Part 1 of a three-part series.
An alarming number of women die while pregnant or shortly after giving birth in Texas. According to national researchers who say the U.S. as a whole has a serious problem, Texas is an “outlier” when it comes to its high rate of maternal deaths.
Last year, Texas lawmakers directed a task force investigating maternal deaths to come up with best practices to curb those deaths. Experts and advocates say that task force should be looking at one state in particular: California.
“California reduced its maternal mortality rate more than half, from 14.0 [deaths per 100,000 births] to 6.2 ... in four years,” Ted Fox, a retired hospital CEO in San Antonio, told members of the taskforce last fall. That's a fraction of Texas' rate of 34 deaths per 100,000 births.
“There are some lessons we can learn,” he said.
Fox spent decades helping small rural hospitals in Louisiana and California near the Mexican border better serve vulnerable populations. As of late, he has turned his eye to Texas and its sharp rise in maternal deaths.
He says the task force, which was created by the state Legislature, has made a series of recommendations that are “too soft” and don’t go far enough to save lives. He and other advocates in Texas say they want the state to adopt some of the initiatives that worked in California.
Doctors, nonprofit officials and advocates who played a major part in decreasing California’s maternal death rate agree. And they say the state’s model can be replicated here.
Dr. Elliott Main, the medical director of the California Maternal Quality Care Collaborative (CMQCC) based at Stanford University, is a central character in the state's success story.
More than a decade ago, he says, California was facing a startling rise in the number of maternal deaths – just like Texas. This took a lot of people by surprise, because maternal mortality was something most public health officials thought was solved.
“The Department of Health noted the rise and then engaged a group of physicians, nurses and social scientists to start examining the actual causes of the rise and what could be done,” Main says.
He and other advocates and experts in California shared some of the lessons they learned with KUT.
Main now leads a maternal death review committee in California.
Most states used to have these teams, which carefully review each death and help inform methods for doctors and midwives to reduce the number of women dying in pregnancy, while giving birth or after having a baby. In fact, the committees did such a good job that most states stopped seeing a need for them.
Main, who also runs a collaborative in the state, says review committees and collaboratives have been essential to driving down rates in California.
“The first thing we ask a state to do is to form a collaborative of your leading physicians, your health department and your hospital association,” he says. “Those are three critical elements to making change.”
In health care, there is a lot of talk about the problem of silos: the idea that too often people in different fields don’t get to share their expertise and help each other. Collaboratives address that problem by bringing people together.
The role of review committees, Main says, should be focused on collecting data.
Main says the best way to identify maternal deaths is to “link birth certificates to death certificates.”
That way, he says, if a woman dies within a year of her child's birth certificate being filed, folks will be able to flag her death for review. Of course, that doesn’t catch women who die with an ectopic pregnancy or miscarriage, he says. In those cases, the committees comb through news clippings and hospital records.
“That actually is a time-consuming part,” he says. “You have to write to hospitals. You have to get authority from your state to get those records ... and then review those cases in detail.”
Main says data are key to having a clear picture of what the scope of the problem is.
Main says the California review committee’s research found that women were dying in high numbers from heart disease, hemorrhage and complications from hypertension.
“This led us to say that there were things that we could do to reduce the rate pretty quickly,” he says. “In turn, that led to the development of quality-improvement toolkits.”
These toolkits are like detailed emergency plans. They're usually hundreds of pages of advice about what to do if something goes wrong and includes a checklist of everything a delivery ward should have available. They combine lessons learned from the data with existing best practices and address a range of issues doctors and nurses might face throughout a delivery. And, Main says, they’ve been effective.
“This is all you need,” Dr. Katarina Lanner-Cusin, an obstetrician-gynecologist, says as she holds one of the toolkits. “This is a toolkit to support vaginal birth and reduce the primary cesarean section,” which tends to lead to more complications than natural births.
Lanner-Cusin is the administrative medical director for women’s services at Alta Bates Summit Medical Center in Berkeley, Calif. She says the toolkits are widely used in her department, because they provide a step-by step-guide through the stages of a delivery and give her staff a game plan for pretty much any scenario.
“You have a map that you can use to implement this at your own site, which makes it very useful,” she says.
Lanner-Cusin says everyone involved in deliveries – from nurses to midwives to surgeons – reads these toolkits so they're all, literally, on the same page when something goes wrong.
Main says getting doctors like Lanner-Cusin to use the toolkits is an essential step in improving outcomes in hospitals.
Lanner-Cusin says she's always interested in improving the performance of her delivery ward, so adopting the toolkits felt like an important step.
She says improving outcomes for women means she and her team have to do better: "For me, there was definite urgency.”
Lanner-Cusin says most doctors are open to trying something new if there is evidence and data to show it’s effective – which she says the toolkits are.
“Our cesarean section rate for first-time moms in labor is usually around 20 percent, which is a very low rate,” she says. In 2015, by comparison, the percentage of C-sections nationwide was 32.
Another big change that led to a drop in maternal mortality in California is that hospitals were being held accountable for different metrics related to a mother's health.
Stephanie Teleki, director of learning and impact for the California Health Care Foundation (CHCF), says her group had been interested in “the transparency and accountability of California’s health care system” since its inception about 20 years ago.
“We got into the maternity-care sphere wanting to push California and help in – any way we could – get better metrics on maternity care,” she says.
Teleki says her foundation gave money to CMQCC and Stanford University to create a database that links hospital discharge data with birth certificates. She says this allowed the CMQCC to provide metrics to the public about things like elective delivery rates, C-section rates and episiotomies, among other things.
“Hospitals see the value in this because they themselves didn’t have this data,” she says. “Most hospitals couldn’t tell you what their C-section rate is, and most doctors can’t tell you what their C-section rate is.”
This data center lets anyone see how participating hospitals are doing compared to others. It also gives the hospitals a wider array of metrics (more than are publicly reported), so they drill down and see the rates of individual doctors.
“It tries to help the hospital have a dashboard to look at: This is how I'm doing; this is how I'm doing compared to other hospitals in the state,” she says.
Teleki says year after year, more hospitals contribute their records to the data center, and the data center’s stats are now available on hospital Yelp pages.
This transparency has led to a sharp decline in C-section rates, she says. And the rate of maternal deaths in California has dropped along with them.
Teleki says the state is now a positive outlier in the country. While the U.S. rate of maternal deaths is about 22 for every 100,000 births, California’s rate is about 7. Texas' rate is five times that.
Teleki says other states can do what California did and that anyone in Texas who says the state is too big or too diverse or that it will cost too much is wrong.
“If California can do it being a large state, being a diverse state, being a state that has had our own share of challenges with budget and things like that," she says. "I think and I hope that it would be something that other states can look to and replicate.”