and Mortality In Texas Lisa M Hollier MD MPH Professor Obstetrics amp Gynecology Baylor College of Medicine Financial Disclosure Lisa M Hollier MD has no relevant financial relationships with commercial interests to disclose ID: 930552
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Slide1
Preventing Maternal Morbidity
and Mortality In Texas
Lisa M. Hollier, MD, MPH
Professor, Obstetrics & Gynecology
Baylor College of Medicine
Slide2Financial Disclosure
Lisa M. Hollier, MD, has no relevant financial relationships with commercial interests to disclose.
Slide3AcknowledgementsSonia BaevaOffice of Program Decision Support
Department of State Health ServicesMembers of the Texas Maternal Mortality and Morbidity Task Force
Slide4Learning ObjectivesAt 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 morbidityImplement local solutions to reduce maternal mortality and morbidity
Slide5Definitions of Maternal DeathCDC / ACOGpregnancy-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.
Slide6Reviewing Maternal DeathTexas 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 morbiditydetermine the feasibility of the task force studying cases of severe maternal morbiditymake recommendations to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas
Slide7Reviewing Maternal DeathTexas 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 populationsbest 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
Slide8MMMTF Biennial Report 2018
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide9Texas Pregnancy-related MortalityLeading underlying
causes of pregnancy-related death in 2012 identified by the Task Force were: cardiovascular and coronary conditions
obstetric hemorrhageinfection/sepsiscardiomyopathy
preeclampsia/eclampsia, mental health conditions, and amniotic fluid embolushttps://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide10Maternal Mortality by Race/Ethnicity
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide11Preventability of PRM
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide12Contributing FactorsTop individual and family level factors
contributing to death:Underlying medical conditionsCardiovascular conditions, including chronic hypertensionObesity
DepressionDelay in or failure to seek care or treatmentlack of patient recognition of early warning signs of worsening condition
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide13Contributing FactorsTop Provider
level factors contributing to death: Failure to recognize high risk maternal health statusfailure to refer high risk patients to appropriate care specialties Failure to recognize and respond to maternal early warning signsdelay in or lack of bedside clinician presence
Delays in diagnosisDelays in initiation of treatmentInadequate or ineffective treatment Lack of effective communication
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide14Contributing FactorsTop facility level
factors included:Failure to recognize high risk statusDelayed and inadequate response to clinical warning signsLack of continuity of care
lack of appropriate hand-off of patients between hospital staff and outpatient providersimpacted by the inability to secure appropriate outpatient care and. Top systems and community level
factors included: Poor care coordination from the inpatient to outpatient settingLack of access to interconception care services and transitional care services.
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide15Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
Days
Post-partum
43-60 Days
Post-partum
61+ Days
Post-
partum
Total
Amniotic Embolism
1
9
0
0
0
10
Cardiac Event
2
12
9
5
27
55
Cerebrovascular Event
0
8
9
1
9
27
Drug Overdose
0
3
7
54964Hemorrhage31220320Homicide21523242Hypertension/Eclampsia0740718Infection/Sepsis131431132Pulmonary Embolism2342213Substance Use Sequelae (e.g., liver cirrhosis)002035Suicide01222833Other55634463Total16646423215382
Maternal Deaths 2012-2015
15
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide16Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
Days
Post-partum
43-60 Days
Post-partum
61+ Days
Post-
partum
Total
Amniotic Embolism
1
9
0
0
0
10
Cardiac Event
2
12
9
5
27
55
Cerebrovascular Event
0
8
9
1
9
27
Drug Overdose
0
3
7
54964Hemorrhage31220320Homicide21523242Hypertension/Eclampsia0740718Infection/Sepsis131431132Pulmonary Embolism2342213Substance Use Sequelae (e.g., liver cirrhosis)002035Suicide01222833Other55634463Total16646423215382
Maternal Deaths 2012-2015
16
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide17Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
Days
Post-partum
43-60 Days
Post-partum
61+ Days
Post-
partum
Total
Amniotic Embolism
1
9
0
0
0
10
Cardiac Event
2
12
9
5
27
55
Cerebrovascular Event
0
8
9
1
9
27
Drug Overdose
0
3
7
54964Hemorrhage31220320Homicide21523242Hypertension/Eclampsia0740718Infection/Sepsis131431132Pulmonary Embolism2342213Substance Use Sequelae (e.g., liver cirrhosis)002035Suicide01222833Other55634463Total16646423215382
Maternal Deaths 2012-2015
17
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide18Cause of Death
While Pregnant
0-7
Days
Post-partum
8-42
Days
Post-partum
43-60 Days
Post-partum
61+ Days
Post-
partum
Total
Amniotic Embolism
1
9
0
0
0
10
Cardiac Event
2
12
9
5
27
55
Cerebrovascular Event
0
8
9
1
9
27
Drug Overdose
0
3
7
54964Hemorrhage31220320Homicide21523242Hypertension/Eclampsia0740718Infection/Sepsis131431132Pulmonary Embolism2342213Substance Use Sequelae (e.g., liver cirrhosis)002035Suicide01222833Other55634463Total16646423215382
Maternal Deaths 2012-2015
18
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide19Top Causes of Confirmed Death: within 1 Year Following End of Pregnancy
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide20Severe Maternal MorbidityFor every woman who dies, about 50 more suffer a severe complication.
Link between maternal mortality, particularly preventable maternal deaths, and severe maternal morbidityOverall rate of severe maternal morbidity (SMM) increased almost 200% F
rom 47.6 per 10,000 in 1993–1994 to 141.6 per 10,000 in 2013–2014Texas SMM rate is 195 per 10,000 in 2014
Slide21Severe Maternal Morbidity - US
Slide22Severe Maternal Morbidity: Top Causes22
Slide23Obstetric Hemorrhage Rates by Race/Ethnicity (Maternal Morbidity)23
Slide24Rates of Obstetric Hemorrhage by County
24
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide25Frequency of Obstetric Hemorrhage by County25
https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm
Slide26MMMTF Recommendations1. 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
Slide27MMMTF Recommendations6. 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
Slide28Time Spent in D/C Instruction
Suplee PD. JOGNN
2016;45(6):894–904
Slide29How Likely to Discuss
Suplee PD. JOGNN 2016
;45(6):894–904
Slide30Slide31Levels 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
Obstet
Gynecol
2015, 212 (3), 259-271.
Slide32Levels of Maternal Care
Hospital Level of Care Designation for Maternal Care
ACOG, Menard et al. Am J
Obstet
Gynecol
2015, 212 (3), 259-271.
Slide33National Agenda to Reduce Maternal Mortality