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AGOS Annual Meeting September 14, 2012

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

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AGOS Annual Meeting September 14, 2012

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  1. Putting the “M” Back in MFM AGOS Annual Meeting September 14, 2012

  2. 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

  3. International Movement to Reduce Maternal Mortality • 1987, Global Safe Motherhood Conference, Nairobi, Kenya • 2000, United Nations' 8 Millennium Development Goals Target #5: Reduce the maternal mortality ratio ratio by 75% from 1990-2015 World Bank United Nations United Nations General Assembly. United Nations millennium declaration. A/RES/55/2. New York (NY): United Nations, 2000.

  4. 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.

  5. Yearly Rate of Change in Maternal Mortality Ratio,1990–2008 Hogan MC, et al. Lancet 2010.

  6. 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. ObstetGynecol 2010, Callaghan WM, SeminPerinatol 36:2-6

  7. Calling Attention to Maternal Mortality in the US Amnesty International Report, 2010: • Maternal Mortality Ratio in 2005 38.7 per100,000 for non-Hispanic, African-American women vs. 10.7 per100,000 for white women

  8. 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

  9. Safe Motherhood Initiative

  10. 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.

  11. 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

  12. Factors Increasing Maternal Mortality and Morbidity • Maternal age • Obesity • Cesarean delivery • More pregnancies in women with significant chronic medical conditions • Hypertension • Pregestational diabetes • Congenital heart disease • Organ transplant

  13. US Pregnancy-Related Mortality 35 Mortality (%) 30 25 20 15 10 5 0 Infection Cardiovasular conditions Cerebrovascular accident Hemorrhage Anesthesia Noncardiovascular medical conditions Thrombotic pulmonary embolism Amniotic fluid embolism Hypertensive disorders of pregnancy Cardiomyopathy Berg CJ et al. Obstet Gynecol 2010.

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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: • 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

  19. A Call to Action

  20. 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

  21. 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

  22. Where is the M in MFM?Feedback "I wonder what will happen in another decade when it will be very rare to have hospital-based MFM physicians and most are office-based, 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

  23. MFM Think Tank 2012: The Participants Sponsor:

  24. MFM Think Tank 2012: The Participants • Richard Berkowitz • Clarissa Bonanno • Haywood Brown • Josh Copel • Gary Cunningham • Mary D’Alton • Tom Garite • Larry Gilstrap • Bill Grobman • Gary Hankins • John Hauth • Brian Iriye • George Macones • Jim Martin • Stephanie Martin • Kate Menard • Dan O’Keefe • Luis Pacheco • Laura Riley • George Saade • Cathy Spong

  25. 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

  26. 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)

  27. 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

  28. Current MFM Fellowship Requirements 12 months clinical rotations 18 months research activities 6 months elective time

  29. 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”

  30. MFM Fellowship Training:ABOG's Response Modified 2013 requirements to increase requirements for: • Clinical rotations - 15months • 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”

  31. 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”

  32. 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”

  33. Annual Birth Volume in U.S. Hospitals, 2008 NUMBERS OF HOSPITALS n = 3,265 Simpson KR, JOGNN 40, 2011

  34. 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

  35. 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

  36. 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”

  37. Summarize the current state of knowledge Develop practice guidelines and checklists for “Best Practices” ACOG Presidential Initiative 2011-2012 • Preeclampsia • Identify the most compelling areas for research

  38. 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

  39. The Relevance of Protocols • National Protocols for Maternal Medicine • Should be derived from evidence-based data • Define the standard of care • Minimize variability • Reduce the need to rely on memory • Enhance patient safety • Reduce duplication of effort

  40. 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.”

  41. 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

  42. 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

  43. 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”

  44. 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”

  45. 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”

  46. 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

  47. Research Recommendations • Develop standardized methods for national surveillance of maternal mortality • Define significant maternal morbidity and “near misses” • Determine appropriate patients for transfer to level III care • Research impact of adverse pregnancy outcomes on long-term maternal health

  48. 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.

  49. 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 pregnancy-related deaths potentially preventable Clark SL, Am J Obstet Gynecol 2008 Berg CJ, Obstet Gynecol 2005, Organized National Response

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