Preventing Maternal Morbidity and Mortality In Texas

1. Preventing Maternal Morbidity and Mortality In Texas Lisa M. Hollier, MD, MPH Professor, Obstetrics & Gynecology Baylor College of Medicine

2. Financial Disclosure Lisa M. Hollier, MD, has no relevant financial relationships with commercial interests to disclose.

3. Acknowledgements • Sonia Baeva • Office of Program Decision Support • Department of State Health Services • Members of the Texas Maternal Mortality and Morbidity Task Force

4. Learning Objectives At the completion of this session, the participants will be able to: • Discuss the most common causes and contributing factors to pregnancy-related death in Texas. • Identify causes of severe maternal morbidity • Implement local solutions to reduce maternal mortality and morbidity

5. Definitions of Maternal Death • CDC / ACOG • pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of pregnancy termination–regardless of the duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. • CDC / ACOG • Pregnancy-associated mortality is the death of any woman, from any cause, while pregnant or within 1 calendar year of termination of pregnancy, regardless of duration and the site of pregnancy.

6. Reviewing Maternal Death Texas MMMTF created by Senate Bill 495, 83rd legislature • Multidisciplinary task force within the Department of State Health Services (DSHS) • Tasked to: • study and review cases of pregnancy-related deaths and trends in severe maternal morbidity • determine the feasibility of the task force studying cases of severe maternal morbidity • make recommendations to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas

7. Reviewing Maternal Death Texas MMMTF amended by Senate Bill 17, 85th legislature • study and review: • trends, rates or disparities in pregnancy-related deaths • health conditions and factors that disproportionately affect the most at-risk populations • best practices and programs operating in other states that have reduced rates of pregnancy-related deaths • compare rates of pregnancy-related deaths based on socioeconomic status of the mother • consult with the Perinatal Advisory Council when making recommendations to help reduce the incidence of pregnancy related deaths and severe morbidity in this state

8. MMMTF Biennial Report 2018 https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

9. Texas Pregnancy-related Mortality • Leading underlying causes of pregnancy-related death in 2012 identified by the Task Force were: • cardiovascular and coronary conditions • obstetric hemorrhage • infection/sepsis • cardiomyopathy • preeclampsia/eclampsia, mental health conditions, and amniotic fluid embolus https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

10. Maternal Mortality by Race/Ethnicity https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

11. Preventability of PRM https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

12. Contributing Factors Top individual and family level factors contributing to death: • Underlying medical conditions • Cardiovascular conditions, including chronic hypertension • Obesity • Depression • Delay in or failure to seek care or treatment • lack of patient recognition of early warning signs of worsening condition https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

13. Contributing Factors Top Providerlevel factors contributing to death: • Failure to recognize high risk maternal health status • failure to refer high risk patients to appropriate care specialties • Failure to recognize and respond to maternal early warning signs • delay in or lack of bedside clinician presence • Delays in diagnosis • Delays in initiation of treatment • Inadequate or ineffective treatment • Lack of effective communication https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

14. Contributing Factors Top facility level factors included: • Failure to recognize high risk status • Delayed and inadequate response to clinical warning signs • Lack of continuity of care • lack of appropriate hand-off of patients between hospital staff and outpatient providers • impacted by the inability to secure appropriate outpatient care and. Top systems and community level factors included: • Poor care coordination from the inpatient to outpatient setting • Lack of access to interconception care services and transitional care services. https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

15. Maternal Deaths 2012-2015 https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

16. Maternal Deaths 2012-2015 https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

17. Maternal Deaths 2012-2015 https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

18. Maternal Deaths 2012-2015 https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

19. Top Causes of Confirmed Death: within 1 Year Following End of Pregnancy https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

20. Severe Maternal Morbidity • For every woman who dies, about 50 more suffer a severe complication. • Link between maternal mortality, particularly preventable maternal deaths, and severe maternal morbidity • Overall rate of severe maternal morbidity (SMM) increased almost 200% • From 47.6 per 10,000 in 1993–1994 to 141.6 per 10,000 in 2013–2014 • Texas SMM rate is 195 per 10,000 in 2014

21. Severe Maternal Morbidity - US

22. Severe Maternal Morbidity: Top Causes

23. Obstetric Hemorrhage Rates by Race/Ethnicity (Maternal Morbidity)

24. Rates of Obstetric Hemorrhage by County https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

25. Frequency of Obstetric Hemorrhage by County https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

26. MMMTF Recommendations 1. Increase access to health services during the year after pregnancy and throughout the interconception period to improve the health of women, facilitate continuity of care, enable effective care transitions, and promote safe birth spacing. 2. Enhance screening and appropriate referral for maternal risk conditions. 3. Prioritize care coordination and management for pregnant and postpartum women. 4. Promote a culture of safety and high reliability through implementation of best practices in birthing facilities. 5. Identify or develop and implement programs to reduce maternal mortality from cardiovascular and coronary conditions, cardiomyopathy and infection. https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

27. MMMTF Recommendations 6. Improve postpartum care management and discharge education for patients and families. 7. Increase maternal health programming to target high-risk populations, especially Black women. 8. Initiate public awareness campaigns to promote health enhancing behaviors. 9. Champion integrated care models combining physical and behavioral health services for women and families. 10. Support strategies to improve the maternal death review process. https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm

28. Time Spent in D/C Instruction Suplee PD. JOGNN 2016;45(6):894–904

29. How Likely to Discuss Suplee PD. JOGNN 2016;45(6):894–904

31. Levels of Maternal Care • The goal is for pregnant women to receive care in facilities that are appropriate to their risk, thereby reducing maternal morbidity and mortality in the United States. ACOG, Menard et al. Am J ObstetGynecol 2015, 212 (3), 259-271.

32. Levels of Maternal Care Hospital Level of Care Designation for Maternal Care ACOG, Menard et al. Am J ObstetGynecol 2015, 212 (3), 259-271.

33. National Agenda to Reduce Maternal Mortality