Transcript Slide 1

Putting the “M”
Back in MFM
AGOS Annual Meeting
September 14, 2012
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
World Bank
United Nations
 2000, United Nations' 8 Millennium
Development Goals
Target #5: Reduce the maternal mortality
ratio
ratio by 75% from 1990-2015
United Nations General Assembly. United Nations millennium declaration. A/RES/55/2. New York
(NY): United Nations, 2000.
Global Maternal Mortality:
Progress
 Comprehensive analysis funded by Bill and
Melinda Gates Foundation
 Estimates of global maternal deaths:
526,300 in 1980  324,900 in 2008
 Yearly rate of decline of global MMR since 1990
was 1.3%
 Gates' pledge of $1.5 billion toward maternal,
newborn, and child health over 5 years
Hogan MC, et al. Lancet 2010.
Yearly Rate of Change in
Maternal Mortality Ratio,1990–2008
Hogan MC, et al. Lancet 2010.
US Maternal Mortality Ratio:
What is the Trend?
 Several other 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 36:2-6
Calling Attention to Maternal
Mortality in the US
Amnesty International
Report, 2010:
 Maternal Mortality Ratio
in 2005
38.7 per 100,000
for non-Hispanic,
African-American women
vs.
10.7 per 100,000
for white women
Calling Attention to Maternal
Mortality in the US
The Joint
Commission 2010:
Preventing
Maternal Death
 Initiatives to decrease maternal mortality
• case reporting and review
• team training and drills
• thromboembolism prophylaxis
Safe Motherhood Initiative
Morbidity During Delivery
Hospitalizations
 Reviewed national hospital discharge survey
1991-2003
• 432,000 records representing 50.6 million deliveries
 Severe morbidity 5.1 per 1,000 deliveries
• Hysterectomy, transfusion, or eclampsia
• Risk factors: Extremes of age, black race
• Severe morbidity 50 x more common than death
 Impacts 20,000 - 30,000 women each year
Callaghan WM et al. AJOG 2008.
The Burden of
Maternal Morbidity
“A review of the more
common causes of
severe maternal
morbidity is likely to
provide a more clinically
relevant measure of the
standard of maternal
care.”
Professor Thomas F. Baskett, MB
Best Prac Res in Clin Ob Gynaecol, 2008
Factors Increasing Maternal
Mortality and Morbidity
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Maternal age
Obesity
Cesarean delivery
More pregnancies in women with significant
chronic medical conditions
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Hypertension
Pregestational diabetes
Congenital heart disease
Organ transplant
US Pregnancy-Related
Mortality
35
Mortality (%)
30
25
20
15
10
5
0
Berg CJ et al. Obstet Gynecol 2010.
MFM: The Historical
Perspective
 1970: MFM is a subspecialty of OB/GYN
 1974: The first MFM board certification exam
 1977: The Society for Perinatal Obstetricians
(now SMFM) was founded
 Today: SMFM consists of more than 2,300
active members and ~ 100 MFM fellows
graduate each year
Advances in Fetal and
Neonatal Medicine
 Prenatal diagnosis and screening programs
• Genetic disorders and congenital anomalies
 Near eradication of Rh disease
 Therapies for women at high risk for PTB
• steroids, antibiotics for PPROM, magnesium
 Progesterone to decrease recurrent PTB
 Reduction of stillbirth
 Fetal therapy
• TTTS, NAIT, myelomeningocele
Changes in Modern
Obstetrical Practice
 Significant decrease in rate of operative
vaginal deliveries
 Near-extinction of vaginal breech deliveries
 Generalists and laborists managing labor and
delivery
 Increased reliance on medical subspecialists
to manage chronic disease in pregnancy
 Increased utilization of GYN oncologists to
assist in complicated obstetrical surgery
 7 MFMs certified in critical care
Where are the MFMs?
 There appears to be an increase in the
popularity of consultative MFM practice
• Predictability of hours and part-time
availability
• Reimbursement differential between fetal
and maternal medicine
• Wide differential in malpractice burden
between outpatient and inpatient services
Measuring Generalists'
Satisfaction with MFM Specialists
 Majority (68%) report satisfaction
 Majority would consult or co-manage with
MFM specialist for 26 of 38 specific maternal,
fetal & obstetric diagnoses/complications
 31% reported dissatisfaction with MFMs:
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Lack of availability (49%)
Lack of daytime availability (26%)
Lack of nighttime availability (35%)
MFM practice limited to diagnostic testing (32%)
Wenstrom K, Am J Perinatol 2012
A Call to Action
What are we doing to reduce
maternal mortality and
morbidity in a maternal
population with an
increasing incidence of
chronic disease?
D’Alton ME, Obstet Gynecol 2010;116:1401–4
Where is the M in MFM?
Feedback
"Residency programs should have more
practicing CLINICIANS to teach the young
residents obstetrics, and not MFM consultants,
who spend the entire day in the office doing
sonos. We are good in detecting anomalies but
when it comes to everyday obstetrics we have
lost our common sense!"
Louis Kokkinakos, MD, Columbia, MD
Where is the M in MFM?
Feedback
"I wonder what will happen in another decade
when it will be very rare to have hospitalbased MFM physicians and most are officebased, consultative physicians who are not
skilled or available in the middle of the night.
If we are to put the ‘M’ back into MFM, I think
it has to start with the academic leaders and
we need to select fellows who will be
committed to this approach…”
Dana P. Damron, MD, MFM, Billings, MT
MFM Think Tank 2012:
The Participants
Sponsor:
MFM Think Tank 2012:
The Participants
 Richard Berkowitz  Larry Gilstrap
 Stephanie Martin
 Clarissa Bonanno
 Bill Grobman
 Kate Menard
 Haywood Brown
 Gary Hankins
 Dan O’Keefe
 Josh Copel
 John Hauth
 Luis Pacheco
 Gary Cunningham  Brian Iriye
 Laura Riley
 Mary D’Alton
 George Macones
 George Saade
 Tom Garite
 Jim Martin
 Cathy Spong
MFM Think Tank 2012:
The Objectives
 Organized, national approach to decrease
maternal mortality and morbidity in the US
• Enhance the training in maternal care for
residents and fellows
• Improve medical care and management of
pregnant women
• Address the critical research gaps in maternal
medicine
Evolution of
MFM Training
 1970s: inception of 2-year Fellowship training
program
 1996: Expansion of MFM Fellowship to 3 years
to include mandatory research training
 Residency work hour restrictions
• 80 hours week (2003)
• 16 hour shifts (2011)
Challenges in Ob/Gyn
Residency Training
Advances in medical knowledge
Accelerating adoption of technology
Increasing restrictions on
resident duty hours
MORE TO LEARN IN LESS TIME
Current MFM
Fellowship Requirements
 12 months clinical
rotations
 18 months research
activities
 6 months elective time
MFM Fellowship Training:
Recommendations
 Modification of MFM Fellowship requirements
to include:
• 18 months of CLINICAL rotations
• 12 months research
• 6 months elective
 Inclusion of mandatory rotations
• Labor and Delivery/Inpatient Obstetrical Services
4 months
• Intensive Care Units 2 months
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
MFM Fellowship Training:
ABOG's Response
Modified 2013 requirements to increase
requirements for:
 Clinical rotations - 15 months
• L& D/Inpatient Services rotation - 2 months
• ICU rotation - 1 month
 Research - 12 months
 Elective - 9 months
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
MFM Fellowship Training:
Recommendations
 Increase in simulation and case-based
learning methodologies
 Certification in Advanced Cardiac Life Support
(ACLS)
 Development subspecialty-specific, in-service
exam for fellowship trainees
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
MFM Think Tank 2012:
Obstetrical Care and Services
 High risk women:
• Timely identification and referral of patients
for tertiary care
 Low risk women:
• Comprehensive national effort to educate
all providers on the prevention and
treatment of obstetrical complications
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
NUMBERS OF HOSPITALS
Annual Birth Volume
in U.S. Hospitals, 2008
n = 3,265
Simpson KR, JOGNN 40, 2011
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
Comprehensive National Effort
 Standard protocols
 Saving Mothers Lives, U.K.
Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. Eighth Report, Confidential Enquiries
into Maternal Deaths in the United Kingdom, BJOG Volume 118, Issue Supplements 2011
• National confidential enquiry system
into maternal deaths published
every 3 years
• Goal to identify remediable factors
to address in guidelines created by
national organizations
Recommended Guidelines
 Urgent development of national
management guidelines:
• Hypertensive disorders in pregnancy
• Postpartum hemorrhage
• Prevention of venous thromboembolism
• Diagnosis and management of placenta accreta
• Management of the obese obstetrical patient
• Management of cardiac disease in pregnancy
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
ACOG Presidential
Initiative 2011-2012
 Preeclampsia
• Summarize the
current state of
knowledge
• Develop practice
guidelines and
checklists for
“Best Practices”
• Identify the most compelling areas for research
Coming Soon From ACOG
 Executive summary of Hypertension
in Pregnancy Working Group
• Upcoming in Obstetrics & Gynecology
 Downloadable protocols
 Updates on new research findings
 Efforts at global consensus guidelines
The Relevance of Protocols
 National Protocols for Maternal Medicine
• Should be derived from evidence-based
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data
Define the standard of care
Minimize variability
Reduce the need to rely on memory
Enhance patient safety
Reduce duplication of effort
Obstetrical Care and Service
 Toward Improving the Outcome of Pregnancy 1976:
Recommendation for the Development of Maternal
and Perinatal Health Services
• Stratified maternal and neonatal care into 3 levels of
complexity: Basic, Specialty & Subspecialty
“. . . it was recognized that to make optimal maternal, fetal
and perinatal care appropriate to the needs of each patient
available to all, the systems approach is essential.”
Obstetrical Care and Service
 Toward Improving the Outcome
of Pregnancy II, 1993: Perinatal
Regionalization Revisited
March of Dimes
 Toward Improving the Outcome
of Pregnancy III, Enhancing
Perinatal Health Through Quality,
Safety and Performance
Initiatives, 2010, March of Dimes
Regionalized Perinatal Care
 Became synonymous with Regionalized
Neonatal Care
 Priority became transfer of women at risk for
delivering neonates with higher care
requirements
 Erroneously assumed that institutions with
Level 3 NICU capabilities were equipped to
care for any maternal medical condition
Obstetrical Care and
Service: Recommendations
 Establish a system for "levels" of maternal care
 Levels of care designated nationally by a single
entity
• Facilitate consistent definitions and standards at
each level
• More informative for physicians and patients
making health care decisions
• Better comparisons of outcomes, resource
utilization, and cost
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
Role of MFM Physicians
 MFM Physicians must take the lead in caring for
medically compromised obstetrical patients
 MFMs have unique expertise in medical and
surgical complications as they relate to
pregnancy and the fetus
To lead the care team,
MFM physicians must be available for
inpatient service
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
Maternal Medicine Physicians
 Majority of time spent in caring for
obstetrical patients with medical problems.
 Act as consultants
 Lead teams that focus on multidisciplinary
care, practice guidelines for safety and
quality related to maternal care
 Be role models for MFM fellows in training
“Putting the ‘M’ Back in Maternal-Fetal Medicine”
Obstetrical Care and Service:
Recommendations
 Incentivize MFM physicians to care for
pregnant women with medical problems:
• Recognition of the importance of maternal
experts by the medical community
• Offer training in practice management and
leadership skills
• Creation of pathways for academic promotion
• Provision of adequate financial compensation
Research Recommendations
1. Develop standardized methods for national
surveillance of maternal mortality
2. Define significant maternal morbidity and
“near misses”
3. Determine appropriate patients for transfer
to level III care
4. Research impact of adverse pregnancy
outcomes on long-term maternal health
NICHD MFM Units Networks
Fourteen U.S.
university-based
clinical centers
focus on clinical
questions in MFM
and obstetrics, in
particular the
continuing problem
of preterm birth.
The Gap Between
Knowing and Doing
“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
28% - 40% of
pregnancyrelated deaths
potentially
preventable
Clark SL, Am J Obstet Gynecol 2008
Berg CJ, Obstet Gynecol 2005,
Organized
National
Response
Putting the “M”
Back in MFM
AGOS Annual Meeting
September 14, 2012