Maternal death rate lowered in California, but racial disparity remains

 
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After the launch of an initiative to reduce maternal mortality in California, which focused on preventing death caused by hemorrhage and preeclampsia, the maternal death rate fell from an average of 13.1 per 100,000 live births from 2005 to 2009 to 7.0 between 2011 and 2013, according to new research in Health Affairs.

Though maternal mortality rates fell for both black and white mothers, the gap between the two remained. In other words, maternal mortality rates for black mothers were still three to four times higher.

Dr. Elliott K. Main, professor of obstetrics and gynecology at Stanford University and lead author of the paper, explained that effort launched after the California State Department of Public Health noticed in 2006 a two-decade rise in the number of women who died from childbirth or pregnancy-related causes.

“It set off alarm bells and they said ‘OK, we need to dig deeper,’” Main told Journalist’s Resource. “Everybody wants to avoid maternal death; it’s one of the biggest catastrophes I can think of in medicine,” he said.

The state put together a maternal mortality review committee, which Main chaired.

“The philosophy was, this is research, but it also was a prelude to action,” Main said. The committee analyzed the state’s maternal deaths with a focus on initiatives that would reduce the maternal mortality rate.

They brought together key stakeholders, including hospitals, clinicians, professional societies, the California Hospital Association, state agencies, consumer organizations, policymakers and researchers through the California Maternal Quality Care Collaborative.

The group developed quality improvement toolkits and learning collaboratives for the two most preventable causes of maternal deaths according to their records review – hemorrhage and preeclampsia. The toolkits included “examples of evidence-based practices, sample policies, mini-reviews of key topics, implementation recommendations, and an educational slide set,” the authors explain. The learning collaboratives tracked hospitals’ efforts to reduce maternal mortality, providing quality improvement support and collecting real-time data.

Main said that the wide-ranging Collaborative allows the project to create change at scale. This is especially key, Main said, because of the state’s large size and population — 1 of every 8 babies in the United States is born in California.

Over the last decade, the efforts have reached almost every hospital in California.

The initiative also comprised a concerted data collection system, in which 212 of California’s 240 hospitals are enrolled.

As hospitals across the state rolled out the toolkits and participated in learning collaboratives, maternal mortality decreased.

Specifically, the researchers found:

  • The 99 hospitals that participated in a learning collaborative on reducing severe maternal morbidity “saw a reduction in severe maternal morbidity among women with hemorrhage of more than 20 percent, compared to the 1.2 percent reduction in a contemporary comparison group of 48 hospitals … that were not yet participating in the collaborative.”
  • Some of these hospitals previously had participated in another learning collaborative on the topic of hemorrhage, and they did even better – they saw a 28.6 percent improvement, compared with 15.4 percent among hospitals that were first-time participants.

Main said that while the study doesn’t prove a causal connection between the Collaborative’s efforts and the statewide reduction in maternal mortality, the researchers were not aware of other activities going on in the state that shared this specific focus. He did note, however, that as a state, California “embraced” the Affordable Care Act. The rate of uninsured people in the state dropped to below 7 percent after it was enacted, and expanding access to care might have played some role.

The Collaborative is now focusing on reducing the state’s cesarean birth rate. In the first year of this effort, the state has seen a reduction of almost 4 percentage points in low-risk first-birth cesarean deliveries – a drop from 28.8 percent to 24.9 percent.

Meanwhile, other states are following suit. The National Network of Perinatal Quality Collaboratives, a project launched by the Centers for Disease Control and Prevention and the March of Dimes, and the Alliance for Innovation on Maternal Health have both initiated multi-state efforts to reduce maternal mortality.

 

Looking for more research? We’ve covered scholarship that highlights risks that rural mothers face and the links between neighborhood crime and premature birth.

Last updated: September 11, 2018

 

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Citation: Main, Elliott K.; Markow, Cathie; Gould, Jeff. "Addressing Maternal Mortality and Morbidity in California Through Public-Private Partnerships," Health Affairs, 2018. DOI: 10.1377/hlthaff.2018.0463.