Maternal morbidity opportunities for improvement

It is widely recognized that the U.S. experiences more deaths per pregnant mother than seems reasonable for a wealthy country with an advanced health system. In fact, there are 17.4 maternal deaths for every 100,000 live births, compared to France, the next highest rate of comparable countries, at 8.7 maternal deaths. This translates to about 800 maternal deaths a year in the U.S. This is an unacceptable number for such an extreme outcome, but there are other severe complications that can occur at a more frequent and increasing rate. 

According to the Centers for Disease Control and Prevention (CDC) there are more than 50,000 severe maternal morbidity events per year and the number is increasing. This is especially problematic for Medicaid payers since it finances 40-60 percent of U.S. births, depending on the state. These complications mean a poor experience for the mother, possible impact to the infant and future risk to both. They also represent a higher expense than deliveries without complications, even before factoring in any mid- or long-term challenges.  

Knowing there is a widespread problem is step one. Simply identifying maternal morbidity events is not enough, because the events have already occurred. How do we locate the actionable parts of the system to improve the problem? Creating fair risk adjustment and identifying variation in complications through a fair lens can show where there is opportunity. Using those methods can help bolster deliberate action and maximization of scarce resources. 

The CDC examines 21 complications that they consider severe impactable maternal morbidity events. These are things like blood transfusions, embolism, shock, sepsis, renal failure or hysterectomy. Hospitals can use 3M’s methodologies to recognize complication criteria, as well as adverse events for consideration. 3M also tracks potentially avoidable post-delivery admissions to the hospital or emergency room within 30 days of delivery. Using this broader brush on maternal adverse events gives a fuller picture of potentially avoidable quality defects among deliveries to identify variation and take action.  

Potentially preventable complications (PPC) are easiest when viewed as rates per 10,000 births. Expected values can be calculated using the risk-adjusted cohorts. When comparing the actual occurrences to the expected value, based on the risk of the mothers and severity of the deliveries, variation can point to where action should be taken. Some complications may be unavoidable, but where there is an excessive amount, there is opportunity for improvement. For example, a hospital with a rate of 104 PPCs may look better than another hospital with 123 PPCs. But what if the second hospital is providing services to mothers that have higher risk factors and underlying chronic illnesses? The expected value for the first hospital may be only 85 complications and so they are actually struggling, while the second, with a complicated patient panel, has an expected rate of 140 and is therefore doing better than expected. Bringing the expected values, which incorporate risk adjustment into the discussion, shows much more clearly and fairly the true performance of each hospital. Further, adding in post-delivery hospital and emergency room visits to the analysis doubles the number of complications per 10,000 deliveries, allowing for more views of variation and opportunity for action. 

3M is working on a study of the patterns of maternal complications over the previous two years, with a look at variation in complications by delivery site, practice, health plan lines, geography, age and race as potential variables. If you represent a state or health plan and are interested in participating, contact us here.  

Sandeep Wadhwa, MD, MBA, is global chief medical officer at 3M Health Information Systems.

Shannon Garrison, MBA, MJ, is lead health care policy specialist at 3M Health Information Systems.