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î Good News

î Bad News

î The News That We Don’t Know

Maternal Mortality in Nebraske

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Germ theory

of disease

Obstetric

interventions

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Germ theory

of disease

Obstetric

interventions

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Germ theory

of disease

Obstetric

interventions

Despite past progress, pregnancy-related deaths in the U.S. have been increasing since 1987

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

0

10

20

30

40

50

60

Total Non-Hispanic black Non-Hispanic white Hispanic

2008-2009

2013-2014

Pregnancy-related death rates vary by maternal race and ethnicity

• Maternal Death – death to a woman while pregnant or within 42 days of termination of pregnancy, regardless of the duration of pregnancy, from any cause related or aggravated by pregnancy or its management, but not from accidental or incidental causes. Used by World Health Organization (WHO) and National Center for Health Statistics (NCHS)

• Maternal Mortality – death during pregnancy, childbirth, and the postpartum period (up to 365 days from the end of pregnancy); includes pregnancy-associated, pregnancy-related and pregnancy-associated but not related. Used by the U.S. Pregnancy Mortality Surveillance System.

https://reviewtoaction.org/learn/definitions

Pregnancy-associated, but not related: The death of a woman during pregnancy or within one year of the end of pregnancy, from a cause that is not related to pregnancy (e.g.. a pregnant woman dies in an earthquake).

Pregnancy-related: The death of a woman during pregnancy or within one year of the end of pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.

Pregnancy-associated: The death of a woman while pregnant or within one year of the termination of pregnancy, regardless of the cause. These deaths make up the universe of maternal mortality.

Maternal Mortality Rate • number of maternal deaths per 100,000 women ages 15-44

Maternal Mortality Ratio• number of deaths per 100,000 live births

Pregnancy-related Mortality Ratio • number of pregnancy-related deaths per 100,000 live births

https://reviewtoaction.org/learn/definitions

Data Sources: Nebraska Vital Records, Nebraska Child and Maternal Death Review Team

40.73 41.25 39.8743.13 42.73

51.2146.77

0.00

10.00

20.00

30.00

40.00

50.00

60.00

2009-2011 2010-2012 2011-2013 2012-2014 2013-2015 2014-2016 2015-2017

Pe

r 1

00

,00

0 L

ive

Bir

ths

Nebraska Pregnancy-Associated

Maternal Mortality Ratio (2009-2017)

Data Sources: Nebraska Vital Records, Nebraska Child and Maternal Death Review Team

Maternal Death Category Total

Intentional Injury

Suicide 9

Homicide 6

Unintentional Injury

Fire 1

Motor Vehicle Accident 19

Accidental Overdose 7

Other (fall and heat exhaustion) 2

Medical

Autoimmune Disease 1

Cancer 12

Cardiac 7

Cardiomyopathy 2

Cerebrovascular 2

Embolism 7

Hemorrhage 2

Infection 11

Metabolic/Endocrine Conditions 4

Pre-Eclampsia/Eclampsia 4

Pulmonary Conditions 3

Unknown 4

Total 103

Purpose: to understand medical and non-medical contributors to deaths, determine preventability, and make recommendations to reduce death.

Data Sources• Death certificate linked to fetal death and/or live birth certificates • Medical and behavioral health records • Autopsy • Social service records • Law enforcement reports

Multidisciplinary team determines• Whether death was pregnancy-related• Underlying causes of death• Pregnancy-related Mortality Ratio

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Colorado (2008—2012)Delaware (2009—2015) Georgia (2012—2014)Hawaii (2015) Illinois (2015) North Carolina (2014—2015)Ohio (2008—2015)South Carolina (2014—2017) Utah (2014)

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Leading Underlying Causes of Pregnancy-Related Deaths*

*Amniotic fluid embolism is not included in the embolism grouping due to differences in etiology and interventions Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs.

Leading Underlying Causes of Pregnancy

Findings are not necessarily transferable to Nebraska.

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There is a least some chance of the death being averted by

one or more reasonable changes to patient, family, provider,

facility, systems of care, and or community factors.

Findings of nine state report, 60% preventable. ?

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Distribution of Preventability Among Pregnancy-Related Deaths

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs.

Findings are not necessarily transferable to Nebraska.

1993 - Child Death Review Act

Nebraska Revised Statute §71-3404 to 71-3011*

2005 - Nebraska implements revisions to the US Standard Birth and Death Certificate that includes the pregnancy checkbox

2013 - Child and Maternal Death Review Act

Nebraska Revised Statute §71-3404 to 71-3011*

2014 – NMA Medical Reviews

2018 – NDHHS Maternal Mortality Review Committee (MMRC) of the CMDRT

multi-disciplinary public health review committee

2019 – MMRC reviews 2017 deaths

* https://nebraskalegislature.gov/laws/statutes.php?statute=71-3404

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Maternal Mortality Review Committee 2019 -2022

Robert Bonebrake, MD (MFM), Chair

Todd Lovgren, MD (MFM)

Teresa Berg, MD (MFM)

June Wedergren, MD (OB-GYN)

Jillian Fickenscher, MD (FP)

Susan Weekly, RNC-OB, MS (OB)

Cathleen Peterson-Layne, MD (Anesthesiology)

Sharon Hammer, MD (Psychiatry)

Deborah Perry, MD (Pathology)

Shannon Maloney, PHD (Public Health)

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Statutory requirements• Conduct comprehensive, integrated review of all maternal deaths

• Create a system for statewide retrospective review of existing records

• Identify trends

• Recommend systemic changes to prevent future maternal deaths

Goals• Improve the availability, quantity and quality of data on maternal deaths

• Develop and promote actionable recommendations

• Prevent deaths

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Is:• Ongoing, anonymous and confidential process of data collection, analysis,

interpretation, and action• Systematic process guided by policies, statutes, rules and best practices

• Focused on moving from data to prevention activities

Is Not:• A mechanism for assigning blame or responsibility for any death

• A research study • Subject to ethical (IRB) review

• Disclosable

Berg, C., Danel, I., Atrash, H., Zane, S., Bartlett, L. (Eds.). Strategies to reduce pregnancy-related death: From identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001

• Pregnancy checkbox, OB causes of death to women of reproductive age, death records linked to live birth and fetal death certificates

• Acquire records pertinent to death• Abstract facts into case narrative for in-depth

review

• Use Committee Decision Form to: • Determine if a death was preventable• Make case-specific recommendations

• Deliver recommendations to: · Legislature, NPQIC, Public Health

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î 1. Was the death pregnancy - related?

î 2. What was the cause of death ?

î 3. Was the death preventable?

î 4. What were the critical contributing factors to the death?

î 5. What recommendations and actions address the contributing

factors?

î 6. What is the anticipated impact of these actions?

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Decision Form

MMRC Decision Making Form

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Ø Improve training

Ø Enforce policies and procedures

Ø Adopt maternal levels of care/ensure appropriate level of care

determination

Ø Improve access to care

Ø Improve patient/provider communication

Ø Improve patient management for mental health conditions

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal

mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs.

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Ø Improve procedures related to communication and coordination

between providers

Ø Improve standards regarding assessment, diagnosis and

treatment decisions

Ø Improve policies related to patient management, communication

and coordination between providers, and language translation

Ø Improve policies regarding prevention initiatives, including

screening procedures and substance use prevention or

treatment programs

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal

mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs.

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Deaths

Near Misses

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization

Maternal Morbidity Resulting in Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

Eliminate preventable

maternal deathsTip of the proverbial iceberg…

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Deaths

Near Misses

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization

Maternal Morbidity Resulting in Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

Eliminate preventable

maternal deaths

Reduce maternal morbidity

Improve population health of women

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Eliminate preventable

maternal deaths

Reduce maternal morbidity

Improve population health of women

Deaths

Near Misses

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization

Maternal Morbidity Resulting in Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

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î Review data on deaths from 2017

î Increase awareness of Nebraska’s MMRC among providers and

public health professionals

î Implement the CDC ‘s Maternal Mortality Review Information App to

improve the quality and usability of Nebraska’s data

î Obtain dedicated funding to support activities

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Robert Bonebrake, MD, FACOG

Methodist Health System

Robert.Bonebrake@nmhs.org

402-815-1970

Jennifer Severe-Oforah

Maternal and Child Health Epidemiology Coordinator

Nebraska Department of Health and Human Services

Jennifer.severeoforah@nebraska.gov

402-471-2091