AIMing to Save Lives: More Standardized Care Could Bring Down Texas' Maternal Death Rate
By Sean Price Texas Medicine April 2019


Maternal mortality remains a top public health concern in Texas, and adopting guidelines set up by the Alliance for Innovation on Maternal Health (AIM) is widely seen as the state’s best tool for combatting the problem.

For Shanna Combs, MD, a Fort Worth obstetrician-gynecologist, the “ah-ha” moment came during a routine vaginal delivery. Following AIM best practices, her hospital had recently stopped merely estimating blood loss during delivery and began measuring it by weighing the 4-by-4 gauze pads that soak up the blood. The goal is to recognize more quickly when women start hemorrhaging, a top cause of maternal illness and death.

“If I’d estimated it [during that delivery], I would have said it was about 1,000 milliliters [of blood],” Dr. Combs said. “It was actually almost 1,600 milliliters — a significantly larger amount. That really brought it home for me.”

In this case, the mother was fine. But measuring blood loss confirmed for the hospital staff that the hours of training and preparation required by the AIM guidelines on hemorrhage had been worth the staff’s time, says Dr. Combs, past chair of the Texas Medical Association’s Committee on Reproductive, Women’s, and Perinatal Health.

“It was nice to prove that, while change is hard, this might actually be for the better,” she said.

AIM’s end goal is a radical change in Texas’ maternal death rate. In 2012, the last year for which there is accurate data, that rate ranged from 14.6 to 18.6 deaths per 100,000 live births. While that put Texas near the national average of 15.9 per 100,000 for 2012, as reported by the U.S. Centers for Disease Control and Prevention, the U.S. rate is alarmingly high compared with other developed countries — and it’s climbing.

Thanks to a comprehensive initiative, California became one of the first states to buck this trend.

Between 2006 and 2013, California’s maternal death rate plunged 55 percent from 16.9 deaths per 100,000 to 7.3, according to the California Department of Public Health. In 2006, state health leaders had hospitals study each pregnancy-related death, and then identified ways to prevent future deaths. California’s lessons were later packaged into bundles — or collections of best practices — for hospitals to follow. (See “AIM Bundles,” page 22.)

Those bundles form the backbone of AIM, says Manda Hall, MD, who oversees Texas’ version of the program as associate commissioner for community health improvement at the Texas Department of State Health Services (DSHS).

“Additional states have come on board, and they have seen improvements as well,” she said.

AIM is now a national program overseen by the American College of Obstetricians and Gynecologists (ACOG). Preliminary data in a handful of states that implemented two AIM bundles in 2015 show an 8- to 22-percent drop in morbidity rates, ACOG reports.

Inspired by those results, DSHS launched TexasAIM in January 2018 to encourage all Texas hospitals offering delivery services to voluntarily adopt the AIM bundles. As of February 2019, 207 hospitals — 92 percent — had done so, Dr. Hall says.

In 2017, the Texas Legislature passed Senate Bill 17, which requires DSHS to implement a maternal health and safety initiative like AIM. With TMA’s support, Texas lawmakers are once again looking for ways to improve the state’s maternal death and illness rates. (See “Bill Watch: Maternal Health,” page 23.)


AIM is designed not just to reduce deaths but also to minimize the trauma that thousands of Texas women face when giving birth, DSHS Commissioner John Hellerstedt, MD, said at TMA’s Distinguished Speaker Series in January.

“The important thing to remember about maternal mortality is that the women who die are the tip of an iceberg,” he said. “We know that for every woman who dies … there’s anywhere between 50 and 100 who suffer serious morbidity, serious complications.”

The Four R’s

AIM is designed to help hospital staff respond more effectively to life-threatening complications for women giving birth, says OB-Gyn Rakhi Dimino, MD, medical director of operations for Ob Hospitalist Group in Houston. Rather than one-size-fits-all mandates, AIM gives physicians and hospital staff a goal — like preventing hemorrhage or hypertension — and helps them come up with methods that fit the hospital’s staff and resources, Dr. Dimino says.

“It’s a plan to help that hospital institute their own protocol for how they would address these problems,” she said.

That begins with AIM’s four R’s: readiness, recognition, response, and report. The vast majority of hospitals don’t have unified, evidence-based protocols that address all four of these pieces, says Dr. Dimino, a member of TMA’s Council on Science and Public Health.

When it comes to readiness, she says, some hospitals might already have rules that spell out certain medications to be given in certain situations, but even that is rare.

“Many hospitals simply rely on the physician who happens to be there to remember some of the things that they learned about how to react to hemorrhage [or other problems], and it’s completely up to that physician about how to progress,” she said.

Even fewer hospitals have plans in place to identify a crisis as it’s developing, she says.

AIM also guides hospitals in coordinating responses from outside the hospital, such as procuring blood quickly. Most importantly, it gets the physicians and nurses working as a team, spelling out duties clearly so that everyone can react with maximum efficiency, Dr. Dimino says.

“Before [AIM], the physician could call for these things, but it would be like, ‘Oh, it’s going to take a long time to get the blood,’ or ‘I have to leave the room and get your dose of methergine,’” she said. “Doctors would often know what to do, but the response was slowed down because the hospital wasn’t ready for [the emergency].”

The final “R,” report, means that hospitals collect data about their experiences to help each hospital improve future care. This can include anything from the number of staff needed during certain procedures, to the units of blood used in a month. Some hospitals also use in-person meetings to collaborate with other hospitals.

“Hospitals are learning from each other,” Dr. Hall said. “There may be some [new] things people want to implement [as a result]. But ultimately, it’s going to be up to that team, up to that hospital, on how to implement it within their system.”

Apr_19_TM_CoverPublicHealth_Sidebar1Texas hospitals are implementing the AIM bundles at varying speeds. Some already use several on topics like hemorrhage, preeclampsia, and opioid use, Dr. Hall says. Others still are training staff to use their first bundle.

Following AIM protocols, like measuring blood loss, has not radically changed Dr. Combs’ approach to deliveries. But she says it has made her more aware of what’s happening with the mom and baby.

“The biggest thing in medicine is that we tend to think, ‘I want to practice my way — I’m a trained physician, I know how to do this,’” Dr. Combs said. “But I think [AIM] helps us see the gaps. This is showing us how we can do things better.”

Making AIM happen

Starting in 2020, DSHS will rank Texas hospitals on their maternal levels of care, with Level I hospitals able to accept only low-risk patients and Level IV able to handle anything pregnancy-related. The hospitals will be graded in part on having a quality improvement component to their care. AIM satisfies that requirement, and that is one reason nearly all birthing hospitals in Texas have committed to participating in AIM, Dr. Dimino says.

Most large, urban hospitals won’t see any new costs associated with AIM bundles; smaller, rural hospitals — such as those without dedicated labor and delivery staff — likely will have to spend more money, says Catherine Eppes, MD, an OB-Gyn and assistant professor at Baylor College of Medicine in Houston.

While AIM bundles are effective in stopping maternal death in hospital settings, most life-threatening problems arise after moms take their babies home. Between 2012 and 2015, 56 percent of maternal deaths in Texas occurred more than 60 days after birth, according to the Maternal Mortality and Morbidity Task Force and the DSHS Joint Biennial Report (

Because substance use disorder is a major contributor to these mostly preventable deaths, AIM is working with 10 Texas hospitals to pilot a bundle on treating opioid-use disorder, scheduled for wider release in summer 2020, according to DSHS.

Dr. Eppes, who helps hospitals implement AIM, says staff grumble at first that it seems like yet one more task. But she adds that most of those objections tend to melt away once people see that the time spent learning new procedures and putting them in place can save lives.

Tex Med. 2019;115(4):21-23
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Last Updated On

September 12, 2019

Originally Published On

March 19, 2019

Sean Price


(512) 370-1392

Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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