Background
Maternal hemorrhage is one of the most common causes of maternal
death worldwide. Approximately one woman dies of maternal hemorrhage
worldwide every four minutes or approximately 140,000 women annually.1
In 1998, The Los Angeles County Maternal Mortality Review Report
was jointly produced by the California Department of Health Services,
Maternal Child Health Branch, and the Los Angeles. County Department
of Health Services through a Federal Title V block grant. The
purpose of the review was to identify causes and contributing
factors as well as strategies to reduce the number of preventable
maternal deaths. Three main causes of death identified in the
report were hemorrhage, embolism, and hypertension. African- American
women were identified as being at higher risk. Accordingly 75%
of the deaths had some chance of being prevented. In this review,
provider factors contributed most commonly, patient factors contributed
some and facility and community factors contributed less. Recommendations
of the review panel to decrease maternal mortality addressed many
types of contributing factors and dealt with all stages of pregnancy
from improved women’s health care and preconception counseling
to postpartum education and follow-up.
2
A review of data from 1999 to 2003 indicate that African-American
women in Los Angeles County are three times more likely to die
from a pregnancy related cause than all other women (Figure.1).
The accuracy of data collected during this same time period regarding
the leading causes of maternal mortality is hindered by the fact
that 68% of the “other” category was chosen as the cause of death.
Figure 1. Los Angeles County Maternal Mortality Rates by Ethnicity
With 2.5 million women of childbearing age residing in Los Angeles
County and one in twenty U.S. births occurring here, successful
implementation of the Los Angeles Quality Improvement Project
will result in significant reduction of hemorrhage-related morbidity
and mortality, the most common cause of maternal death worldwide.
In 2005, 22 maternal deaths (the total number of hemorrhage-related
deaths is undetermined due to coding inconsistencies) occurred
in the county. The strategies described have the potential not
only to reduce the overall mortality rate, but can also prevent
approximately 220 near misses and 2,200 serious morbidities.
Project Summary
The goal of the Los Angeles County Maternal Care Quality Improvement
Project is to reduce the overall incidence of maternal morbidity
and mortality by focusing on prevention, early recognition, and
response to obstetrical hemorrhage (OBH).The project targets obstetrical
providers, hospitals, and pregnant women in Los Angeles County
at the top 10 delivery hospitals. We have assembled representatives
from the American College of Obstetricians and Gynecologists (ACOG),
Regional Perinatal Programs of California (RPPC), managed care
health plans, community based organizations, local public health
departments, key hospitals, and obstetrical providers. Additional
partners include the Black Infant Health (BIH) Program, American
College of Nurse Midwives, March of Dimes, and other key organizations.
A three-tired approach targeting obstetrical providers, hospitals,
and pregnant women will be implemented. A Core Advisory
Group comprised of key stakeholders from provider, hospital and
patient organizations will be the body that will work with use
to implement the desired state. Based on an identified knowledge
gap, the ACOG Practice Bulletin on postpartum hemorrhage, and
other evidence-based recommendations and algorithms, will be used
as the basis for educating providers, through grand rounds, direct
mailing, as well as other methods.
To inform and educate pregnant women, educational materials related
to reducing postpartum hemorrhage risk will be developed in English
and Spanish to be distributed to Black Infant Health Programs,
health plans, Comprehensive Perinatal Services Providers, and
case management programs working with the top 10 delivery hospitals.
Strategies
Improving maternal hemorrhage in Los Angeles County will clearly
impact the maternal mortality statistics in California as a whole,
since over one third of the births in California occur in Los
Angeles County, and one-third of ob/gyn providers in California
practice in Los Angeles County. Our proposal will successfully
close the gap in Los Angeles County and will provide significant
leverage to close the gap in California as a whole. We propose
a three tiered approach:
Providers:
The ACOG Practice Bulletin on postpartum hemorrhage, and other
evidence-based recommendations and algorithms, will be used as
the basis for educating providers, through Grand Rounds, e-mail,
public health publications, and direct mailings from health plans.
Pre and post assessments will be implemented as part of the learning,
retention and implementation of the information disseminated.
Figure 2. Strategies for Provider Implementation:
Hospitals:
Collaboration with delivery hospitals will be accomplished through
risk management teams, health plans, and RPPC to refine existing
hemorrhage protocols, disseminate protocols, and urge implementation
of hemorrhage drills. This will enable implementation of a validated
emergency response. Incorporation of these recommendations will
be done in a rapid cycle-change approach to quality improvement
(Figure 3). These initial hospitals will be the early adaptors
and facilitators for adoption of the hemorrhage protocol/drill
by other hospitals. Through reminders and reinforcement of JACCHO
requirements, we hope hospitals will incorporate the drill into
their routine practice and review. Follow up meeting/evaluation
with hospital representatives will track the implementation and
perpetuity of the trainings and drill exercises.
Efforts to improve the accuracy and usefulness of postpartum hemorrhage
coding will also be championed by these hospital partners. The
hope is that the refined coding system would eventually incorporate
and replace the current method of coding maternal morbidity and
mortality. Follow-up and tracking of L.A. County vital statistics
will be one way of monitoring the impact of the data coding modification.
An early alert system for hospitalized patients at risk for obstetrical
hemorrhage is the final hospital component. Similar to an allergy
band that is placed on a patient while hospitalized, a woman at
risk for obstetrical hemorrhage would have a “high risk” band
place on her hand. This will assure immediate identification of
the patient’s risk by any one caring for her, whether it is a
nurse coming to cover for another nurse or a new provider coming
on shift, the early identification band will be an immediate signal
that the patient is at risk for maternal hemorrhage. For patients
without the ability to communicate in English, the maternal risk
band will be a quick non-verbal way of indicating the patient’s
risk to anyone caring for her. This identification band will be
placed on high risk for obstetrical hemorrhage patients admitted
to one of the initial 10 pilot delivering hospitals. Through improved
coding, direct feedback from healthcare providers and hospital
administrators, the effectiveness and usefulness of the early
identification band will be assessed. In the future, our aim is
to expand this early alert system to all the hospitals in Los
Angeles County and eventually implement it into the prenatal care
period.
Figure 3. Rapid-Cycle Change Approach to Quality Improvement:
MAP IT:
Mobilize Groups,
Assess Data,
Plan Standards & Changes,
Implement Changes,
Track
Progress
Patients:
Finally, to inform and educate women of reproductive age, focus
group tested educational materials related to reducing postpartum
hemorrhage maternal morbidity and mortality will be developed
in English and Spanish and distributed through health plans, CPSP
providers, and case management programs. An indirect way of tracking
the efficacy of the educational and communication efforts will
be to incorporate questions related to obstetrical hemorrhage
risks in currently ongoing surveys in Los Angeles County such
as the LAMB (Los Angeles Mommy and Baby Survey) and the L.A. HOPE
(Health Assessment of a Pregnancy Event). With a response rate
of over 50%, these surveys are sent out to over 20,000 women,
and are providing a representative sample of all racial and geographic
areas of Los Angeles County. African American women are over-sampled
in these surveys because of the high negative perinatal outcomes.
The surveys returned from the selected top 10 delivering hospitals
will be reviewed to assess the efficacy of the teaching materials
as well as the communication patients had with their obstetrical
provider regarding obstetrical hemorrhage maternal morbidity and
mortality.
References
1.Abouzher C. Antepartum and postpartum hemorrhage. In: Murray
CJ, Lopez AD eds. Health dimensions of sex and reproduction: the
global burden of sexually transmitted disease, HIV, maternal conditions,
perinatal disorders , and congenital anomalies. Boston: Harvard
University press, 1998:172-4.
2. Maternal Mortality in Los Angeles County 1994-1996, County
of Los Angeles Department of health Services Family Health Programs.
Available at: http://lapublichealth.org/mch/fimr/report.pdf. Retrieved
April 1, 2008.
Resource and Links
California Maternal Quality Care
Collaborative
Obstetric Hemorrhage - Designed to promote a systemized and a
standard response
Safe Motherhood Project Update
Obetretric Hemorrhage - Improvements in Health Care
Maternal Hemorrhage - Prevention of Maternal Deaths
Catastrophic Obstetric Hemorrage
Maternal
Mortality - Obstetric Hemorrhage
Patient Brochure on Heavy Bleeding
(Englsih)
(revised)
Patient Prochure on Heavy Bleeding (Spanish)
LACMQCC Intranet (log in required) - Coming Soon!
For more information, please contact
the Los Angeles County Maternal Care Quality Improvement Project
staff, Diana Ramos, MD, MPH at
dramos@ph.lacounty.gov
or Giannina Donatoni, PhD at
gdonatoni@ph.lacounty.gov.
Preconception Health
