California cut its maternal mortality rate in half by identifying common but preventable causes of death. Many of the most dangerous childbirth complications can be solved with simple fixes, such as giving hospitals clear, step-by-step instructions on how to act in case of emergency. The US is the most dangerous country in the developed world to give birth in, and its maternal mortality rate is still rising.
Results & Impact
The maternal mortality rate in California was reduced by more than 55% from 2006-2013, saving an average of almost fifty women’s lives each year. This stands in contrast to national trends - from 2000-2014 the maternal mortality rate in the US soared by 27%, and California’s rate now stands at a third of the national average. Maternal illness, such as hemorrhage and pre-eclampsia (high blood pressure caused by pregnancy), was also reduced in participating hospitals by 20%.
California Maternal Quality Care Collaborative (CMQCC), California Healthcare Foundation, California Department of Public Health, Centers for Disease Control and Prevention
The reduction in maternal deaths was based on better data collection. A collective of hospital administrators, nurses, doctors, and midwives collated detailed data on maternal deaths in the state and used existing research to develop quality improvement toolkits for common but preventable causes of death. The toolkits are downloaded from a website, and are clear, step-by-step instructions for how hospitals can most ready themselves for life-threatening childbirth complications. For example, one suggests that each hospital should have a rolling “hemorrhage cart” filled with all the equipment needed to instantly manage dangerous blood loss. Continued data collection is now carried out through the Maternal Data Center, an online platform through which doctors and nurses can link hospital patient discharge data with state birth certificate data. This generates a wide range of performance metrics that can be used for further quality improvements.
Cost & Value
The program was initially funded entirely by state grants, and information about the size of these is not publicly available. However, hospitals now pay annual membership fees, which range from $2,000 to $10,000 a year per system (this can be one individual hospital or a system with multiple sites). Hospitals with more low-income mothers on Medicaid pay less. Membership fees cover approximately 45-50% of CMQCC’s total costs.
Running since 2006
The program only addresses care that occurs inside hospitals, and its improvements have come from eliminating preventable clinical complications. However, maternal mortality is increasingly related to lifestyle-based health factors, such as heart disease, diabetes, opioid addiction, and obesity. There has also been limited progress on the collaborative’s aims to reduce racial disparities in maternal health (black mothers in the US have a maternal mortality rate three times that of white mothers).
The states of Washington and Oregon now have their own Maternal Data Centres.
California is defying rising maternal mortality rates in the US by using better data to find simple fixes. The state collected detailed information to identify common but preventable causes of death, and informed hospitals about the steps they could take to quickly improve outcomes.
Many of the most dangerous childbirth complications can be survived if hospitals are fully prepared.
The US is the most dangerous country in the developed world to give birth in; between 2000 and 2014, the national maternal mortality rate soared by 27%. Yet, California has turned things around in a dramatic way. The state cut its maternal mortality rate by more than 55% from 2006-2013, saving an average of almost 50 women’s lives each year. California’s rate now stands at a third of the US average. The change has been achieved by improving hospital responsiveness to common but preventable clinical complications.
The first step to discovering which maternal deaths could be prevented was better data collection. In 2006, a collective of hospital administrators, nurses, doctors, and midwives came together to form California Maternal Quality Care Collaborative (CMQCC), based out of Stanford. They collected detailed data on maternal deaths in the state and identified hemorrhage and pre-eclampsia (high blood pressure caused by pregnancy) as two of the most common and preventable causes.
“This really began with understanding what is driving the maternal mortality rate and being able to identify those things where we could have an impact and improve the quality; the preventable drivers,” said Cathie Markow, Administrative Director of CMQCC.
Many states do not collect disaggregated data on maternal deaths, and the US National Center for Health Statistics last published an official national maternal mortality rate in 2007.
CMQCC then used research evidence to develop quality improvement toolkits for those complications identified as common but preventable causes of death. Toolkits can be easily downloaded from a website by participating hospitals; they consist of instructions on the key steps hospitals can take to most ready themselves. As an example, the hemorrhage toolkit says every hospital should have a red “hemorrhage cart” on wheels, modelled on a similar system used widely for speedy treatment of cardiac arrests. The cart is filled with all the equipment and instruments needed to instantly manage dangerous blood loss.
CMQCC is now a partnership of more than 40 public and private agencies. The partners are crucial in a state in which healthcare is largely decentralised. “Where the partners have helped us is using the different levers to get the hospitals, clinicians and so on engaged,” said Markow.
As well as the declining mortality rate, the quality improvements brought about by these toolkits have meant that maternal illness, such as hemorrhage and preeclampsia (pregnancy-induced severe high blood pressure), has also been reduced in participating hospitals by 20%.
Data collection remains at the core of CMQCC, as it is through data that areas for further quality improvement can be identified. It is aggregated through the Maternal Data Center, an online platform on which doctors and nurses can link hospital patient discharge data with state birth certificate data. This generates various performance metrics. Washington and Oregon have now also created their own Maternal Data Centers based on the Californian model.
However, the program faces limitations in the scope of what it can achieve. CMQCC only deals with care inside hospitals, and its success has resulted from preventing clinical complications. Yet, maternal mortality, both in California and in high-income countries in general, is increasingly linked to lifestyle-based health factors, including heart disease, diabetes, opioid addiction, and obesity. “There are more women with chronic conditions, such as obesity, hypertension, heart disease, which contributes to the bad outcomes. The social factors are going to be much more challenging to address than the actual care that occurs in a hospital,” said Markow.
Progress has also been limited in relation to CMQCC’s stated aim to reduce racial disparities in maternal health (black mothers have a maternal mortality rate three times that of white mothers). Furthermore, future changing to federal funding for low-income mothers’ may also impact some of these issues. “About 50% of the births in the US and in California are paid for by Medicaid, so with some of the current dialogue going on politically, cuts to Medicaid could have a significant impact on those moms,” said Markow.
There is no publicly available information on how much the program costs. It was initially funded by state grants, but now participating hospitals are required to pay member fees. Fees cover approximately 45-50% of CMQCC’s total costs, and annual membership ranges from $2,000 to $10,000 a year per hospital system (this can be one individual hospital or a system with multiple sites). The aim is that these costs are not prohibitive: “We have tried not to make fees a barrier for hospitals to participate,” said Markow. “We reduce our fees significantly for hospitals that have a large percentage of low-income moms on Medicaid.”
Besides Washington and Oregon, there is increasing interest throughout the US in the risks of motherhood. “Illinois is doing a lot, and Florida has a strong program,” said Markow.
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