Keys to Addressing Maternal Mortality at the State Level: Consistency, Collaboration, and Data

December 12, 2017|5:25 p.m.| ASTHO Staff

Despite an overall worldwide decline of 44 percent since 1990, pregnancy-related deaths have increased steadily in the United States. CDC estimates that over 700 women die each year due to pregnancy or delivery complications. The rate of severe maternal morbidity (SMM), an unexpected outcome to labor and delivery that results in significant short or long term consequences to a woman’s health, increased nearly 200 percent from 1994 to 2014. To address the increase in maternal mortality, states are focusing efforts on increasing consistency in care, fostering coordination and collaboration, and improving data systems. Fourteen states and CNMI are implementing maternal safety bundles through enrollment in the Alliance for Innovation on Maternal Health (AIM). Thirty-three states have established maternal mortality review processes and several states have developed policies and practices intended to reduce to maternal morbidity and mortality. ASTHO affirms that reducing preventable maternal morbidity and mortality will improve both maternal and infant health outcomes and is crucial for the promotion of health.

Increasing Consistency in Obstetric Practice

Countries with standardized approaches to obstetric care exhibit lower maternal mortality rates. A consistent approach to managing complications and emergencies during pregnancy helps to identify problems sooner so they can be treated appropriately. Ongoing national efforts to improve consistency and standardization in obstetric practice include programs such as AIM and policies such as perinatal regionalization.

AIM is a national alliance that promotes consistent and safe maternity care, with the goal of reducing maternal mortality. States enrolled in AIM conduct a needs assessment, select appropriate patient safety bundles, receive bundle implementation support including tools, training and guidance, and track progress through the AIM data center. AIM seeks to reduce maternal mortality and SMM by helping states implement consistent maternity care practices through data-driven quality improvement to address obstetric issues such as severe hypertension, obstetric hemorrhage, maternal opioid use disorders, and peripartum racial disparities. Enrollment in AIM Maternal is voluntary and available on a rolling basis. 

Another method to improve consistency in care is perinatal regionalization, which is an evidence-based strategy that designates where infants are born or transferred according to the level of care they need at birth. This strategy improves both maternal and infant outcomes by ensuring that babies are delivered in risk-appropriate settings. CDC developed the LOCATe tool to give states a standardized method to assess hospital levels of care and to assist in developing regionalized perinatal systems.Twelve states, including Illinois, Wyoming, and California, have utilized the LOCATe tool.

Fostering Coordination and Collaboration

Improving coordination and collaboration among healthcare providers, including OBGYNs, primary care and mental health professionals ensures that issues are identified early and that patients are referred to needed services as appropriate. Many states develop coordination strategies through perinatal quality collaboratives (PQCs). PQCs are state or multi-state groups comprised of perinatal care providers and public health professionals who work to achieve improved health outcomes for mothers and babies through continuous quality improvement. PQCs are currently available in 44 states. The AIM program works with PQCs in participating states to implement initiatives due to the critical multidisciplinary expertise, partnerships and outreach that these collaboratives can provide. 

Members of PQCs can include hospitals, pediatricians, neonatologists, obstetricians, perinatologists, midwives, nurses, state health department staff, quality improvement experts, and others. The groups identify healthcare processes that need to be improved and leverage their partnerships to make changes quickly. PQCs should engage well-connected clinical leadership in obstetrics and pediatrics, involve key state agencies and professional organizations as partners, and integrate community and academic partners. The ability of PQCs to engage community based organizations in high-risk areas makes them well-positioned to address the persistent racial and ethnic disparities in maternal mortality. PQCs are also able to identify barriers to coordination and collaboration between providers and can act to minimize those barriers. The Ohio Department of Health addressed challenges with maintaining clinician involvement in birth outcome improvement efforts by linking clinicians to hospital-specific outcomes data purchased from the Vermont-Oxford Network. This laid the foundation for strong clinical leadership and collaboration in the Ohio Perinatal Quality Collaborative.

Improving Data Systems

To effectively reduce pregnancy-related deaths and severe maternal morbidity, states need access to data on the incidence and causes of maternal mortality. CDC has developed a national pregnancy surveillance system; however, states can face challenges in accessing state-level data on maternal outcomes due to a lack of consistent, standardized tracking and state-level surveillance. To respond to this need, many states have developed maternal mortality review committees.

Maternal mortality review committees are multidisciplinary teams of medical and public health professionals who review pregnancy-related deaths, identify risk factors, make determinations about preventability, and recommend changes to improve maternal outcomes. Thirty-three states have implemented maternal mortality review processes. Michigan’s maternal mortality surveillance (MMMS) began in 1950 and continues to work to improve the health of Michigan mothers, identifying major causes of pregnancy-associated deaths and disparities and making recommendations for action. The MMMS review findings increased awareness among state health leadership of the impact of chronic illness and co-occurring mental and substance use disorders on maternal mortality and morbidity. When asked about the importance of maternal mortality review processes, Lynette Biery, PA-C, MSc, bureau director of family health services at the Michigan Department of Health and Human Services, said “each maternal death has something to teach us.” States can access a rich source of important maternal mortality data and information when reviews are implemented. This data not only helps state maternal mortality surveillance efforts, but also serves as a foundation for PQCs to address maternal health issues in their communities by shaping population-level interventions. To assist states in collecting data and information from maternal mortality reviews, The CDC Foundation, with partners including Merck for Mothers and CDC's National Center for Chronic Disease Prevention and Health Promotion, developed a Maternal Mortality Review Information Application (MMRIA).

There are approximately four million live births in the United States every year and childbirth is the most common reason for hospitalization. Focusing on improving maternal outcomes has a wide-ranging public health impact. By integrating strategies across the three focus areas of consistency, collaboration, and data, states can reduce pregnancy-related deaths, severe maternal morbidity, and racial and ethnic disparities in maternal mortality.