By Melinda Young
When California was faced with unacceptably high rates of maternal deaths and disparities among minority patients, the state formed a collaborative to tackle this problem and find solutions.
Called the California Maternal Quality Care Collaborative (CMQCC), the multi-stakeholder organization works to end preventable morbidity, mortality, and racial disparities in the state’s maternity care.1 Between 1999 and 2016, California’s maternal mortality ratio declined while the United States’ maternal mortality rate rose. In California, maternal mortality peaked at 16.9 deaths per 100,000 live births in 2006. It fell to 5.9 maternal deaths per 100,000 live births in 2016. In the United States, the maternal mortality rate was 13.3 maternal deaths per 100,000 live births in 2006, and it rose to 21.8 maternal deaths per 100,000 live births in 2016.1 The collaborative’s efforts also led to a decrease in rates of severe maternal morbidity due to hemorrhage in all races and reduced the gap between Black and white women.2
“Our pregnancy-associated mortality review identified the most common problems — hypertension and hemorrhage — and denial and delay in doing too little too late,” says Deirdre Lyell, MD, co-chair and co-principal investigator of the CMQCC and the California Perinatal Quality Care Collaborative (CPQCC) and a professor of obstetrics and gynecology at Stanford Medicine in Palo Alto, CA.
There was a systems problem in how pregnant patients were treated in emergency departments and hospitals, she notes. If the system allows individuals to make decisions that are not based on evidence and system-created protocols, then mistakes can occur. Individuals can miss patterns that suggest severe problems, but an evidence-based toolkit adopted by a system is more likely to catch problems before they become severe.
Healthcare providers sometimes do too little too late when they recognize the severity of an event affecting a pregnant woman’s health, Lyell says. “So, the collaborative’s work was done to help hospitals switch to earlier recognition of an event that has severe circumstances,” she adds. CMQCC accomplished this through using toolkits and promoting a quality improvement initiative.
For example, CMQCC developed a toolkit that directs hospitals to begin an emergency response to a hypertension crisis and standardizes best practices that are easily understood by the entire team, she explains. Pregnancy management guidelines align with guidelines by the American College of Obstetricians and Gynecologists (ACOG), she adds.
“Sometimes, standardization of care in responding to an acute emergency can benefit a patient when perhaps an individual is not able to do it,” Lyell says. “This takes it out of the hands of one individual.”
The first step was to collect data, which is the role of maternal mortality review committees (MMRC), including the California Pregnancy-Associated Mortality Review, which was launched in 2006 and has included a Pregnancy-Associated Mortality Surveillance System (PMSS) since 2008. There also is the Southern California Pregnancy-Associated Review Committee, started in 2019.3 Once the state identified the problem, they worked to identify systemic solutions, thinking through how providers respond to a maternal crisis from start to finish.
“Who is in the room taking care of each patient, and how can we support every provider?” Lyell explains. “There is something in the toolkit that helps everybody bring their best to the emergency.” It could be recommendations on which medications to give or making sure they have easy access to obtaining those medications to ensure they are not in a locked box.
The toolkits also help hospitals simulate emergencies and identify barriers so they can respond quickly and effectively. “It uses readiness, awareness, and standardization, team training, and communication, as well as debriefing afterwards, reviewing what went well and what could be improved,” Lyell says.
“It’s been very important to us to understand what the proximate causes are for maternal mortality, as well as morbidity,” she adds. “This approach has been critical and is also important to standardize care, and it’s something we’re very proud of.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
- California Maternal Quality Care Collaborative. Who We Are. https://www.cmqcc.org/who-we-are
- Main EK, Chang S-C, Dhurjati R, et al. Reduction in racial disparities in severe maternal morbidity from hemorrhage in a large-scale quality improvement collaborative. Am J Obstet Gynecol. 2020;223(1):123.e14.
- California Maternal Quality Care Collaborative. CA-PAMR (Maternal Mortality Review). https://www.cmqcc.org/research/ca-pamr-maternal-mortality-review
When California was faced with unacceptably high rates of maternal deaths and disparities among minority patients, the state formed a collaborative to tackle this problem and find solutions.
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