How California nearly halved its maternal death rate
- California's maternal death rate fell from 13.1 deaths per 100,000 live births in 2005–09 to 7 per 100,000 in 2011–13, according to a new Health Affairs study. Researchers from the California Maternal Quality Care Collaborative, the public-private partnership that drove those results, explain the four steps they took to nearly halve the state's maternal death rate.
- Those steps were: creating a link between public health data and clinical action steps, mobilizing public and private partners, establishing a data system to support improvement efforts and implementing large-scale interventions by integrating providers with public health services.
- CMQCC is hoping other states will adopt and scale its collaborative model. "This kind of success has caught attention nationally," Elliott Main, medical director of the collaborative, told Healthcare Dive. "It can be done."
Maternal mortality rates in the U.S. increased by 16.7% between 1990 and 2015, according to a report from the World Health Organization and UNICEF based on data from the U.S. Centers for Disease Control. The majority of those deaths — 75%, according to WHO — stem from complications such as infections and high blood pressure.
Yet, the authors of the Health Affairs study cite research that shows the maternal mortality rate in the U.S. has increased by as much as 50% to 70% over the past two decades. Regardless, the United States has a maternal mortality problem, which the study's authors attribute to overtreatment of low-risk women and lack of advanced care for high-risk mothers.
"These are young people who shouldn't die," Main, who is also a professor of obstetrics and gynecology at Stanford University, said. "Most are preventable, so it really hits to your core as a person and as a physician."
The plan the collaborative developed touches on many hot-button issues like data interoperability, public-private partnerships, data-driven best practices and care coordination on large and small scales. While tackling these subjects is easier said than done, this and other projects show the potential for progress.
Two key lessons in reversing maternal mortality, Main said, are denial and delay. "People want to deny that she's as sick as she is. 'It's going to get better, the bleeding will stop, blood pressure will come down,'" Main said. "That invariably leads to delay in treatment."
The first of CMQCC's four steps, linking public health data to action steps, pulls public health from its vacuum where Main said data exists "unconnected to clinical medicine." The group convened a multidisciplinary committee tasked with analyzing cases of maternal mortality, identifying opportunities for improvement and developing quality improvement toolkits.
Second, CMQCC gathered what Main called a "wide set of public and private partners" including hospital associations, Medicaid, commercial payers, clinicians and patient and public groups. Main said one important step forward is the development of bundled payments for maternity care.
The establishment of a data system, CMQCC's third key step, depends on non-public clinical information gleaned from birth certificates and hospital discharge diagnosis files. "That gives us a pretty rich data source ot build on," Main said. "Data is costly for hospitals to collect, particularly if you have to open a chart. It's actually very hard to get stuff out of an EHR."
The last step, implementing large-scale interventions by integrating providers with public health services, begins with a bundle, a quality improvement toolkit defining best practices and the creation of learning collaboratives. The largest of CMQCC's learning collaboratives, which includes 99 hospitals that collectively report more than 250,000 annual births, reduced severe maternal morbidity among women with hemorrhage by 20% using an obstetric hemorrhage toolkit.
Of course, different states will face different hurdles in adopting CMQCC's collaborative model. In California, Main said the support of the state's Medicaid director and numerous hospital systems was vital.
"The states that are more challenged are challenged for two different reasons," Main said. "One is the extent and penetration of the opioid epidemic. That is not nearly as big a problem [elsewhere] as it is in Appalachia. Another big challenge is the Deep South. There are so many structural issues in those states — very low rates of Medicaid uptake and almost no Medicaid coverage between pregnancies for poor women."
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