Our Leading Change series profiles leaders in efforts to transform maternity care. This month we bring readers an interview with Christine Morton, PhD, a medical sociologist at the California Maternal Quality Care Collaborative. Christine and I discuss the rising rate of maternal mortality, how standardizing care for obstetric hemorrhage can help, the need for better data collection and reporting, and how state quality collaboratives can lead change. Thanks Christine for taking the time to answer these questions, and thanks everyone at CMQCC for your work to transform maternity care!
TMC Blog: Obstetric hemorrhage is a leading cause of maternal death and the leading complication of birth. Most cases are deemed preventable. CMQCC participated in a state-wide investigation of maternal deaths and developed a toolkit to improve the obstetric response to hemorrhage. How did the process of investigating maternal deaths inform the development of the toolkit?
Christine Morton: The California Pregnancy Associated Mortality Review (CA-PAMR) was initiated by the California Department of Public Health, Maternal Child Adolescent Health Division (CDPH/MCAH) upon seeing the rise in maternal mortality. This project was possible thanks to the strong visionary leadership at CDPH/MCAH and through use of federal Title V funding. CMQCC is a partner in the project along with the Public Health Institute. CA-PAMR is a good example of effective cross organizational collaboration, and committed clinician volunteers, to not only investigate why women were increasingly dying of pregnancy-related causes, but also fund initiatives to address the rise and the associated racial/ethnic disparities.
Christine Morton, PhD
During 2007, the first year of the CA-PAMR, we saw many preventable deaths due to obstetric hemorrhage. And of course, there were other causes of death, such as preeclampsia/eclampsia, where hemorrhage occurs, so it was a key place to start. It was also an issue that resonated with obstetric clinicians. So even before we published our data, we began work on the obstetric hemorrhage toolkit. The report published in April 2011 showed that for the 2002-2003 pregnancy-associated deaths, those due to OB hemorrhage accounted for about 10% of the total but in 70% of cases there was a good or strong chance to alter the outcome.
Furthermore, the quality improvement (QI) opportunities identified in our review directly informed toolkit development. We saw, for example, that teams were slow to recognize the severity of the hemorrhage, and when they did, and began to act, they were missing some key treatments, and were slow in getting blood products. That led us to develop a multi-disciplinary and cross-organizational toolkit. We realized that, in many facilities, blood loss was not being quantitatively assessed nor cumulatively tracked across the woman’s hospital stay. By introducing the Quantitated Blood Loss (QBL) component, we gave nurses and physicians an objective communications tool, when nurses need to call a physician to the bedside to assess and treat a woman’s hemorrhage. We also saw a need for OB departments to have better communications with their blood bank, to facilitate more rapid response to requests, and with their pharmacies, so they’d have the needed medications on hand during an emergency. We also provide information about tools beyond a D&C for addressing a hemorrhage, like the balloon and the B-Lynch suture, and encourage the creation of specialized “OB Hemorrhage carts” where units store all the needed equipment that can be quickly accessed in an emergent situation.
The CA-PAMR committee is made up of a diverse group of very experienced clinicians, who have many years’ experience in a wide range of clinical settings; their perspectives and ability to “read between the lines” in the medical record were invaluable in identifying these issues. We also obtained important insights from our surveys of nursing and medical leaders at delivery hospitals, both before and after our toolkit was released.
TMC Blog: A recent article concluded that prior cesarean, augmentation of labor, and induction of labor are highly associated with postpartum hemorrhage. The approach to reducing the risk of hemorrhage-related morbidity and mortality in the United States, reflected in the hemorrhage toolkit, has focused on management of the third stage of labor and treatment of acute postpartum hemorrhage. How is CMQCC addressing these other “upstream” factors?
CM: Yes, you’re right there are upstream factors that cause hemorrhage. Most women who have a hemorrhage don’t die since most women giving birth are generally young, healthy and strong. While administrative data typically underreports hemorrhage, we know that rates of severe morbidity are increasing, with hemorrhage accounting for over 50% of those cases. The women who died often had other risk factors going into the pregnancy or at intrapartum. So we knew with the increasing cesarean rate and the declining VBAC rate, there would be more women giving birth who have had prior cesareans and thus have greater risk of hemorrhage. So we saw this toolkit as an opportunity to help prepare maternity care clinicians for the future.
At the same time, we want to work to reduce non-medically indicated cesareans and so we are addressing that in two ways. We have been working to develop and raise awareness of maternal quality measures around outcomes like Elective Deliveries Less Than 39 Weeks Gestation and the Low Risk First Birth Cesarean (aka Nulliparous, Term, Singleton, Vertex Cesarean). While ED<39 weeks only account for about 10% of all births, it’s critical that there be no elective inductions or scheduled cesareans for non-medical reasons before 39 weeks’ gestation at a minimum. This measure has been developed into a Toolkit that CMQCC co-authored with the March of Dimes, and with funding from CDPH/MCAH through federal Title V monies. California gave a great gift to the country, since subsequently, the March of Dimes created a national campaign to build awareness of the issue and many states have launched initiatives to implement this policy: North Carolina, Oklahoma, Oregon, South Carolina, Washington and West Virginia. Of course, other states did important work in this area, like Ohio and Utah, before we published the Toolkit.
CDPH/MCAH also funded two projects at the county level: Local Assistance in Maternal Health, in which Los Angeles County MCAH worked with hospitals on implementing the OB Hemorrhage Toolkit, and in San Bernardino County, which addressed the issue of elective inductions among all hospitals. CMQCC provided technical assistance to both counties, and we all learned a lot about how local health jurisdictions can develop new relationships with hospitals around maternal quality improvement projects. It’s very innovative for counties to work at that level.
We are also working on a project to reduce cesareans among low risk women giving birth for the first time, and our recently released white paper outlines where we see quality opportunities. This paper, entitled, Cesarean Deliveries, Outcomes and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality, is available as a free public download from our website.
TMC Blog: California is a state with better data collection and reporting than many other states. How has the availability of data helped your work? What data are not systematically collected or reported that you see as a priority for maternity care quality improvement?
CM: California is better than other states in terms of collecting and reporting data but we have a long way to go before we have optimal data systems that support timely and relevant reporting of key maternity quality measures to providers, payers, and of course, the public.
With regard to case ascertainment of maternal death, it helps that we can link maternal death certificates to fetal death or live birth certificates, and we have the ability to identify maternal deaths not classified as such on the death certificates, by looking at timing of deaths, the pregnancy check box, and key words from the coroner and autopsy reports that alert us to the possibility that it might be a pregnancy-related death. Our maternal mortality review also helps us see the opposite – when deaths were coded as pregnancy-related but were determined by our committee to not be related to the pregnancy or its management. This is a great contribution to our understanding of maternal mortality, since even the CDC isn’t able to access more than the death certificate data. However, maternal death is relatively rare, and it is critical that maternal morbidity and maternal quality be tracked and reported more accurately.
The California Hospital Assessment and Reporting Taskforce (CHART), a hospital-payer collaborative, has been reporting hospitals’ maternity measures on CalHospitalCompare.org for some years. While this is more than many states, we still have a way to go before timely, clearly defined data are transparently reported. For example, CHART reports the AHRQ cesarean measure – the primary cesarean rate among low risk women, yet doesn’t clearly define what this means on its site. While CHART reports the most recent data available, this is variable by measure. In late 2011, the latest data available are 2007 rates for the cesarean and VBAC measures, 2008 episiotomy rates, 2009 breastfeeding rates and 2011 NICU level data (since those are primary measures collected by our sister organization, CPQCC). So we clearly have a problem with old maternity data being reported. The other problem is that there are over 300 hospitals in California, and 280 or so have more than 50 births a year. CHART collects data from just 240 hospitals. So folks looking at CalHospitalCompare.org, the public reporting website, may not have data for their hospital, or if they do, they won’t realize how old the data is or understand how to interpret a particular rate. Finally, only data from one point in time are reported, so there is no ability to see change over time.
Unfortunately, the California Hospital Association recently sent a letter to CHART, which oversees the score cards, announcing its intention to withdraw from the project. This has put the entire project into jeopardy. If CalHospitalCompare.org is discontinued, it will be extremely difficult for the public to compare maternity outcomes in California.
We know the need for usable, valid quality measures in maternity care is rapidly gaining national attention; their development, implementation and tracking are central to quality improvement efforts. Some hospitals are able to provide such data for internal efforts, but many are not. A California Maternal Data Center with the capacity to provide a robust source of near-real-time outcome data for large-scale maternity quality improvement projects is being created through collaboration between CMQCC and several state agencies and other stakeholders. Initial planning support has come from the California HealthCare Foundation, and will move forward with funding from the U.S. Centers for Disease Control and Prevention.
TMC Blog: The California Healthcare Foundation recently issued a report on variation, demonstrating that where a woman lives is a major predictor of whether she’ll undergo elective procedures, including obstetric procedures like elective induction and c-section, as well as VBAC. What do you see as the role of state-wide quality collaboratives in addressing practice variation?
CM: We were pleased to see that report, and have discussed this issue with Stanford professor Dr. Laurence Baker, who conducted the analysis. We have done our own analysis of first birth, low-risk cesarean delivery rates, using a unique linked dataset of both hospital discharge and birth certificate data, and this is featured in our white paper, mentioned above. This observed variation among low risk women is a key issue in how we frame the problem of cesarean delivery and where the opportunities for improvement lie. Statewide quality collaboratives can bring this information to the public, and leverage organizational connections among key stakeholders (payers, hospitals, clinicians, and women) to work on improvement initiatives.
TMC Blog: How has CMQCC engaged childbearing women in quality improvement work? What opportunities do you see for maternity care grassroots advocates to contribute to the work of state quality collaboratives?
CM: CMQCC’s mission is to end preventable morbidity, mortality and racial disparities in California maternity care. The primary way we achieve that mission is through data driven quality improvement for maternity care clinicians. CMQCC leaders saw the most opportunity for change at the site of care where most women give birth – in the hospital — and with those who care for the most women: obstetricians and labor & delivery nurses. Despite our many accomplishments and growing influence, CMQCC is a small operation, with 3.5 FTE staff in addition to Dr. Elliott Main, our medical director, who also practices obstetrics and chairs a large ob/gyn department in San Francisco. We have been able to accomplish as much as we have thanks to the tremendous volunteer labor of dedicated maternity care clinicians who serve on our committees and task forces. Recently, we have established a collaborative relationship with The Preeclampsia Foundation, and one of their California volunteers is currently serving as a patient representative on our Preeclampsia Task Force. Consumer Reports has been doing more in the maternity space, and a representative from their group has been involved in the California Maternal Data Center. We are have created a resources section on our website and are participating in a recently convened statewide initiative focused on Perinatal Mood Disorders.
This is a start, but there are other challenges in engaging childbearing women in our work. There is a diverse organizational landscape when it comes to representing childbearing women, and women are not a unified group with similar interests. CMQCC, a statewide organization, receives a significant proportion of our funding from CDPH/MCAH, and so CMQCC needs to represent and work on behalf of all childbearing women. Of the nearly half a million childbearing women in California, about 50% receive Medi-caid, and 51% are Latina. We are working to build connections through organizations such as the National Latina Institute for Reproductive Health (NLIRH) and their Healthy Pregnancies initiative along with California Latinas for Reproductive Justice.
We welcome ideas from your readership for continued engagement with organizations that support data driven maternal quality improvement.
Christine H. Morton, PhD, is a medical sociologist, whose research and publications have focused on women’s reproductive experiences and maternity care advocacy roles, including doulas and childbirth educators. Since 2008, she has been employed at California Maternal Quality Care Collaborative, an organization working to improve maternal quality care and eliminate preventable maternal death and injury and associated racial disparities.
