Maternal mortality in the U.S. has come into focus as a growing national concern in recent months, even inspiring a funding request by Congress in July aimed at reducing the deaths of mothers during childbirth.
Now a report published in Health Affairs on Tuesday shows how California sought to tackle maternal deaths , reporting that its maternal death rate was cut nearly in half even as the U.S. national maternal death rate doubled.
“These deaths were largely preventable and they’re all tragic," said lead author Elliott Main, M.D., medical director of the California Maternal Quality Care Collaborative (CMQCC), in an interview with FierceHealthcare. The CMQCC was founded at Stanford University School of Medicine together with the state of California and includes more than 200 member hospitals. The multistakeholder organization was created in 2006 to address rising maternal mortality and morbidity rates.
Eliott Main, M.D. (CMQCC)
While they cannot specifically attribute the drop to any single action taken by the collaborative, California’s maternal death rate has fallen from 13.1 maternal deaths per 100,000 live births in 2005-2009 to 7 deaths per 100,000 live births in 2011-2013—a rate comparable to that of Western Europe. The study outlines several key developments made by the collaborative that may be associated with the improvements.
"We really needed to honor the women in the families who have these losses by being better," Main said. "And that is a powerful message that people sit up for."
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How they did it
The authors of the study said the CMQCC identified a four-step approach to reverse pregnancy-related mortality: linking public health information to action steps, mobilizing public and private partners, establishing a data system to support improvement efforts, and implementing large-scale interventions that integrated providers with public health services.
That included creating what they called the Maternal Data Center. The report describes how the data system linked birth certificate data and mother and infant hospital discharge diagnosis files for all births at each member hospital.
The data is updated 45 days after the end of every month and creates over 50 maternal and infant performance standards. Hospitals can receive performance feedback through the data center by using data visualization to conduct multiple peer comparisons, benchmark and track progress over time. This gives facilities the ability to drill down and understand why their rates were elevated—a critical first step in informing and directing quality-improvement measures, the authors of the study wrote.
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Starting in 2006, the state also formed a multidisciplinary committee review of all maternal deaths. The committee began analyzing contributing factors and opportunities for future improvement on every case, a process that now informs future intervention strategies. As a result, large-scale quality improvement toolkits were initially created for the treatment of obstetric hemorrhage and preeclampsia. The study reports that the toolkits had a far-reaching effect with over 10,000 downloads each from the collaborative's website.
The authors also found that 92% of California hospitals had adopted the obstetric hemorrhage toolkit, and 75% had adopted the preeclampsia toolkit by 2016, according to an independent survey. New toolkits have since been developed to address cardiovascular disease and venous thromboembolism, as well as for the support of vaginal birth and reduction of primary cesareans.
California’s ability to mobilize and engage all professional organizations invested in maternal health has also played a key role in the success of the CMQCC, Main said.
The findings are positive news for addressing the nation’s rising maternal mortality and morbidity rates, with the authors concluding that aspects of the state’s model can be used to improve outcomes nationwide. The study reports that components of California’s model are being developed nationwide with support from the Centers for Disease Control and Prevention and with a network of state collaboratives. The study also reports that over 20 states currently have active perinatal quality collaboratives at varying stages of development.
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“You can’t do this one segment alone—this is not a doctor thing, this is not a nurse thing, or a public health thing or a hospital thing,” said Main. “You have to engage them all at the same time and that’s how you really leverage the data into action.”