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High maternal death rates raise concerns

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Childbirth

A larger percentage of women in the United States die from childbirth-related causes than in any other developed country, studies show.

While some of the socioeconomic factors contributing to the seemingly surprising trend are outside the control of health care institutions and their risk managers, increased attention is being paid to effective hospital risk management programs that can reduce maternal death rates.

Many observers point to the success of a California program that has significantly reduced maternal deaths.

Meanwhile, although there is a consensus that the high death rate leads to higher medical malpractice insurance rates, its precise effect is difficult to assess.

According to the Centers for Disease Control and Prevention in Atlanta, 700 women die from pregnancy-related complications each year in the United States, and about three in five of those cases are preventable.

Heart disease and strokes cause most pregnancy related deaths, which can occur up to a year after birth, while obstetric emergencies such as severe bleeding and amniotic fluid embolisms, where amniotic fluid enters a mother’s bloodstream, cause most deaths during delivery, according to the CDC.

“There is a rising number of maternal complications and severely poor outcomes and it’s probably due to a multitude of factors,” said Dr. John C. Evanko, chief medical officer for Burlington, Vermont-based med mal insurer MCIC Vermont, a reciprocal risk retention group.

“The reason this is happening is complicated, and can be influenced by many factors, including increased rates of chronic diseases, differences in access to care, maternal age at the time of pregnancy and various social factors such as housing and education,” all of which “can contribute to elevated maternal mortality rates,” said Dr. Laurie Zephyrin, vice president, health care delivery system reform, at the Boston-based Commonwealth Fund foundation, a private foundation that supports health care research that conducted a study of the issue.

Up until relatively recently, women typically had their first babies in their 20s, said William J. McDonough, Washington-based managing principal and member of EPIC Insurance Broker & Consultants’ health care practice. Today, a significant number of women have their first child in their 40s, which presents higher risks, he said.

Another factor in high-risk maternal deaths is the prevalence of high blood pressure, diabetes, obesity and alcohol and drug abuse in the United States, medical experts say.

Death rates also vary by ethnicity. Black, American Indian and Alaska native women are two-to-three times more likely to die from pregnancy related causes than white women, according to a CDC report issued in September.

Income disparity is greater in the United States than in most other developed countries, and many women in the U.S. do not have access to health care or are underinsured and, therefore, are more likely to delay their first prenatal visits, said Dr. Jeffrey Levin-Scherz, Boston-based health management practice co-leader at Willis Towers Watson PLC and an assistant professor at Harvard Medical School.

There has also been a lack of attention to the issue. “What we see is, a lot of hospital protocols don’t streamline procedures for dealing with fatal complications and there needs to be more best practices around that,” said Lainie Dorneker, Chicago-based president of IronHealth, a Liberty Mutual Insurance Group unit.

To some extent, the focus in the medical malpractice sector has been on infant claims, which are sympathetic cases that require expensive life care plans.

There is “a lot less focus on maternal death claims, I think, because the damages aren’t as severe,” Ms. Dorneker said. “The awards aren’t as high, so they don’t garner as much attention.”

Every hospital “needs to examine their practices and processes,” said Robin Begley, Chicago-based chief nursing officer for the American Hospital Association.

Risk management

Hospitals with captive insurers can access valuable data that can help improve risk management protocols, said Michael Maglaras, Ashford, Connecticut-based principal with insurance and risk management consultancy Michael Maglaras & Co.

“One of the secrets to getting our arms around a reduction in maternal mortality” is more effectively using the data that has been collected by captive insurance companies for more than 25 years, he said.

For many years, he said, captive insurers’ reports were submitted to health institutions’ chief financial officers. “The smart money today” is on reporting structures where risk management and the captive program report back to the chief medical officer, the person in the organization who can take that data and “translate it internally” into quality improvement, said Mr. Maglaras.

“What risk managers are doing, and need to do, is place this issue, as they have for infant mortality, on their risk radar screen,” said Mr. McDonough. Risk managers should focus on patient safety protocols, present information to committees, and “get the administrative and clinical leadership aware that it is a major issue,” he said.

Risk managers played a significant role in developing safety guidelines for infant care and have the opportunity to do the same for maternal health during pregnancy and delivery, said Mr. McDonough.

Risk managers should manage the risk based on their location and patient demographics, said Dr. Evanko. If they are at a remote site at a distance from more sophisticated medical centers, for instance, they should have policies in place to identify and move patients who must be transferred to other facilities, so they do “not get stuck with a bad scenario,” he said.

“Risk managers can help to reduce rates of maternal mortality by staying informed about, and supporting the implementation of, evolving evidence-based practices in obstetrics,” said Theresa Vander Vennet, director of clinical risk management and associate general counsel at Yale New Haven Health in Greenwich, Connecticut, in an email.

“In addition, advocating for the implementation of high reliability safety practices, team training and supportive, objective medical peer review processes are all within the purview of the hospital risk managers,” she said.

Simulation exercises where “teams get together and work on scenarios that are usually high severity, but low frequency” can also be effective, said Darrell Ranum, Columbus, Ohio-based vice president of patient safety for medical malpractice insurer The Doctors Co.

Post-partum hemorrhaging, for example, “doesn’t happen very often, but the consequences can be catastrophic.” Simulation exercises “improve teamwork, reduce response time and improve the quality of care” provided, he said.

Janell Forget, senior director, risk management at UMass Memorial Health Care, a Worcester, Massachusetts-based health care system that includes five hospitals, said after the death of a young mother in one of its hospitals about a year ago, the system increased its “white code” drills to be prepared for any maternity-related resuscitation, whether mother or infant.

The hospital system has also changed its triage processes for any maternity case.

Pregnant women are no longer categorized separately as obstetrical patients, but are considered regular patients, unless they were “specifically sent into the hospital with a known obstetrical issue,” she said.

“People forget that they may be pregnant, but they have other things wrong with them,” Ms. Forget said. The approach has “really made a difference.”

Risk managers should make sure hospitals are “equipped to manage these emergencies,” can identify those at risk of complications, and know how to handle and prevent them, said Dr. Victor Klein, system director of quality and patient safety obstetrics and gynecology at health system Northwell Health in Great Neck, New York, who is a risk manager.

From a risk manager’s perspective, it is a matter of having the health care team recognize and react in a timely fashion, said Bruce C. Shulan, president and CEO of med mal insurer Physicians Reciprocal Insurers in Roslyn, New York.

Risk managers “who are in a position to be able to effect that outcome” will play an “extremely significant” role, he said.

 

 

 

 

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