Virginia Maternal Mortality Review – From Case Review to Action

1. Virginia Maternal Mortality Review – From Case Review to Action Melanie J. Rouse, PhD., CoordinatorMaternal Mortality Review TeamVirginia Department of HealthOffice of the Chief Medical Examiner

2. Historical Perspective • Maternal death review dates to 1928 in Virginia. • Collaboration between the Medical Society of Virginia and Virginia Department of Health. • Early reviews focused on medical issues and natural deaths. • Lack of funding and support: review activities declined in 1990s.

3. Historical Perspective (cont.) • Throughout the 1900’s, the maternal mortality rate declined significantly: • Principles of asepsis were instituted • Shift from home to hospital deliveries • Institutional practice guidelines and guidelines defining physician qualifications for hospital delivery privileges • Use of antibiotics • Safer blood transfusions • Better management of hypertensive disorders of pregnancy

4. Challenge for the 21st Century • In 2002, re-established maternal mortality review by … • Developing a partnership within VDH between Office of Family Health Services and the Office of the Chief Medical Examiner. • Funding provided through Title V monies. • Establishing a statewide multidisciplinary team. • Adding violent deaths to reviews. • Reviewing deaths in the spirit of public health and injury and death prevention.

5. Current Team Membership Virginia Chapters of … • American College of Nurse Midwives • American College of Obstetricians and Gynecologists • National Association of Social Workers • Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) • Virginia College of Emergency Room Physicians Virginia Department of Health … • Family Health Services • Office of Chief Medical Examiner • Women’s and Infant’s Health Medical Society of Virginia Virginia Hospital and Healthcare Association The Virginia Sexual and Domestic Violence Action Alliance Virginia Academy of Nutrition and Dietetics Virginia Department of Behavioral Health and Developmental Services Virginia Department of Social Services Virginia Department of Medical Assistance Services Pharmacy Psychiatry

6. Team Purpose • understand the causes of maternal death. • educate colleagues and policymakers about these deaths and the need for changes. • recommend improvements for prevention.

7. Case Definition Pregnancy-Associated Maternal Death (PAD): All deaths of women occurring during pregnancy or within one year of termination of pregnancy. • Regardless of cause of death. • Regardless of outcome of pregnancy.

8. Case Identification • ICD 10 Code: Pregnancy-related death. • Vital records match: Fetal death certificate or birth certificate with maternal death certificate. • Death certificate check box: In Virginia, woman was pregnant within 365 days of her death.

9. Preparation for Case Review • Office of Health Statistics provides death certificates and birth/fetal death certificates to Women’s and Infants’ Health who then provides them to the Team Coordinator. • Record collection begins with information on those certificates: • Hospital where death occurred • Hospital where birth occurred • Birth Attendant

10. Case Summary The Team Coordinator prepares a de-identified, narrative case summary which includes medical, surgical, and psychiatric history; family history; social history; obstetrical history; prenatal care; delivery; events of death, pathological/toxicological findings and law enforcement involvement.

11. Case Review - three primary questions • Was this death pregnancy-related? • Was this death preventable? • What factors contributed to the death and what reasonable changes could have been made to alter the outcome?

12. Preventable? Preventable death is broadly defined as a death that may have been averted by one or more changes in: • clinical care • facility infrastructure • community • systems response to patient factors These determinations were made with the benefit of retrospective review and current clinical practice guidelines.

13. Identification of Risk Factors • After review of all deaths occurring during a calendar year, aggregate data is compiled and presented to the Team. This includes: • Narrative description of characteristics of all cases. • Aggregate data on factors determined to have contributed to the deaths. • Qualitative list of ideas for prevention and intervention generated from all cases reviewed.

14. Policy Influenced by Data and Team Recommendations • Aggregate data is used to establish priorities for programming and funding. “For every maternal death, approximately 50 women experience severe morbidity ~20,000 women/year.”* *Callaghan, W.M., MacKay, A.P. & Berg, C.J. (2008) Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. AJOG, 199, 133.

15. Report: Chronic Disease in Pregnancy Associate Deaths in Virginia, 1999-2012: Need for Coordination of Care • Purpose: • To examine the prevalence of chronic diseases and co-morbidities in cases of PAD • To identify gaps in the coordination of care received by pregnant women during the prenatal, perinatal and postpartum period • To identify areas in which improvements can be made in the management of and coordination of care for pregnant women with chronic diseases

16. Chronic Disease Categories • Cardiovascular Diseases • Chronic Infectious diseases • Chronic Mental Illnesses • Chronic Substance Abuse • Collagen-Vascular Diseases • Endocrine Disorders • Gastrointestinal Diseases • Genital Diseases • Hematologic Malignancies • Neoplasia • Neuromuscular Diseases • Pulmonary Diseases • Urinary Diseases

17. Demographic Differences Between women with chronic diseases and those without • Maternal Mortality Ratios were significantly higher among women with a chronic disease. • For both groups, White women died more frequently, however, the maternal mortality ratio for Black women was significantly higher • Over 42% of those with a chronic condition were aged 30 and older compared to 27.9% of those without a chronic condition • The Eastern Health Planning Region had the maternal mortality ratio for both groups • The maternal mortality ratio for women with a chronic disease in the Eastern Health Planning region was over twice as high as it was for women without a chronic disease (60.5 vs 25.3) • Over half the women with a chronic condition were on Medicaid (45.1%) or self-pay (5.9%).

18. Differences on Key Pregnancy-Risk Factors by Chronic Disease Status

19. Prevalence of Chronic Diseases

20. Demographic Variables Among Women with a Chronic Disease by Chronic Disease Category • Overall, average age ranged from 27 to 30 for each chronic disease category • Women with a cardiovascular disease had a higher percentage with advanced maternal age (35% ages 35 and older) • Black women were the most common race for women with infectious diseases, hematologic malignancies, pulmonary diseases and urinary diseases • The Eastern Health Planning Region had the highest percentage of cardiovascular disease, endocrine disorders, gastrointestinal diseases, hematologic malignancies, neoplasia, neuromuscular diseases and pulmonary diseases • The Central Health Planning Region had the highest percentage of infectious diseases, chronic mental illnesses, substance abuse and urinary diseases • Women with collagen-vascular diseases, hematologic malignancies, neoplasia and urinary diseases had a higher percentage with private insurance • Women with infectious diseases, chronic mental illnesses, substance abuse, neuromuscular diseases and pulmonary diseases had a higher percentage with Medicaid.

21. Manner, Cause of Death, Identified Substance Misuse Risk and Obesity by Chronic Disease Category • The most common manner of death was natural death for all chronic disease categories except chronic substance abuse. • Women who were chronic substance abusers were more likely to die an accidental death. • Cardiac disorder was the most common cause of death for women with cardiovascular diseases, collagen-vascular diseases, endocrine disorders, gastrointestinal diseases, hematologic malignancies and urinary diseases. • Accidental overdose was the most common cause of death for women with chronic mental illnesses, neuromuscular diseases, pulmonary diseases and chronic substance abuse. • The chronic disease contributed to the death of over 50% of women with a cardiovascular disease, infectious disease, chronic substance abuse, collagen-vascular diseases and neoplasia. • Over 50% of women with a cardiovascular disease, endocrine disorder, hematologic malignancy and/or pulmonary disease were obese. Nearly 5% of women with a cardiovascular disease and 7% of women with an endocrine disorder were considered super obese (BMI ≥ 50.0).

22. Contributors to Mortality: Facility-Related Factors

23. Contributors to Mortality: Community-Related Factors

24. Contributors to Mortality: Provider-Related Factors

25. Coordination of Care in Pregnant Women with Chronic Diseases • Care coordination can contribute to PAD in several ways, including: • Lack of coordination in patient management between providers • Breakdowns in communication between providers • Absence of policies and procedures that facilitate coordination of care • Failures to seek consultations and/or referrals

26. Provider Utilization prior to pregnancy

27. Referrals During Pregnancy

28. Summary and Conclusions • The data shows that incomplete healthcare coverage outside of pregnancy (prior to becoming pregnant and after the postpartum period) is contributing to maternal mortality in Virginia. • This report highlights a lack of provider utilization for the management of chronic diseases prior to pregnancy and a lack of referrals to specialists during pregnancy among these women. • Team reviews of these cases showed that many women were often treated in Emergency Departments and were then left to navigate referrals and other services on their own with little to no coordination of care. • Team reviews also found that several community-, facility-, and provider-related factors contributed to these deaths.

29. Summary and Conclusions • 44% of these cases were found to have a provider-related factor contribute to their death. • A provider-related Failure to Refer or Seek Consultation was the most prevalent provider-related factor in this group. Percent

30. Opportunities for the Prevention of PAD among Women with Chronic Diseases and Improvement of Coordination of Care • Requires both a refined approach to the clinical care of pregnant women and strategies that can be deployed at the practice- and system-level of care delivery. • Strategies should include policy changes, education campaigns and trainings that address: • The lack of routine health care for chronic diseases outside of pregnancy (prior to pregnancy and after the postpartum period). • Limited availability of specialists and women’s health providers in rural areas • The need for the provision of nutrition and dietician services in pregnancy due to high levels of obesity in this group • Interoperability of medical records

31. Report: Chronic Disease in Pregnancy Associate Deaths in Virginia, 1999-2012: Need for Coordination of Care This report will be released in February 2019.

32. Program Contact Melanie J. Rouse, PhDMaternal Mortality Projects CoordinatorOffice of the Chief Medical Examiner400 East Jackson StreetRichmond, VA 23219(804) 205-3853Melanie.rouse@vdh.virginia.govhttp://vdhweb/medexam/index.asp