Strategies to Reduce Maternal Mortality Rates in the US

The Partnership for Maternal and Child Health of Northern New Jersey has many programs to reduce the alarming rates of infant mortality throughout the state of New Jersey, however, the Partnership and many organizations like it tend to neglect the Maternal aspect of maternal and Infant care. With much research, it has come to my attention that maternal mortality is also a very prominent issue in the state of New Jersey and there are very few organizations, yours included, that provide programs to assist. I am proposing that the Partnership start a pilot program with its member hospitals that would mimic the Partnership’s already successful Fetal Infant Mortality Review, but for Maternal Mortality. Multi-disciplinary reviews have proven to help reduce maternal mortality tremendously. The United Kingdom and California are great and relevant examples because of their socioeconomic and cultural similarities to New Jersey. I believe that this pilot program could set precedent for New Jersey policymakers and hospital standards in the near future as maternal and infant health is at the forefront of the current New Jersey health legislation. This would be great for the partnership not only reputationally, but financially as new bills are being passed in New Jersey to fund maternal death research and prevention efforts.

The United States, The Only Developed Nation with Increasing Maternal Mortality Rates

Medical advances since the late 20th century such as blood transfusions, antibiotic use, and antisepsis have worked to decrease the number of maternal deaths significantly. In developed, or high-income, countries the maternal mortality rate (MMR) has decreased from 1,000 maternal deaths per 100,000 live births in the early 1900s (Neggers,72) to 12 maternal deaths per 100,000 live births in 2015 (Ozimeck and Kilpatrick,176). According to the United Nations Maternal Mortality Estimation Inter-Agency Group, of the 171 countries that were studied over the last 25 years, 158 showed decreasing MMRs while 13 showed increasing MMRs. The United States the only developed nation among those with increasing maternal deaths (Ozimeck and Kilpatrick,176). As a developed nation this is unheard of especially given that 99% of pregnancy-related deaths occur in low- and middle-income countries (Neggers,72). The last global report of Maternal Mortality conduced in 2015 by the World Health Organization put the United States’ MMR at 14 maternal deaths per 100,000 live births. For perspective that is almost 2 times greater than countries that would be considered both culturally and financially similar such as Canada, with an MMR of 7 deaths per 100,000 live births, the United Kingdom, with an MMR of 9 deaths per 100,000 births (Ozimeck and Kilpatrick,176-177). As of 2018, the United States' MMR has increased significantly to 20.7 maternal deaths per 100,000 live births. (Health of Women and Children)

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Although the overall MMR for the United States is high, the number varies greatly state to state. California has the lowest in the country at 4.5 maternal deaths per 100,000 live births and Georgia has the highest at 46.2 maternal deaths per 100,000 live births. New Jersey is in a significantly unique place when it comes to maternal mortality as we have one of the highest MMRs in the country at 38.1 maternal deaths per 100,000 live births almost 2 times more than the national rate and ranked 45th out of the 48 states that reported. (Health of Women and Children). Even more so we have the highest MMR for African American women at a rate of 102.3 deaths per 100,000 live births, more than two times higher than the national MMR for African American women of 47.2 deaths per 100,000 live births. This is interesting as a study demonstrated a correlation between states with high MMRs and high percentages of non-Hispanic African American women in the population (Ozimeck and Kilpatrick,179); While this may be true for other states New Jersey’s African American Female population is about the national average at approximately 6% (US Census Data 2010). This is the reason I wanted to focus on Northern New Jersey as it contains three of the top five cities in New Jersey with the largest African American population (These Are The 10 New Jersey Cities with The Largest Black Population For 2019). Therefore, it would be an amazing place to start the pilot program to reduce overall maternal mortality rates but may also help to reduce the racial gap.

How the United Kingdom and California Reduced Maternal Mortality Rates?

For the past 60 years in the United Kingdom, they have used a national system to review maternal deaths called Confidential Enquires into Maternal Deaths. In this system, pregnancy-related deaths are reported to the Mothers and Babies Reducing Risk through Audits and Confidential Enquiries across the United Kingdom (MBRRACE-UK) database within a week of the death occurrence. (Ozimeck and Kilpatrick,181) While a majority of these reports come from the facility where the death occurred, reports can come from coroners, pathologists, midwifery offices and public members. These reports are then cross-checked with the records from the office for national statistics and national records Scotland which provide details on the pregnancy-specific cause listed on the death certificate. In addition to submitted reports, maternal details and birth records are linked to death records of women of reproductive age to identify maternal deaths where pregnancy or pregnancy-specific causes are not listed on the Death certificate. Once it is confirmed that these cases were not already reported the facility in which the birth and death occurred are asked to provide records. (Knight, Nair, Tuffnell, Kenyon, Shakespeare, Brocklehurst, & Kurnczuk,3)

After a report is crosschecked a notification pack is sent to the facility where the death occurred to receive collect more information on the incident. The facility is asked to provide basic demographic and clinical details as well as full medical records and contact details of the clinicians involved in managing the women's care within one month of the death. Once contact information for the clinicians is received they are then sent forms to report on the women's care from their perspective. The timeline for this is usually about three months from the date of the woman's death. All records surrounding the death, pregnancy, or delivery are then obtained by MBRRACE-UK. Due to privacy laws across to the United Kingdom most identifiable information is collected by the regional offices and then redacted from the woman's file. Once all information is collected the case is ready to be assessed. (Knight et.al.,6)

Each case is then reviewed by a pathologist and obstetrician or physician as required. Once the likely cause of death is established her records are then allocated to the appropriate assessors.  The assessors come from various specialty groups, including anesthetics, intensive care, obstetrics, midwifery, psychiatry, pathology, general practice, emergency medicine and various medical specialties, including obstetric physicians, cardiologists, infectious diseases physicians, and neurologists. All assessors are volunteers and do not receive financial benefits for participating but can classify their work as part of professional development. Assessors also undergo a training process and are provided details of relevant standards of care, which deaths are assessed against, most of which comes from national sources and professional organizations. Each case is reviewed by one or two obstetricians, midwives, anesthetists, and other specialist assessors as required, including psychiatrists, general practitioners, physicians, emergency medicine specialists, and intensive care specialists, ultimately totaling about 10-15 expert reviewers. (Knight et.al.,7)

Each primary assessor completes an independent review that is then examined by a second assessor if necessary for specialty review. To ensure anonymity and unbias reports assessors do not review cases inside their region. The assessors give their opinions on the quality of care according to three criteria: 1. good care where no improvements were identified 2. improvement in care identified which would have made no difference to the outcome and 3. improvements in care identified which may have made a difference to the outcome. In certain extreme cases, such as death attributed to abuse or neglect or professional misconduct, the Healthcare Quality Improvement Partnership, an organization that sets standard protocols of care is notified for further investigation. (Knight et.al.,7) This thorough review process allows examination for every case that highlights specific points of improvement as well as gives information for statistical analysis so that likely causes can be identified and then addressed. The data collected throughout this process is then analyzed and published in the yearly MBRRACE-UK Maternal Report. Much of this information is used to inform best practices and minimum care requirements, which has helped the United Kingdom maintain low Maternal Mortality Rates. (Morton, Vanotterloo, Seacrist, & Main, 253)

California has a very similar program that is based on the United Kingdom’s system. In 2006 after reports of increased pregnancy-related deaths the Maternal Child and Adolescent Health Division of the California Department of Health initiated the California Pregnancy Associated Mortality Review (CA-PAMR) to investigate causes maternal mortality and its associated racial disparities (Morton et.al., 253). The California program has four key components: (1)  enhanced surveillance of death maternal deaths using available public health data; (2) medical record review to produce a synopsis of events cumulating in the death of each woman;(3) case review by a multidisciplinary group of maternal health experts to determine causation and preventability; And (4) translation of findings in the quality improvement initiatives to improve maternity care and overall maternal health (Mitchell, Lawton, Morton, McCain, Holtby, and Main, 519). Much of the California program is structured after the United Kingdom’s program with a few key differences. One main difference is how each case is reviewed. For CA-PAMR, each case is assigned to three primary reviewers according to expertise after an initial review by a trained abstractor. Then the primary review is submitted for a full committee discussion. The committee consists of about 20 members who meet quarterly for daylong case review sessions. Committee determinations are then captured on a structured form where contributing factors are categorized into three groups: patient, healthcare provider or healthcare facility/system related. The committee is then prompted to answer this question "What alternative approaches to recognition, diagnosis, treatment or follow-up, if implemented, may have led to better patient care and/or a better outcome?" Once determined these quality improvement opportunities are reflected back to the committee and weighed. (Mitchell et. al., 520) Then a determination of preventability is made on a scale based upon the degree of probability to alter fatal outcomes, the scale has the following options: strong, good, some, none, and unable to determine (Morton et al. 254). Once all data is collected the analysis of QIOs are organized into the same three domains as contributing factors: patient, healthcare provider, and healthcare facility or system and tagged with greater specificity. The findings gave better clarity on the causes of pregnancy-related deaths as well as its contributing factors. (Morton et al., 256) The cases that identified with a good to strong chance to alter outcomes provided quality information that suggested priority areas of improvement strategies to prevent future severe morbidity and deaths. (Mitchell et.al.,523) Findings from this program have informed best practices and care standards that has allowed California to reduce its maternal mortality rate from 14 maternal deaths per 100,000 live births in 2006 when the program started to its low 4.5 maternal deaths per 100,000 live births today. 

A Plan to Save New Jersey Mothers  

I plan to take the best practices from both programs and scale them to a level maintainable for the Partnership. All member hospitals of the Partnership would be responsible to report all maternal deaths within a week of the occurrence to make the review board.  Within three weeks the facility must provide all medical information and records as well as detailed accounts from all clinicians involved. The Nation Council of State Boards of Nursing has created a system called the Taxonomy of Error, Root Cause Analysis and Practice Responsibility (TERCAP) that would assist in the process of reporting. This system has a specific tool known as the TERCAP’s Maternal Morbidity and Mortality Inquiry tool that asks nurses that were present to present their perspectives on the incident. (Agosto, Wilson, and Byfield, 866).   This information would then be reviewed and recorded by a physician, nurse, and midwife. To ensure accurate and unbiased recount and analysis all paperwork regarding the clinicians would be anonymous as well as assurance that the assessors could not work in the county that the death occurred. All assessors would need to be volunteers and must be trained on best practices and care standards published Once a primary analysis is done and specialty concerns are acknowledged, The cases would be brought to a multi-disciplinary committee of at least five members to review the case individually and create individual reports.  Once the individual reports are submitted a consensus will be taken from those reports A group of secondary assessors to highlight quality improvement opportunities. Those opportunities will then be categorized into three groups patient healthcare provider or healthcare facility/system related improvement.  My program would help to identify the causes of maternal mortality in New Jersey and highlight the racial disparities given the high population of African-Americans in northern New Jersey.

The Cost of Life

With programs such as this one, there will always be cost. Training for the committee members would be the biggest price as no one on the committee would be paid. E-learning courses can be created for an average of about $22,000 per hour of content (How much does it cost to create an online course?). Also, a training program for the hospital employees on proper reporting methods would put the program cost at a minimum for about $50,000. I believe this cost is minimal compared to a mother losing her life from a preventable cause. I will be making a more in-depth and detailed presentation of this plan and everything discussed in this letter on July 10, 2019, at Scott Hall, 43 College Ave, New Brunswick, NJ 08901. I hope you will attend as I believe this program will be a great step towards lowering the number of maternal deaths happening in our state. I appreciate your time and attention and I hope to see you soon.

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Works Cited

Agostino, Margaret-Rose, Wilson, Barbara, Byfield, Renee. Identifying Potentially Preventable               Elements in Severe Adverse Maternal Events. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2016;45(6):865-869.

Health of Women and Children | New Jersey. (n.d.). Retrieved June 19, 2019, from  https://www.americashealthrankings.org/explore/health-of-women-              andchildren/measure/maternal_mortality/state/NJ

How much does it cost to create an online course? (2019, January 31). Retrieved June 24, 2019,               from https://raccoongang.com/blog/how-much-does-it-cost-create-online-course/

Knight M, Nair M, Tuffnell D, Kenyon S, Shakespeare J, Brocklehurst P, Kurinczuk JJ (Eds.) on               behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of               maternal deaths in the UK 2012-14 and lessons learned to inform maternity care from the               UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-14.               Oxford: National Perinatal Epidemiology Unit, University of Oxford 2016.

Mitchell, Connie, Lawton, Elizabeth, Morton, Christine, McCain, Christy, Holtby, Sue, Main,               Elliott. California Pregnancy-Associated Mortality Review: Mixed Methods Approach                             for Improved Case Identification, Cause of Death Analyses and Translation of               Findings. Maternal and Child Health Journal. 2014;18(3):518-526.

Morton, Christine H., Vanotterloo, Lucy R., Seacrist, Marla J., Main, Elliott K. Translating               Maternal Mortality Review Into Quality Improvement Opportunities in Response to               Pregnancy-Related Deaths in California. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2019;48(3):252-262.

Neggers, Yasmin H. Trends in maternal mortality in the United States. Reproductive Toxicology.               2016;64:72-76. 

Ozimek, John A., Kilpatrick, Sarah J. Maternal Mortality in the Twenty-First Century. Obstetrics and Gynecology Clinics of North America. 2018;45(2):175-186.

These Are The 10 New Jersey Cities with The Largest Black Population For 2019. (2018,               December 09). Retrieved June 24, 2019, from https://www.roadsnacks.net/most-african                           american-cities-in-new-jersey/