Christine H. Morton

Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities.

OBJECTIVE: To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs. METHODS: California pregnancy-related deaths from 2002–2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population. RESULTS: Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death. CONCLUSION: Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs. LEVEL OF EVIDENCE: II

Recent Increases in the U.s. Maternal Mortality Rate: Disentangling Trends From Measurement Issues

OBJECTIVE: To develop methods for trend analysis of vital statistics maternal mortality data, taking into account changes in pregnancy question formats over time and between states, and to provide an overview of U.S. maternal mortality trends from 2000 to 2014. METHODS: This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year of adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions. RESULTS: The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington, DC (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, whereas Texas had a sudden increase in 2011–2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported. CONCLUSION: Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington, DC, increased from 2000 to 2014; the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.Background A pregnancy question was added to the U.S. standard death certificate in 2003 to improve ascertainment of maternal deaths. The delayed adoption of this question among states led to data incompatibilities, and impeded accurate trend analysis. Our objectives were to develop methods for trend analysis, and to provide an overview of U.S. maternal mortality trends from 2000–2014.

CreatingaPublicAgendaforMaternitySafety and Quality in Cesarean Delivery

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy

OBJECTIVE Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors. STUDY DESIGN The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data. RESULTS Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes. CONCLUSION African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

Contemporary dilemmas in american childbirth education: findings from a comparative ethnographic study.

In this article, we examine key dilemmas childbirth educators experienced as they made crucial decisions about the content and format of their classes in the current U.S. maternity-care context. This ethnographic study demonstrates that childbirth education is a cultural phenomenon with deeply embedded values regarding the nature and importance of information, scientific evidence, and consumer choice. Articulating how culture shapes the presentation, content, and format of childbirth classes is an important step in understanding and increasing the relevance of this experience for birthing women.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Safety in childbirth and the three 'C's: Community, context and culture

The term ‘hospitalism’ was coined to describe disease promoting qualities of hospitals in the last century. Current estimates from the World Health Organization generally show that there is a 1:10 adverse event rate for people who enter hospital in high-income countries worldwide, with about half being preventable (www. who.int/patientsafety/en). The patient safety movement has been driven by evidence that health care sometimes causes harm to the people it is designed to help, with a focus on the prevention of practices that are harmful. However curiously, debates around safety in maternity care do not always reflect this gaze on the harmful activities of providers and health-care organisations, but on the behaviours and characteristics of women.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Hospital-ownership status and cesareans in the United States: The effect of for-profit hospitals

BACKGROUND Given the increasing proportion of United States hospitals that are for-profit, we examined whether women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. We hypothesized that cesareans are more likely to occur in for-profit hospitals because of the organizational emphasis on short-term financial indicators, including payment of shareholder dividends. METHODS We used logistic regression and difference of means tests to analyze data from the Listening to Mothers III survey of women who gave birth in the United States in 2011 and 2012. RESULTS Controlling for patient-level characteristics, we found that the odds of a womans having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed. CONCLUSION This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

Peripartum Cardiomyopathy Narratives: Lessons for Obstetric Nurses

Poster Presentation Objective To contribute to the theoretical understanding of diagnosis peripartum cardiomyopathy (PPCM) and inform the clinician and patient education components of the Maternity Care Improvement Toolkit on Cardiovascular Disease in Pregnancy. Design Qualitative descriptive study using publically available Internet narratives posted by women diagnosed with PPCM. Setting Three online support groups for women diagnosed with PPCM. Sample Unique narratives ( N = 94). Methods We conducted an online search using the terms PPCM and support. We found three websites that contained publicly accessible stories or biographies (narratives) posted by women diagnosed with PPCM, yielding narratives from 94 women. Narratives were downloaded and deidentified prior to analysis. Narratives were analyzed thematically according the methods of Braun and Clarke. Results The primary themes included symptom experience, dismissal of symptoms by health care providers, including obstetric providers, cardiology providers, and emergency department providers, and a degree of fragmentation in care that endangered women in potentially life‐threatening situations. Symptoms such as shortness of breath, fatigue or exhaustion, fluid retention, and excessive weight gain overlap with normal discomforts of pregnancy, creating space for clinicians to overlook the seriousness of their situation. This analysis highlights missed opportunities for timely, potentially lifesaving, diagnosis of PPCM; the importance of valuing womens knowledge of their bodies; the importance of positive interactions with maternity clinicians; and the critical role of ongoing social support throughout treatment and recovery. Conclusion/Implications for Nursing Practice Cardiovascular disease, especially PPCM, is the leading cause of death among California women, based on the California Pregnancy‐Associated Mortality Review, 2002 to 2004. Taking women seriously and valuing their knowledge as authoritative is critical to prompt accurate diagnosis. Women who receive this diagnosis, similar to other severe morbidities, are likely to experience posttraumatic stress disorder and require additional supportive care and resources as they adjust to postpartum life and recover from life‐threatening illness.