MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITYWHAT CAN WE DO TO PREVENT THE AVOIDABLE ?Randall J. Morgan MD MBADecember 13, 2016

Goals and objectives• Discuss trends of maternal mortality in the USA• Discuss methods to reduce maternal mortality by ½

• I have no conflict of interest

What is definition of maternal mortality ratio • Maternal death is 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. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduced: Pregnancy-related death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

• Expressed as number/100,000 births• Behind very mortality is a person/family/care givers

CDC severe maternal morbidity

Severe maternal morbidity continued (CDC)

Pregnancy-related mortality ratio.

Pregnancy-related mortality ratios by age and race and ethnicity: United States, 2006–2010.Fig. 2. Creanga. Pregnancy-Related Mortality in the United States. Obstet Gynecol 2015.

Copyright © 2016 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 8

Pregnancy-Related Mortality in the United States, 2006–2010

Creanga, Andreea A.; Berg, Cynthia J.; Syverson, Carla; Seed, Kristi; Bruce, F. Carol; Callaghan, William M.Obstetrics & Gynecology. 125(1):5-12, January 2015.doi: 10.1097/AOG.0000000000000564

Pregnancy-related mortality

Pregnancy-related mortality ratios by year and race and ethnicity: United States, 2006–2010. *Number of pregnancy-related deaths per 100,000 live births.Fig. 1. Creanga. Pregnancy-Related Mortality in the United States. Obstet Gynecol 2015.

Copyright © 2016 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 9

Pregnancy-Related Mortality in the United States, 2006–2010

Creanga, Andreea A.; Berg, Cynthia J.; Syverson, Carla; Seed, Kristi; Bruce, F. Carol; Callaghan, William M.Obstetrics & Gynecology. 125(1):5-12, January 2015.doi: 10.1097/AOG.0000000000000564

Cause-specific proportion maternal mortality.

Cause-specific proportionate pregnancy-related mortality: United States, 1987–2010.Fig. 3. Creanga. Pregnancy-Related Mortality in the United States. Obstet Gynecol 2015.

Copyright © 2016 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 13

Pregnancy-Related Mortality in the United States, 2006–2010

Creanga, Andreea A.; Berg, Cynthia J.; Syverson, Carla; Seed, Kristi; Bruce, F. Carol; Callaghan, William M.Obstetrics & Gynecology. 125(1):5-12, January 2015.doi: 10.1097/AOG.0000000000000564

Chance to alter outcome California maternal mortality

Chance to alter outcome among major causes of pregnancy-related death (n=205*), California, 2002–2005. *The California Pregnancy-Associated Mortality Review Committee was unable to determine preventability in one cardiovascular disease death and one eclampsia death. †Significantly more likely to have good-to-strong chance than cardiovascular disease deaths and amniotic fluid embolism deaths. ‡Significantly less likely to have good-to-strong chance than all causes.Fig. 3. Main. Pregnancy-Related Mortality in California. Obstet Gynecol 2015.Copyright © 2016 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 14

Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities

Main, Elliott K.; McCain, Christy L.; Morton, Christine H.; Holtby, Susan; Lawton, Elizabeth S.Obstetrics & Gynecology. 125(4):938-947, April 2015.doi: 10.1097/AOG.0000000000000746

Obstetric hemorrhage and Preeclampsia• Most common preventable causes of maternal mortality• Most common causes of severe maternal morbidity

(80%)• Financial costly• Opportunity to improve quality

• Denial• Delay

Geller et al. The Continuum of severe maternal morbidity and mortality: Factors associated with severity. Am J OB Gyn 2004; 191: 939-44

The National Safety Bundles for Hemorrhage California strategy (based on CA, NY and AWHONN)• Readiness• Recognition and prevention• Response• Reporting systems learning

The National Safety Bundle for Hemorrhage California strategy (based on CA, NY and AWHONN)• Readiness

• Every Unit• hemorrhage cart (supplies, checklist, instruction cards for

intrauterine balloons and compression stitches)• Immediate access to hemorrhage medication (kit or equivalent)• Establish a response team (who to call when help is needed-

blood bank, advanced gynecologic surgery, other support and tertiary services)

• Recognition and prevention• Response• Reporting systems learning

The National Safety Bundle for Hemorrhage California strategy (based on CA, NY and AWHONN)• Readiness• Recognition and prevention

• Every patient• Assessment of hemorrhage risk (perinatal, on

admission and at other appropriate times)• Measurement of cumulative blood loss (formal), as

quantitative as possible)• Active management of the 3rd stage (department

protocol)• Response• Reporting systems learning

The National Safety Bundle for Hemorrhage California strategy (based on CA, NY and AWHONN)• Readiness• Recognition and prevention• Response

• Every hemorrhage• Unit-standard, stage based, obstetric hemorrhage

emergency management begins with checklists• Support program for patients, families and staff for all

significant hemorrhages• Reporting systems learning

The National Safety Bundle for Hemorrhage California strategy (based on CA, NY and AWHONN)• Readiness• Recognition and prevention• Response• Reporting systems learning

• Every unit• Establish a culture of huddles for high risk patients and

past-event checklists to identify successes and opportunities

• Multidisciplinary review of serious hemorrhages for systems issues

• Monitor outcomes and process metrics in perinatal quality improvement (QI opportunities)

The National Safety Bundle for Preeclampsia California strategy (based on CA, NY and AWHONN)

• Readiness• Every unit

• Standards for early warning signs, diagnostic criteria, monitoring and treatment of severe preeclampsia/eclampsia (include order sets and algorithms)

• Unit education on protocols, unit-based drills (with post-drill debrief)• Process for timely triage and evaluation of pregnant and postpartum

women with hypertension include emergency department and outpatient areas

• Rapid access to medications used for severe hypertension/eclampsia. Medications should be stocked and immediately available on L&D and in other areas where patients may be treated. Include brief guide for administration and dosage.

• System plan fr escalation, obtaining appropriate consultation, and maternal transport, as needed.

• Recognition & Prevention

The National Safety Bundle for Preeclampsia California strategy (based on CA, NY and AWHONN)

• Readiness• Recognition & Prevention

• Every patient• Standard protocol for measurement and assessment

of BP and urine protein for all pregnant and post partum women

• Standard response to maternal early warning signs including listening to and investigating patient symptoms and assessment of labs (e.g. CBC with platelets, AST and ALT)

• Facility-wide standards for educating prenatal and postpartum women on signs and symptoms of hypertension and preeclampsia

• https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit

• Kansas and WMC• What do we need to do to prevent avoidable maternal mortality?

Contributing factors...

Contributing factors among major causes of pregnancy-related death, California, 2002–2005. Health care provider factors (A), facility factors (B), and patient factors (C).Fig. 4. Main. Pregnancy-Related Mortality in California. Obstet Gynecol 2015.

Copyright © 2016 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins. 35

Pregnancy-Related Mortality in California: Causes, Characteristics, and Improvement Opportunities

Main, Elliott K.; McCain, Christy L.; Morton, Christine H.; Holtby, Susan; Lawton, Elizabeth S.Obstetrics & Gynecology. 125(4):938-947, April 2015.doi: 10.1097/AOG.0000000000000746