1. Preventing Maternal Mortality and Morbidity in Texas: Every Mom Matters
SLIDE 1
Good morning.
I’m Dr. Carla Ortique, Vice-Chair of the Department of State Health Services’ Maternal Mortality & Morbidity Task Force.
The presentation today is about preventing maternal mortality and morbidity in Texas, and the role of maternal safety bundles by the Alliance for Innovation on Maternal Health or AIM.
Carla Ortique, M.D.
Vice-Chair, Maternal Mortality & Morbidity Task Force
August 8, Texas Children's Hospital Pavilion for Women

2. ACKNOWLEDGEMENTS
Thanks to Dr Manda Hall and the DSHS team with special thanks to the Maternal and Child Health epidemiology team:
Karen Ruggiero, PhD. Director
Sonia Baeva
Natalie Archer
Allison Badgley
Council on Patient Safety In Womens Healthcare and the Alliance for Innovation on Maternal Health

3. Overview Maternal mortality and morbidity data
2) AIM maternal safety bundles and Implementation in Texas
3) Maternal Early Warning Systems
SLIDE 2
We will first look at what we know from maternal mortality and morbidity data.
Next, we will look at maternal safety bundles by AIM, and their effectiveness in the prevention of maternal mortality and morbidity.
I’ll then outline the plans to implement AIM bundles here in Texas.

4. “Women are not dying because the diseases cannot be prevented but because societies have not decided their lives are worth saving.” Professor Fathalla Past President International Federation of Obstetrics and Gynecology to the UN 2006

5. Texas Maternal Mortality
SLIDE 3
This is the Texas maternal mortality rate or MMR using death certificate data and the standard definition.
The standard definition of maternal mortality is death during pregnancy or within 42 days following the end of the pregnancy.
_____________
JUST FOR YOUR INFORMATION
We continue to learn from recently published articles that maternal deaths identified using only death certificate data is quite imprecise and can lead to inflated estimates of maternal mortality.
Error may be due to incorrect pregnancy status and cause of death information on the death certificate.
However, there are several efforts that DSHS is undertaking to improve the accuracy of its death certificates, as highlighted in a recent TMA feature article.

6. Texas Maternal Mortality by Racial/Ethnic Group
SLIDE 4
Similar to national trends, the maternal mortality rate in Texas is highest among Black women, and the disparity between African American women and all others has been increasing over time.

7. Top Causes of Confirmed Maternal Death
SLIDE 6
Here are the leading causes of confirmed maternal death within 1 year following the end of pregnancy for 2012 to 2015.
Overall, drug overdose was the most common cause of maternal death, followed by cardiac event, homicide, and suicide.
However, drug overdose, homicide, and suicide are all causes of death that are not solely related to pregnancy.
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JUST FOR YOUR INFORMATION
Maternal deaths were confirmed by linking a woman’s death record with a birth or fetal death record within 365 days.
Timing of death was determined using a combination of pregnancy status on the death record for death while pregnant, or days elapsed between delivery and death for postpartum maternal death.
Cause of death was taken directly from the death record.

8. Maternal Death within 7 Days
SLIDE 7
To help distinguish those causes of maternal death that occur during inpatient hospital stay and are directly related to pregnancy, the top causes of maternal death during pregnancy or up to 7 days postpartum were examined.
There were a total of 79 confirmed maternal deaths that occurred either during pregnancy or from 0 to 7 days postpartum between
The top 6 causes of maternal death during this timeframe are shown.
Roughly a fifth of all maternal deaths during this timeframe were due to Disseminated Intravascular Coagulation or Hemorrhage.
 _____________
JUST FOR YOUR INFORMATION
Of the 15 DIC/Hemorrhage cases, there were 12 hemorrhages and only 3 DICs. While DIC and hemorrhage tend to occur in concert, we gave priority to “DIC” only in cases where acute blood loss was not mentioned explicitly and/or there was no pregnancy-specific verbiage (e.g., uterine rupture, placenta accreta, postpartum hemorrhage, etc.). 7

9. Severe Maternal Morbidity
Serious complications during or after delivery
Identified using specific ICD codes for delivery hospitalizations
Examples include:
Hemorrhage
Eclampsia
Emergency hysterectomy
Thrombotic embolism
SLIDE 8
Severe maternal morbidity or serious complications during or after delivery, is what maternal safety bundles were designed to directly prevent.
Severe maternal morbidity is identified using specific ICD codes for delivery hospitalizations, excluding motor vehicle accidents.
For example, obstetric hemorrhage, eclampsia, emergency hysterectomy, and thrombotic embolism, are all considered severe maternal morbidities. 8

10. Severe Maternal Morbidity: Top Causes
SLIDE 9
Obstetric hemorrhage and eclampsia continue to contribute greatly to severe maternal morbidity in Texas, with these two causes having maternal safety bundles for prevention supported by the Alliance for Innovation on Maternal Health or AIM.
There are many severe complications related to preeclampsia. These include pulmonary edema, renal insufficiency, not just eclampsia. 9

11. Role of Opioid Overdoses in Maternal Deaths
Drug overdose leading cause of maternal death, mostly occurring after 60 days postpartum
Combination of drugs involved in 77%
Opioids detected in 58%
SLIDE 10
Also, as shown at the open portion of the last Task Force meeting in December, there is also a need for maternal opioid use prevention.
An investigation of confirmed maternal deaths that occurred between 2012 and 2015 found drug overdose to be the leading cause of maternal death, with the vast majority of these drug overdose maternal deaths occurring after 60 days postpartum.
In fact, a follow-up analysis of these drug overdose maternal deaths revealed that 77% involved a combination of drugs.
And opioids were detected in 58% of these drug overdose maternal deaths. 10

12. Preventability of Maternal Mortality
SLIDE 11
This is from the work by Dr. Elliott Main and his colleagues in California.
In the detailed maternal mortality reviews, they identified that the majority of maternal deaths due to preeclampsia or eclampsia had a good-to-strong chance of prevention.
Additionally, the majority of deaths due to hemorrhage also had a good-to-strong chance of being prevented.
From: Main et al. Obstet Gynecol 2015;125(4): 11

13. Protocols and Checklists
ACOG Committee Opinion #629 recommends/ encourages use of checklists and protocols, which are two major features of AIM bundles
Use of protocols and checklists:
Help practitioners perform critical tasks same way every time, which can reduce error
Have been shown to reduce patient harm through improved standardization
Have been clearly demonstrated to improve outcomes
SLIDE 12
ACOG Committee Opinion #629 recommends and encourages the use of protocols and checklists, which are two major features of maternal safety bundles.
Use of protocols and checklists help practitioners perform critical tasks the same way every time, which can reduce error.
They have been shown to reduce patient harm through improved standardization, and have been demonstrated to improve outcomes and to decrease morbidity and mortality.
The recognition of the benefits of protocols and checklists prompted multiple organizations to begin to address obstetric complications using these processes, including the National Council on Patient Safety in Women’s Health. 12

14. Senate Bill 17 85th Legislature 1st Special Session
Sec MATERNAL HEALTH AND SAFETY INITIATIVE.
(a) Using existing resources, the department, in collaboration with the task force, shall promote and facilitate the use among health care providers in this state of maternal health and safety informational materials, including tools and procedures related to best practices in maternal health and safety.
SLIDE 21
This will allow us to effectively put into place what DSHS, in collaboration with the Task Force, have been legislatively mandated to do.
In fact, the first report on our implementation of this maternal health and safety initiative is due to the Texas legislature on December 1st, 2018. 21

15. Maternal Levels of Care
Implementation of safety bundles is included in rules for all maternal levels of care in Texas
AIM program implementation provides hospitals a simple, successful program with significant support
SLIDE 22
Implementation of safety bundles is also included in the rules for all maternal levels of care in Texas.
AIM program implementation provides hospitals a simple, successful program with significant support. 22

16. Alliance for Innovation on Maternal Health
National data-driven maternal safety and quality improvement initiative working to:
Reduce maternal mortality
Reduce severe maternal morbidity
Disseminates condition-specific “bundles”— evidence- based action steps to guide best care
Multi-Disciplinary Multi-Organization
“Stewardship”
SLIDE 13
The National Council on Patient Safety in Women’s Health has 19 member organizations, including the Society for Obstetric Anesthesia and Perinatology, and two patient groups.
This multi-disciplinary multi-organization group provides infrastructure, guidance, and coordination of safety projects.
The Alliance for Innovation on Maternal Health or AIM was borne out of the Council.
AIM is a national program based on successful implementation approaches to improving maternal safety and outcomes.
The goal of AIM is to reduce maternal mortality and severe morbidity.
AIM works through state teams and health systems to develop a culture of safety in hospitals.
This culture change is critically important because research has demonstrated that provider and system failures explain a significant proportion of maternal deaths and severe complications.
The most common complications associated with childbirth involve delays in diagnosis and in response from the health care team.
AIM works with the Council on Patient Safety in Women’s Health as the dissemination and implementation arm for patient safety and condition-specific bundles.
Implementation to National Scale 13

17. AIM Quality and Safety Bundles
Obstetric Hemorrhage
Severe Hypertension in Pregnancy
Maternal VTE Prevention
Just Out
Patient, Family and Staff Support
Safe Reduction of Primary Cesarean Births
Obstetric Care for Women with Opioid Use Disorder
SLIDE 14
Sets of evidence-based practices or bundles, when implemented together and reliably, have been proven to improve patient outcomes.
AIM safety bundles consist of instructions, checklists, and supplies for health care staff to effectively prepare, identify, and prevent maternal mortality and morbidity that arises from specific causes.
AIM bundles are accompanied by supplemental materials and technical assistance to promote effective implementation in U.S. hospitals.
In the pink box, you see the condition-specific bundles to address complications like obstetric hemorrhage and severe hypertension in pregnancy.
In the striped box, there are bundles for every birth to help hospitals address disparities in maternity care, and to optimize care of women who have recently delivered.
The bundle “Obstetric Care for Women with Opioid Use Disorder” was just initiated 4 months ago.
Maternal Early Warning Criteria
For
Every
Birth
Reducing Disparities in Maternity Care
Safety Tools
SMM Case Review Forms
Postpartum Care Basics
Maternal Mental Health
Interconception Care
Coming Soon 14

18. AIM Bundle Details Four sections/domains:
Readiness
Recognition & Prevention
Response
Reporting & Systems Learning
Developed by official representatives from provider organizations, public health, and patient advocates
Vetted by the National Council on Patient Safety in Women’s Health
Reviewed semi-annually for updates
Commentaries co-published in journals of organizations developing bundles
SLIDE 15
Each AIM bundle has 4 sections or domains: Readiness, Recognition & Prevention, Response, and Reporting & Systems Learning — the four Rs.
The bundle is more than just pieces of paper — it provides resources to assist in the implementation of all 4 sections, while still allowing customization for individual hospitals and/or hospital systems.
Each bundle is developed by official representatives from provider organizations and public health departments, as well as patient advocates.
Each is also vetted by the National Council on Patient Safety in Women’s Health, and is reviewed semi-annually for updates.
Commentaries on the bundles are co-published in the journals of the organizations developing the bundles. 15

19. Texas Maternal Mortality
SLIDE 5
Here now is the California maternal mortality rate using death certificate data and the same standard definition — death during pregnancy or within 42 days of end of the pregnancy.
Why is it so different?
There are many reasons, including the early recognition of the problem, thoughtful analysis, and sequential work to address the risks.
What this demonstrates is that significant improvement in maternal mortality can occur.
Do we have a situation in Texas where introduction of maternal safety practices for hemorrhage and hypertension would be beneficial?
Yes, our state data supports this. 4

20. Severe Morbidity Reduction - Hemorrhage1
Hospitals that implemented hemorrhage safety bundle had 11.7% decrease in severe maternal morbidity among all obstetric patients (compared to baseline)
SLIDE 18
Introduction of the AIM hemorrhage bundle in California resulted in a reduction in severe morbidity due to hemorrhage compared to baseline, as you can see here for the intervention group.
In addition, hospitals who implemented the hemorrhage safety bundle had an 11.7% decrease in severe maternal morbidity among all obstetric patients, compared to baseline.
_____________
JUST FOR YOUR INFORMATION
Earlier studies have shown improvement in single hospitals8 or with a group of hospitals within a hospital system.9 
In such examples, it can be hard to differentiate the effects of a strong leader or the centralized resources of a hospital system from the approach of the intervention project itself.
In California, more that 200 hospitals were involved in this project.
The large number and range of hospitals that engaged and the ability to demonstrate widespread improvement supports the ability to scale up multidisciplinary improvement projects and supports the potential role of state-based maternal safety initiatives who can lead statewide implementation.
Main et al. Am J Obstet Gynecol 2017;216(3):298.e1-298.e11. 18

21. Severe Morbidity Reduction
The four initial AIM states submitted baseline data for three years prior to joining the initiative
Each state’s baseline data indicated a severe maternal morbidity rate between 1.9% to 2.1%
Data from AIM participating hospitals in those same states for the second to fourth quarter of (collectively representing 266,717 births) showed a reduction in the severe maternal morbidity rate to 1.5% to 1.9% — an overall 20% decrease
SLIDE 19
The four initial AIM states submitted baseline data for three years before they joined the initiative.
Each state’s baseline data indicated a severe maternal morbidity rate between 1.9 to 2.1 percent.
Data from AIM participating hospitals in those same states for the second to fourth quarter of 2016 showed a reduction in the severe maternal morbidity rate to 1.5 to 1.9 percent — an overall 20% decrease. 19
ACOG Press Release, January 2018

22. Obstetric Hemorrhage Bundle
DSHS AIM Bundle Focus
Obstetric Care for Women with Opioid Use Disorder
Bundle
Obstetric Hemorrhage Bundle
Severe Hypertension in Pregnancy
Bundle
SLIDE 23
There are three AIM maternal safety bundles that will be implemented in Texas, including the AIM bundle for obstetric care for women with opioid use disorder — which is being developed and will be finalized soon, the AIM bundle to prevent obstetric hemorrhage, and the severe hypertension in pregnancy AIM bundle.
Implementation of each AIM bundle emphasizes readiness, recognition, response, and reporting — the four Rs that I showed you earlier.
Also, at a recent meeting of the National Network of Perinatal Quality Collaboratives, there was a discussion on the AIM bundle “Reduction in Peripartum Racial/Ethnic Disparities”, including a fifth ‘R’ for race.
We know that race encompasses a lot of factors, but it too needs to be considered throughout implementation.
Readiness
Recognition
Response
Reporting 23

23. RECOGNITION
The United States Joint Commission requires hospitals to have written criteria to observe change or deterioration in a patient’ condition and how to recruit staff to manage patient care.
Joint Commission Sentinel Event Alert, Issue 44: Preventing Maternal Death (2010)

24. What are Early Warning Signs
Early warning signs are
“ a set of predetermined ‘calling criteria’ (based on periodic charting of vital signs) as indicators of the need to escalate monitoring or call for assistance”
Mackintosh,N.(2014).Value of a modified early obstetric warning system(MEOWS) in managing maternal complications in the peripartum period: an ethnographic study BMJ Qual Saf, 23, 26-34

25. Why Maternal Early Warning System (MEWS)?
40-50% of maternal deaths are potentially preventable
Delays in recognition, diagnosis and treatment precede majority of deaths from:
Hemorrhage
Hypertension
Infection
Venous thrombosis
California Dept of Public Health,2011; Cantwell et al,2011, Farquhar et al, 2011, Saucedo et al, 2013

26. Maternal Early Warning Criteria AND Escalation Policy
What Is MEWS?
Maternal Early Warning Criteria AND Escalation Policy
Anticipated Results:
Prompt reporting
Bedside Evaluation by MD
Prevention of clinical deterioration

27. Maternal Early Warning Criteria
. Systolic BP (mm Hg) <90or >160
Diastolic BP (mmHg) >100
Heart rate (beats/min) <50 or >120
Oxygen Saturation (room air sea level) <95%
Oliguria, ml/hr for >/= 2hr <35
Maternal Agitation, confusion, or unresponsiveness
Preeclamptic reporting a non remitting headache or shortness of breath
. Mhyre, JM. (In press). Obstet Gynecol.
Clark SL. (2012). Preventing maternal death: 10 clinical diamonds. Obstet Gynecol , 119,

28. Bedside Evaluation by MD?!?!?
Maternal Mortality reviews repeatedly identify the lethal consequences of phone based management in women developing critical illness
Who is Hospital dependent; OB, ER, Anesthesiologist, Hospitalist, residents etc
When: Any red criteria, persistent (>/=15min) or multiple white

29. Bedside Evaluation Outcomes
Non-diagnostic or normal physiology
-tailor plan for subsequent monitoring, notification and review
2. Recurrent MEWS criteria
- diagnostic evaluation and interventions until criteria resolve
- change intensity and frequency of monitoring
3. Critically ill or high likelihood of clinical deterioration
- resuscitative, diagnositic and therapeutic interventions
-Rapid Response or OB Emergency response teams
-Transfer to higher acuity setting

30. NO “I” IN TEAM ESCALATION Plan Essentials Simple Clear
Activated by any member of hospital personnel
Family and Patient included

32. Thank you
SLIDE 30
To conclude, there is a need for these AIM bundles in Texas, and these evidence-based bundles represent best-practice in maternal safety.
As Vice-Chair of the Maternal Mortality & Morbidity Task Force, and as an ob-gyn, I believe that these bundles are needed to improve maternal health in Texas.
Won’t you join us in this effort? 30

33. Maternal Mortality & Morbidity Internet Landing Page
Background for understanding maternal mortality and severe maternal morbidity in Texas, with current public health prevention efforts described
Methods for calculating maternal mortality rates are explained
Topical publications and presentations also available
Link to Texas AIM webpage
Visit: Morbidity-in-Texas/.aspx
SLIDE 29
In the meantime, please check out the new DSHS internet landing page on maternal mortality and morbidity that can be found at the address listed above.
This new DSHS resource offers some background information for understanding maternal mortality and severe maternal morbidity in Texas, with current public health prevention efforts also described.
There is also a link to a page that explains the different methods that DSHS uses to calculate maternal mortality rates.
DSHS publications and presentations related to maternal mortality and morbidity in Texas also available here.
A Texas AIM webpage is being created, and a link to it will soon be added to this landing page.