sets
Institutional Systemic Approaches to Hemorrhage
• Hemorrhage drills
• Organized response team for unanticipated blood
loss
• Ob, Anesthesiology, Blood Bank, Nursing, other
staff
30
Poster for Labor and
Delivery and Operating
Rooms
31
Who supports MMMRB for Texas
• The American Congress of Obstetrics and
Gynecologists (ACOG)
• Texas Association of Obstetricians and Gynecologists
(TAOG)
• Association of Women, Obstetric and Neonatal Nursing
• Childbirth Connections
• Association of Texas Midwives
• Doctors for Change – Houston
• Texas Medical Center – Women’s Health Network
• Greater Houston Partnership
What are we doing about it
nationally?
Federal bill HR 894 Maternal Health
Accountability Bill of 2011