Preserving Mother's Day

New Task Force Works to Reduce Maternal Deaths

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Public Health Feature – September 2013

Tex Med. 2013;109(9):53-56.

By Crystal Zuzek 
Associate Editor

Lisa Hollier, MD, was ecstatic when she learned Texas will finally have a way to study and track pregnancy-related deaths across the state, thanks to passage of legislation.

In this year's legislative session, lawmakers passed Senate Bill 495 by Sen. Joan Huffman (R-Houston), aimed at helping physicians and public health officials reduce the tragic toll of maternal death in the state. It creates the Maternal Mortality and Morbidity Review Task Force under the Texas Department of State Health Services (DSHS).

Dr. Hollier, chair of the Texas District of the American Congress of Obstetricians and Gynecologists (ACOG), is passionate about reducing the maternal death rate in the state. She specializes in high-risk pregnancy, predominantly among Medicaid patients.

"I think there is no question with the rising maternal mortality rates in Texas that this task force was needed. It's time to start investigating these deaths and to identify potential prevention strategies that can be implemented," she said.

The law took effect Sept. 1 and directs the task force to study and review pregnancy-related deaths and to make recommendations to help reduce pregnancy-related deaths and severe maternal morbidity in Texas. Severe maternal morbidity is any life-threatening health condition that occurs during pregnancy, labor, or delivery, or within the first year following pregnancy. An example is preeclampsia or high blood pressure during pregnancy.

"My legislation sends a strong message that Texas is serious about decreasing its maternal mortality rate and preventing poor health outcomes for countless other mothers," Senator Huffman said.

Without a state entity examining the causes of maternal deaths, Dr. Hollier says, physicians only had access to relevant data within their own institutions.

"That's very limiting and doesn't give us the broad picture we need. The task force's analyses and recommendations will help physicians make a difference in maternal health across multiple health systems," she said.

This past legislative session, the Texas Medical Association worked to pass SB 495 and its companion, House Bill 1085 by Rep. Armando Walle (D-Houston). During the 2011 session, Representative Walle filed legislation to create a maternal mortality review process in the state, but it never made it out of the House Committee on Public Health.

Margo Hilliard, MD, a pediatrician and senior vice president of Health and Wellness Services for the Harris County Health System, says Representative Walle was instrumental in generating support for creating the Maternal Mortality and Morbidity Review Task Force.

"His early leadership and support made passage of this legislation possible," Dr. Hilliard said.  

The TMA Committee on Maternal and Perinatal Health studied pregnancy-related deaths in Texas and recommended policy on the subject at TexMed 2013. The policy, adopted by the TMA House of Delegates, directs the association to support having a qualified committee that reviews maternal mortality to improve services and systems to prevent future deaths. It also says TMA members should be on the task force and recommends the group use CDC's national best-practice guidelines in creating and operating Texas' maternal mortality review system.

Carla Ortique, MD, a Houston obstetrician-gynecologist and chair of the TMA Committee on Maternal and Perinatal Health, testified for the policy at a TMA reference committee meeting at TexMed. She said at the time Texas was the most populous state without a maternal mortality review process. According to Amnesty International, Texas joins 23 other states that have maternal mortality review boards.

"I am extremely excited and happy SB 495 passed. Identifying, collecting, and reviewing maternal mortality data will help us develop and implement recommendations that will have a positive impact on the state's maternal death rate," Dr. Ortique said.

Best of Both Worlds  

Dr. Hollier testified in support of HB 1085 before the House Committee on Public Health. She told lawmakers a task force could identify gaps in services and systems to prevent future deaths and complications and to disseminate findings and recommendations.

"By clearly identifying preventable causes of death and complications, we can better direct resources to improve health for women while reducing health care costs – the best of both worlds," Dr. Hollier testified.

Dr. Ortique says ACOG has long prioritized the reduction of the maternal mortality rate in the United States and started calling for state maternal mortality review boards around 2010.

Dr. Hilliard says that for every maternal death, an estimated 50 pregnant women have near-death complications.

"We need to know what is contributing to this problem, and we need to look at this from a public health standpoint. Doing so will help us identify the factors and correct them," she said.

June Hanke, a nurse and strategic analyst at Harris County Health System, says Illinois' maternal mortality review board determined postpartum hemorrhage caused many deaths.

"If that were an identified contributing factor here in Texas, we could educate health professionals on appropriate actions to minimize it," Ms. Hanke said.

Dr. Ortique told the reference committee at TexMed that maternal mortality is particularly acute in minority populations. According to ACOG, there were 9.1 deaths nationally per 100,000 live births for white women in 2006, compared with 34.8 for African-American women the same year.

"Research by the CDC and Hospital Corporation of America indicate African-American women are three to four times more likely to die from pregnancy-related complications regardless of their socioeconomic status and level of education," Dr. Ortique said.

Pinpointing why African-American women have a higher rate of maternal death requires data.

"Among African-American women there's a higher incidence of obesity and hypertensive disorder, which could be contributing to the maternal death rate. But without data and further study, we can't prove that. I'm hopeful the work of the task force will benefit all women in the state, including minority women," Dr. Ortique said.

She added that the task force's recommendations related to minority and high-risk patients will raise physician awareness of pregnancy-related health disparities.

"If physicians know in advance, for example, that their African-American patients are more likely to suffer complications during pregnancy, they can make different delivery recommendations or triage in advance to ensure these women receive additional medical resources," Dr. Ortique said.

Studying Maternal Death Causes

Why Texas' maternal mortality rate towers above the U.S. average isn't clear. Dr. Ortique says the state's obesity epidemic could provide a clue, but data gathered and analyzed by the task force will help paint a clearer picture of the problem facing Texas women.

Amnesty International has studied factors contributing to pregnancy-related deaths nationally. Deadly Delivery: The Maternal Health Care Crisis in the USA, a 2010 report by the organization, lists the five main causes of maternal death in this country: 

  1. Embolism (20 percent),
  2. Hemorrhage (17 percent),
  3. Preeclampsia and eclampsia (16 percent),
  4. Infection (13 percent), and
  5. Cardiomyopathy (8 percent). 

The report recommends that states establish a maternal mortality review committee if they do not have one. "Committees should receive ongoing funding to collect, analyze, and review data on all pregnancy-related deaths and address disparities. Efforts at the state level should be coordinated nationally by the CDC in order to identify and implement best practice," the report states.

Evelyn Delgado, assistant commissioner of DSHS Family and Community Health Services, says DSHS will randomly select cases containing de-identified information for the task force to review. The task force will have closed meetings at least quarterly. DSHS Commissioner David Lakey, MD, will appoint 13 of the task force's 15 members by Dec. 1. The state epidemiologist and a representative from the department's Division for Family and Community Health Services will round out membership. Ms. Delgado says the task force will likely have its first meeting in January or February of next year.

The bill specifies members must reflect the state's racial, ethnic, and linguistic diversity. Dr. Lakey also must select members from different geographic regions that have communities affected by pregnancy-related death, severe maternal morbidity, and lack of access to perinatal and childbirth services.

The legislation says DSHS may consult with any relevant experts and stakeholders, including anesthesiologists, critical care physicians, nutritionists, substance abuse treatment specialists, hospital staff or employees, Medicaid program representatives, paramedics or other emergency medical personnel, hospital-based risk management specialists, local health department and public health district representatives, public health experts, government representatives or officials, and law enforcement officials. SB 495 allows DSHS and the task force to consult with representatives of state professional associations and organizations, including TMA and others.

SB 495 gives the department an option to establish and maintain an electronic database to track cases of pregnancy-related deaths and severe maternal morbidity. Ms. Delgado says that the department intends to establish a database, but that it didn't receive any funding to do so.

"We'll develop a database in house using existing resources. Once the task force determines how cases will be analyzed, the department will have a better idea of the data elements we need to track. We'll then be able to start designing the system," Ms. Delgado said.

The bill also requires DSHS and the task force to submit a joint biennial report to the legislature on best practices to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity by Sept. 1, 2016. DSHS must report to the legislature by Sept. 1, 2014, on the task force's progress and recommendations for legislation that would help the department examine pregnancy-related deaths and severe maternal morbidity.

 Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.

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