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Maternal Mortality and Morbidity TEXAS AND THE RIO GRANDE VALLEY
OverviewHistory of Maternal Health• Brief overview of western maternal health• Key moments and persons
Key Agencies• World• United States• Texas
Maternal Mortality and Morbidity• Top Causes• Contributing Factors• Reduction
History:Antiquity to Middle Ages (BCE to ≈ 1400)
Midwife – the woman who is with women.• The midwife, often referred to as wise woman, was
responsible for the health and wellbeing of women.• Often associated with the birth of babies, but
responsible for a myriad of other women’s health issues.
• Primary goal during delivery was safety of the mother.
From Ostia, now in the Welcome Collection of Medical ObjectsRetrieved from Quatr.us
African-American Midwifery, a History and a Lament, 2017; Goode and Rothman
History:Middle Ages to Enlightenment (≈1400-1700)
Barber Surgeon – is a barber whom also practiced surgery and dentistry.• Barber Surgeons increasingly moved into the realm of
child birth.• Surgical instruments were used by the surgeon for
those deliveries that required more intrusive means and had to be performed by the local Barber Surgeon.
Retrieved from: Medievalist.net
African-American Midwifery, a History and a Lament, 2017; Goode and Rothman
History: Enlightenment to Now (≈1700 onward)
Medical Doctor – is an educated professional who practices medicine, which is concerned with promoting, maintaining, and restoring health.• Rapid advancement in medical education, human
anatomy and physiology, and general scientific knowledge
• Oversight Committees began to govern and assess medical practices
• Bureaus were formed to look into Maternal and Infant Mortality and welfare
Clinical Review, 1843, Lee
Puerperal Fever
Childbed fever• Onset of symptoms: 3 days after childbirth• Rapid Progression with severe abdominal pain, fever, and debility/weakness
Early 19th Century, mortality rates were as high as 25% • Atmospheric toxins• Epidemic constitutions of some women• Putrid air• Solar and magnetic influences
Epidemiology, 5th Ed. Gordis, pg.9
Ignaz Philipp Semmelweis (1818-1865)July 1846 Semmelweis was placed to be in charge of the First Obstetrical Clinic of the Vienna General Hospital (Allgemeine Krankenhaus)
He noticed Clinic One staffed with physicians had a much higher mortality rate (2x higher) than Clinic Two which was staffed by midwifes
Semmelweis conducted an investigation (first hospital-based epidemiologic study)• Determined a pathogen was carried on the hands of physicians• Physicians conducted autopsies on women who died of Puerperal Fever and then delivered babies• Midwives did not conduct autopsies and washed their hands in a chloride of lime solution
• Findings confirmed in 1847
Once handwashing policies were implemented, Clinic One reduced their maternal mortality to that of Clinic Two
1861 publishes a paper – “The Etiology, Concept, and Prophylaxis of Childbed Fever”
Oliver Wendell Holmes Ignaz Philipp Semmelweis: Preventing the Transmission of Puerperal Fever, 2010; Lane, Blum, and Fee
The United States Children’s Bureau
1909 White House Conference on Child Welfare Standards• “social workers, educators, juvenile court judges, labor leaders, and other men and women concerned
with child welfare endorsed the idea of a Federal Children’s Bureau” The Story of the Children’s Bureau
1912 The Children’s Bureau is created with a budget of $25,640• One of the first major investigations was infant and maternal mortality• Discovered the United States had a high maternal mortality rate• Maternal mortality rates had a correlation with poverty• 80% of expectant mothers received no advice or trained care
The Story of the Children’s Bureau: 100 years of serving our nation’s children and families, 2012
The Sheppard-Towner Act
1921 Sheppard-Towner maternity and infancy protection act is passed into law• Provided instruction in hygiene of maternity and infancy • Public health nurses, visiting nurses, consultation centers, literature distribution, and more
• $5,000 would go to each state with an additional $5,000 if the state matched the funds• Administering the program could not exceed $50,000
• The moneys would be channeled through the Children’s Bureau
The Sheppard Towner Act came under fire and lawsuits to overturn the legislation with counter suits following
The law was allowed to expire in 1929, but the accomplishments provided evidence that state and federal programs benefited the population
The Sheppard-Towner Act: Progressivism in the 1920’s, 1969; Lemons
Accomplishments
•183,252 health conferences
•2,978 prenatal care centers established
•3,131,996 home visits by nurses
•22,020,489 pieces of literature were distributed
Maternal death rate 1921: 67.3 per 1,000
1927: 62.3 per 1,000
Most states recognized the importance of the problem and continued the programs
The Sheppard-Towner Act: Progressivism in the 1920’s, 1969; Lemons
Maternal Mortality Study Committees1917- New York Academy of Medicine under G.W. Kosmak suggests a subcommittee to study puerperal fever• Forms, dissolves, and reforms in 1930 as the Committee on Public Health Relations of the New York
Academy of Medicine
1920 – National Committee on Maternal Welfare was established
1930 – Philadelphia County Medical Society established the Maternal Welfare Committee
1935 – “A Maternal Mortality Study in Seven Cities of the Pacific Coast” by T. Floyd Bell is published• Texas establishes a maternal mortality study committee
1948 – The AMA established a Committee on Maternal and Child Care• 1957 – Guide for Maternal Death Studies is published
1968 – 44 states and DC have maternal mortality review committeesAfter Office Hours: History of the maternal mortality study committees in the United States, 1969; Marmol, Scriggins, and Vollman
Reports in Media and Publications
• Poverty• Age• Nutrition• Sepsis• Hemorrhage• Induction• Ethics
Definitions
Maternal Mortality• 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. (WHO)
Pregnancy-related Death• The death of a woman while pregnant or within 1 year of the end of a pregnancy – regardless of the
outcome, 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 – Pregnancy Mortality Surveillance System)
Definitions
Maternal Morbidity• Physical and psychological conditions that result from or are aggravated by pregnancy and have an
adverse effect on a woman’s health (CDC)
Severe Maternal Morbidity• Unexpected outcomes of labor and delivery that result in significant short or long-term consequences to
a woman’s health (CDC)
World Health Organization (WHO)
Maintains and researches treatment for a variety of infections, co-infections, and health issues women face when pregnant• How to treat a pregnant women when she has a parasitic infection• Types of co-infections based on country of origin
Researches maternal morbidity and creates recommendations for treatment• Causes of maternal morbidity• Partner care and presence in the birthing process• Midwifery
Develops guidelines for treatment in a variety of setting and countries
https://www.who.int/maternal-health/en/
What’s Happening in the World
•830 women die daily from preventable pregnancy and childbirth causes
•Maternal mortality is higher in rural areas than in urban areas
•Having a skilled practitioner before, during, and after childbirth can save the life of the mother and the baby
Major causes of maternal mortality in the world• Sever bleeding• Infections• High blood pressure during pregnancy• Complications from delivery• Unsafe abortions
https://www.who.int/maternal-health/en/
Pregnancy Mortality Surveillance System (PMSS) - CDC
CDC and the American College of Obstetrician and Gynecologist (ACOG) established a national surveillance of pregnancy related deaths in 1986 to better understand the causes of maternal death and to fill gaps in clinical information
The information gathered allows for: • Analysis of trends in maternal mortality over time• Analysis for disparities among populations• Analysis of the causes of maternal death and the risk factors associated with maternal
Disseminate information and data to clinicians and public health professionals to further understanding of maternal death causes to implement actions to prevent them
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
Trends in pregnancy-related mortality in the US: 1987-2015
National Pregnancy-related Mortality Ratio by age, race-ethnicity, and overall 2011-2013
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744583/
National Pregnancy-related Mortality Ratio by specific cause and cohort years
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744583/
Maternal Morbidity in the United States
Postpartum Depression• 1 in 9 women experience postpartum depression symptoms in the United States• In addition to traditional symptoms PPD sufferers may experience:• Crying more often than usual• Feelings of anger• Withdrawing from loved ones• Feeling numb or disconnected from you baby• Worrying that you will hurt the baby
https://www.cdc.gov/reproductivehealth/depression/index.htm
Severe Maternal Morbidity
Indicators for Severe Maternal Morbidity• Blood transfusion• Acute myocardial infarction/Aneurysm• Acute renal failure• Adult respiratory distress syndrome• Cardiac arrest, fibrillation/ Conversion of cardiac
rhythm• Shock• Ventilation/Temporary tracheostomy• Sepsis• Hysterectomy• Disseminated intravascular coagulation• Air and thrombotic embolism
• Amniotic fluid embolism• Acute congestive heart failure or pulmonary edema• Puerperal cerebrovascular disorders• Heart failure or arrest during surgery or procedure• Eclampsia• Severe anesthesia complications• Sickle cell disease
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm
0
20
40
60
80
100
120
140
160
1993 1994 1997 1998 2001 2002 2005 2006 2009 2010 2013 2014
Blood Transfusions Without Transfusions
Rates of Severe Maternal Morbidity by Blood Transfusion Status per 10,000 Hospitalizations
Adapted from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm
Hysterectomy DIC
Ventilation/Temp Tracheostomy
Sepsis
Adult Respiratory Distress …
Acute Renal FailureShock
Air/Thrombotic Embolism
Cardiac Arrest, Conversion of …
Acute Myocardial …
0
1
2
3
4
5
6
7
8
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rates of Severe Maternal Morbidity by Indicator per 10,000 Hospitalizations
Adapted from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm
Maternal Mortality in Texas
• 87% increase in maternal deaths
• 18.3 per 100,000 for years 2006-2010
• 34.2 per 100,000 for years 2011-2015
Theguardian.com
https://www.texastribune.org/2018/01/04/maternal-deaths-are-increasing-texas-probably-not-much-officials-thoug/
Propublica.org
Maternal Mortality and Morbidity Task Force
Established in 2013 (SB495) and implemented in 2015, due to reports of maternal deaths increasing 87% over a five year period
Task Force meets quarterly to review maternal death records• A portion of each meeting is open to the public• The remainder is behind closed doors to protect the health information of individuals (HIPPA)◦ Determines whether the death is pregnancy-related using guidelines established by the CDC
Task Force and DSHS submit a joint report on the finding• No later than September 1 of each even-numbered year• Report shall contain information on trends, disparities, health conditions and factors, best practices of other states with low
maternal deaths, and make recommendations after consulting with the Perinatal Advisory Council
Maternal Mortality and Morbidity Task Force, 2018, DSHS
What we know about maternal mortality in Texas
Black women are most at risk for pregnancy-related death• This gap remained high across all levels of socioeconomic status
Majority of maternal deaths are to women enrolled in Medicaid at time of delivery• Socioeconomic/poverty is a factor
Most pregnancy-related deaths are potentially preventable• Found that at least some chance of death being avoided
Complex interactions contribute to maternal mortality• Personal, provider, systems, facility, and community
Causes of death likelihood are time dependent• Most deaths occur more than 42 days postpartum
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Causes of Death
0
10
20
30
40
50
60
70
Drug Over
dose
Cardiac
Event
Homicid
e
Suicid
e
Infectio
n/Sepsi
s
Cerebrovas
cular
Event
Hemorrh
age
Hyperte
nsion/E
clampsi
a
Pulmon
ary Em
bolism
Amniotic Em
bolism
Substa
nce Use
Squela
e
Other Cause
s
Trends in Pregnancy-related Deaths in Texas by Cause 2012-2015
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Causes of Death by Pregnancy/Childbirth Time
0
10
20
30
40
50
60
70
Drug Over
dose
Cardiac
Event
Homicid
e
Suicid
e
Infectio
n/Sepsi
s
Cerebrovas
cular
Event
Hemorrh
age
Hyperte
nsion/E
clampsi
a
Pulmon
ary Em
bolism
Amniotic Em
bolism
Substa
nce Use
Squela
e
Other Cause
s
Trends in Pregnancy-related Deaths in Texas 2012-2015
While Pregnant 0-7 DaysPP 8-42 Days PP 43-60 Days PP 61+ Days PP
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Causes of Death for Black Women
0
2
4
6
8
10
12
14
While Pregnant 0-7 Days PP 8-42 Days PP 43-60 Days PP 61+ Days PP Total
Top 5 Causes of Pregnancy-related Deaths among Black Women in Texas by Cause and Timing 2012-2015
Cardiac Event Homicide Hypertension/Eclampsia Drug Overdose Cerobrovascular Event
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Factors which contribute to an increased risk of pregnancy-related death
•Unmarried
•Had at high school diploma
•Medicaid
Factors for Black Women
•Married
•Private insurance
•Normal weight
Maternal Mortality and Morbidity Task Force, 2018, DSHS
•40 years of age or older
•Late or no prenatal care
•Chronic Health diseases• Pre-pregnancy obesity• Diabetes• Hypertension
•Smoking during pregnancy
•Delivery by Cesarean Section
5 Highest Demographic Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births
Hellerstedt and Hollier, 2018; DSHS Presentation
5 Highest Health Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births
Hellerstedt and Hollier, 2018; DSHS Presentation
National Maternal Mortality Map 2016 and 2018
Americashealthrankings.org
2016 2018
Maternal Mortality in Texas, 2016, DSHS
Examples of Methods
Maternal Morbidity in Texas
• Texas has approximately 400,000 births annually
• Texas accounts for 10% of all births in the United States
• In 2015, Texas had a Maternal Morbidity Rate of 19.7 per 1,000 deliveries
https://www.kut.org
https://www.hcup-us.ahrq.gov
https://www.uthct.edu
Postpartum Depression
•The prevalence rate of women who experience PPD symptoms in Texas is 13.7%, according to pooled PRAMS data for years 2012-2015
•Depression was the most identified mental health condition that contributed to pregnancy-related death
Some Contributing factors to PPD (not exhaustive)• Stressful life events• Low social support• Pregnancy and birth complications• Preterm birth• Teen mother
HRSA.gov Regional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS
Rate of Diagnosed Pregnancy-related Depression per 1,000 Hospitalizations by Race/Ethnicity: 2014
Hellerstedt and Hollier, 2018; DSHS Presentation
Leading causes of Severe Maternal Morbidity Rate per 10,000 Hospitalizations 2014
129.8
25.8
20.4
13.97.1
Hemorrhage DIC Cardiac Event Hysterectomy Eclampsia
Adapted from Maternal Mortality and Morbidity Task Force, 2018, DSHS
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Obstetric Hemorrhage per 10,000 Hospitalizations by Race/Ethnicity in Texas: 2005-2014 (estimates based on blood transfusions)
Obstetric Hypertension per 10,000 Hospitalization by Race/Ethnicity in Texas: 2005-2014
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Public Health Region 11
Major cities in PH Region 11:• Brownsville• Corpus Christi• Edinburgh• Laredo• McAllen
83.7 of the region’s population in 2015 was Hispanic:• Brownsville 93.6%• Laredo 95.2
Median household income:• $22,741-$52,261• 49.1% of female population living below 200% FPL
Regional Analysis of Maternal and Infant Health in Texas, PHR11: 2018, DSHS
Postpartum Depression
•All counties in Public Health Region 11 (except Hidalgo, Kleber, and Nueces) are designated medically underserved• Cameron County and Webb County are partial designations
•Pooled PRAMS data from years 2012-2015 indicate 15.6% of women in PHR 11 reported symptoms of PPD• Highest prevalence of PPD symptoms (along with PHR6/5S)• Hispanic women experienced a higher rate than other women
•Preliminary data from Brownsville’s Maternal and Child Community Health Needs Assessment indicate that mental health is one of the top 3 concerns affecting maternal health
Regional Analysis of Maternal and Infant Health in Texas, PHR11: 2018, DSHS
5 Highest Health Risk Factors for Maternal Mortality in Texas 2012-2015: Rate per 100,000 live Births
Hellerstedt and Hollier, 2018; DSHS Presentation
Proportion of Hypertensive Disorders Complicating Pregnancy: 2010-2014(Hypertension, Pre-eclampsia, and Eclampsia)
https://www.arcgis.com/apps/Cascade/index.html?appid=94dcde5a27c74867b090a3b2f3835930
Proportion of Hypertensive Disorders Complicating Pregnancy: 2010-2014(Hypertension, Pre-eclampsia, and Eclampsia)
0.1-10.2%
10.3-14.4% +1 SD
14.5-18.5% +2 SD
18.6- 22.7% +3 SD22.8%+0 cases <100 Deliveries
LaredoCorpus Christi
Brownsville
Rate per 10,000 Hospitalizations
Hellerstedt and Hollier, 2018; DSHS Presentation
Corpus ChristiLaredo
Brownsville
Obstetric Hemorrhage Public Health Region 11: 2010-2014(blood transfusions)
0.1-118.7
118.8-202.4 +1 SD
Rate per 10,000 Hospitalizations
202.5-286.1 +2 SD
286.2-369.8 +3 SD369.9+0 cases <100 Deliveries
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Percent of Live Births to Mothers with No Reported Prenatal Care 2015
https://utsys-pop-health.maps.arcgis.com/apps/MapSeries/index.html?appid=52a1e80ce96f48c985989dd65789eb2e
Percent of Live Births to Mothers who Smoked During Pregnancy 2015
https://utsys-pop-health.maps.arcgis.com/apps/MapSeries/index.html?appid=52a1e80ce96f48c985989dd65789eb2e
Percent of Live Births to Mothers with Pre-pregnancy Obesity 2015
https://utsys-pop-health.maps.arcgis.com/apps/MapSeries/index.html?appid=52a1e80ce96f48c985989dd65789eb2e
Recommendations
The Maternal Mortality and Morbidity Task Force have identified 5 domains for improvement• Individual• Family• Provider• Facility• System and Community
Implement safety bundles and protocols• “Hospitals that implemented the hemorrhage safety bundle had an 11.7% decrease in severe maternal
morbidity among all obstetric patients (compared to baseline)”
Hellerstedt and Hollier, 2018; DSHS PresentationMaternal Mortality and Morbidity Task Force, 2018, DSHS
Individual and Family Factors Contributing to Poor Maternal OutcomesUnderlying medical conditions• Delay or failure to seek medical care• Cardiovascular disease• Chronic hypertension
Mental Health• Depression
Failure to recognize early warning signs
Obesity• Increased risk for hypertensive disease• Cardiovascular disease• Preeclampsia
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Individual and Family Solutions
Address fundamental social conditions and community-level drivers• Employment, education, language, culture• Adopt health in all policies approach
Build environments that support healthy and active living• Parks, sidewalks, community gardens• Partner and coordinate messaging on benefits of green space
Implement community-based health promotion efforts • Community health workers and outreach efforts to address early warning signs, obesity, hypertension,
chronic illness, and mental health• Case managers to help young and first-time mothers to understand the importance of prenatal care,
good nutrition, and assist in accessing care
Maternal Mortality and Morbidity Task Force, 2018, DSHSRegional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS
Social Conditions as Fundamental Causes, 2010, Phelan et. Al. http://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf
Provider Factors Contributing to Poor Maternal OutcomesInadequate, delayed, or poorly coordinated treatment during pregnancy, delivery, and postpartum• Ineffective treatment• Cesarean section• Labor induction
Failure to recognize early warning signs and high-risk maternal health status• Referral to appropriate care specialist• Lack of bedside clinician presence
Delays, inadequacies, or ineffective treatment of hypertension, hemorrhage, and infection
Prioritizing birth outcome over maternal health status
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Provider Solutions
Improve access to care• Extended hours, weekend hours
Support provider capacity to deliver high quality care• Well-woman• Routine Maternity
Promote coordinated systems across the care continuum• Increase knowledge of local resources• Case worker or designated staff to help access resources
Promote web-based modules and round tables to disseminate best practices
Regional Analysis of Maternal and Infant Health in Texas, PHR11, 2018, DSHS Maternal Mortality and Morbidity Task Force, 2018, DSHShttp://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf
Facility Factors Contributing to Poor Maternal OutcomesInadequate knowledge, judgement, or performance by facility personnel• Lack in recognizing high risk status• Poor documentation in patient’s chart• Delayed response warning signs of declining health by nursing staff
Lack of recognition of risk factors for hemorrhage• Delayed or no response to warning signs
Continuity of care• Inability to secure outpatient care• Hand-off of patients
Maternal Mortality and Morbidity Task Force, 2018, DSHS
Facility SolutionsImprove clinical recognition and response to adverse events• Educate and train medical staff on the early warning signs
Ensure facility readiness for obstetric complications• Hemorrhage safety bundles• Hypertension protocols• Safe reduction of primary cesarean births
Voluntarily participate in organizations which focus on labor and delivery services
Develop posters, quick reference tools, and checklists
Ensure Emergency Department has the necessary training, tools, and staff to hand delivery
Maternal Mortality and Morbidity Task Force, 2018, DSHSHellerstedt and Hollier, 2018; DSHS Presentationhttp://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf
Systems and Community Level Factors Contributing to Poor Maternal OutcomesContinuity of care
Lack of access to interconception care services• Education on birth spacing• Providers to address any underlying health issues
Poor care coordination from inpatient to outpatient• Develop resources for warm hand-off of patient• Follow up to help ensure outpatient care is implemented
Transportation services
Maternal Mortality and Morbidity Task Force, 2018, DSHS
System and Community Level SolutionsTalk to local and state politicians on best practices and access to care issues
Strengthen maternal data systems• Build capacity to learn from each maternal death and complication• Use data to monitor performance and outcomes• Apply data from surveys and qualitative sources
Increase value of investment• Create and participate in maternal health partnerships• Disseminate and share what works
http://www.amchp.org/abouttitlev/resources/documents/health-for-every-mother_Final_weboptimized.pdf Maternal Mortality and Morbidity Task Force, 2018, DSHS
Remember
•Be innovative and creative
•Make connections and network with similar organizations and providers
•Think outside the box
•Stay dedicated and curious
Maternal Mortality and Morbidity Task Force, 2018, DSHS
California Maternal Mortality Rate per 100,000 Live Births: 1999-2013
Thank you!
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