KAREN KOLEGA: Good morning, Joan. Such an honor to be here. And like you said, very excited for this series. We have some great valuable information coming your way.
JOAN PORCARO: Thank you, Karen. We're also joined by Debbie Ketchum. She serves as the clinical engagement specialist at PeriGen. Good morning, Debbie.
DEBBIE KETCHUM: Good morning. Very happy to be here with you.
JOAN PORCARO: And welcome to you both. I asked you both to join me here today to begin a series of discussions that, not only are focused on patient safety, but also looking at avenues to reduce liability for the care team.
And so, I want to begin with my first question that's a worldly question. From what I'm hearing in the news, reading in professional publications, there's been some concerns. There's been some articles and topics about the State of the Union regarding the care of the maternal patient. And I want to take a moment, if you could both give us, bring us up to date what's happening in the world, how are things going?
DEBBIE KETCHUM: Thanks, Joan. Very poignant question and very important. There's so much available information about the global state of maternal health as there continues to be too many maternal deaths. This topic is getting much deserved attention as we have enormous room for improvement. And if you look at the World Health Organization 2020 statistics, a maternal death occurred every two minutes, that's 800 times a day, lower and lower middle-income countries accounted for almost 95% of the maternal deaths, and most could have been prevented.
The worldwide data suggests significant disparities in care as well. Many low-income countries lack skilled healthcare personnel. Social determinants also have significant impact, including income, access to the education, race and ethnicity, which puts populations at greater risk. And the good news is that in the last 20 years, 2000 to 2020, there has been a 34% decrease in maternal mortality worldwide.
JOAN PORCARO: Thank you, Debbie. For those residing in the United States, how does maternal and fetal here compare to global trends? I mean, are we lagging in the US? You mentioned a 34% decrease in maternal mortality and morbidity. Where does the US sit statistically?
KAREN KOLEGA: Hey, Joan. It's KK. I'm going to take that one. So, Deb I think wrapped it up in a beautiful package what's going on in the world. And it's a very hopeful statistic that there's been a 34% decrease worldwide. Unfortunately, the bad news is that we have not seen that decline in the United States. That's a worldwide stat.
So unfortunately, in the United States, we're still seeing rates of maternal morbidity and mortality that, to me, are unacceptable. I mean, those stats that Deb talked about how many women are dying how many minutes. We need to do better absolutely. And the attention that we're getting to this is well overdue.
And I love to see how broad it is, what you're seeing it. Like you said, Joan, when you you're seeing it in articles, you're seeing in the news, you're seeing it in social media. And in fact, it's getting a lot of attention at Capitol Hill, and that brings a lot of hope. But I'm the evidence-based kid, so I'm always going to go to the stats.
And in the United States, according to the CDC, maternal deaths increased between 2018 and 2021. And the disheartening fact is that over 80% are considered preventable. And whenever I say those words considered preventable, I always like to follow it up with didn't have to happen. So again, we need to do better.
And there's significant racial disparities. Black women are three times more likely to die in the United States than White women. The Commonwealth Fund published statistics that demonstrate when compared to other high-income countries, the United States ranks the poorest for maternal mortality. So, we are not winning that race. We are in all the way in the back.
And that data also demonstrates significant racial disparities.
DEBBIE KETCHUM: Yes. Thank you, Karen. Your details are spot on. It sure hits the heart. The White House blueprint for addressing the maternal health crisis also reinforces these details by stating that our country's maternal mortality rate is the highest of any developed nation in the world, and it's more than double the rate of other poor countries. It's just heartbreaking.
Studies show we are lagging in the areas of dignity and respect, which too often results in the complications and mistreatment of our patients. And unfortunately, it is noted that the US has allowed preventable deaths, as you mentioned, which means, like you said, didn't have to happen, life altering complications and untreated mental health and substance use disorders to persist.
The COVID-19 pandemic also added on top of all this information that the recent trends in the closures of rural hospital obstetric services has aided in this long-standing trend. And evidence from maternal mortality review committees in various states around our country suggest the delays in diagnosis, our delays in initiation of treatment, the use of ineffective treatments that contribute to our preventable causes of maternal death.
The World Health Organization sets global targets in 2021 to prevent maternal death, including our global for all women, birthing people, and babies to have access to affordable and high quality care, and before an access to sexual and reproductive health services during the vital times of pregnancy, as well as in the postnatal period, which is great to see that they're expanding services and the attention to the postnatal period, where statistics show 60% of our maternal deaths happen.
So, the World Health Organization has five defined goals with ending the preventable maternal mortality morbidity initiative that targets milestones to reach by 2025. The 90% of pregnant women attend four or more antenatal care visits. 90% of the births to be attended by skilled healthcare personnel. 80% of the women who have been given birth to access postnatal care within two days of delivery, all these are exciting statistics and a good goal to aim for. 60% of the population have access also to emergency obstetric care within two hours of travel time.
And as we're seeing more maternity care deserts evolve, it's important that that we add to our goals as well. 65% of the women to be able to make informed and empowered decisions regarding sexual relations, contraception use, and their reproductive health.
KAREN KOLEGA: Yeah, and if I could just add the thing that popped out to me, Deb, when you read that is the information coming from who. Because in the United States, we don't always look externally, and they really quantified that to have 60% of the population of access to emergency obstetric care within two hours of travel.
And I think the March of Dimes is doing such an incredible job to really highlight the problems we're having with maternal desert and the fact that we're seeing more and more rural facilities close. And that would be great if we could work to adopt that goal here in the United States so that we have that quantifiable-- we need women to have and birthing families to have access. And to do so within a two-hour period, I think, is quite reasonable.
DEBBIE KETCHUM: Right. And reasonable access to care for sure.
JOAN PORCARO: Well, thank you both. Now I want to turn our discussion a little bit. When we think about receiving care, what should a pregnant person expect? What should they know in their heart and soul would be something that should come their way when they're pregnant?
DEBBIE KETCHUM: Well, Joan, that's great. Thank you for that great question. I think I'll take that one. Pretty passionate about this area. I think all of us are, and those listening to our podcast as well. But I think dignity, respect from all members of the care team should be expected. Partnership. The highest standards of care, self-advocacy, the ability to self-advocate and be empowered to get the information, the right information, reasonable access to care as we've discussed, and consistency in care delivery, and no matter what site you go to, the consistency is really important.
The reduction in care inconsistency should be expected. Procedures and protocols that are being developed may create care delivery improvements such as care bundles. But one of the things that we've seen is some individualized care protocols for very high-risk cases like Dr. Jones's looks different than Dr. Smith, and it makes it difficult for the care teams to be spot on with the very rapid care that they need to deliver for our high-risk patients.
JOAN PORCARO: Well, thank you, Debbie. Both your comments and Karen's comments have been a bit sobering. And I want to move towards the other side of the coin, if you will, to talk a little bit more about what has been some of the, or what have been some of the most compelling advancements in the past decade that have improved safety, reduced liability, and made it comfortable for the pregnant person but also for the care team?
DEBBIE KETCHUM: What's really important, and what I've seen, and what's in the literature as well as the development of maternal morbidity care reviews through states we can actually evaluate the data and tackle each issue diagnosis appropriately and with the information that we have at hand to take care of our population. Many caregivers state, nationwide, professional organizations, and nonprofit organizations are dedicated to improving maternal outcomes.
We've seen a significant transition in the creation of care bundles and our care delivery. The bundles allow the providers and care to apply robust evidence-based medicine to ensure the provision of minimal standard of care for all patients. And then the Institute for Healthcare Improvement defines evidence-based care bundle as a structured way of improving the processes of care and patient outcomes. It's a small clear set of evidence-based practices, that when performed collectively and reliably, they have been proven to improve outcomes.
And I just wanted to highlight that definition. So, it was important that they are evidence-based and that the care bundle for consistency, but people do use their critical thinking skills when initiating these bundles, and they look at the individual needs of each patient. The data surrounding early recognition and intervention as a key component in the prevention of maternal death. And this has led to AI, a tool development that's aimed to identify maternal early warning signs to promote an earlier response to rescue and to implement essential interventions.
There are multiple AIs out there for the adult patient population to help identify sepsis, for example. And in the OB space, we now have AI tools and data surrounding our maternal and newborn outcomes such as PeriGen. Just wanted to mention that. And the notification with early warning solutions have advanced to include fetal heart rate, contraction pattern, patient temperature, maternal heart rate, respiratory rate, or O2 sat, blood pressures, pain, and altered mental status.
KAREN KOLEGA: Really great point, Deb, and it's funny with when you do a podcast with these questions. We could go on a long time because there have been so many advancements. And Joan, you said it well. I mean, the statistics are sobering, especially those of us that have dedicated a career to it. So, I think all of us who are change agents, you really want to focus on what can we do to improve.
And patient care bundles have really been a great advancement. They truly have. And I love to talk about what we're doing here locally in Florida. CMS adopted a measure that all hospitals participating in Medicare are required to report, whether they're participating in a national and state perinatal quality collaborative and implementing the safety bundle. So, it is getting attention because we know it is an effective means of improvement.
So, as I said I reside in Florida, we have a very active Florida perinatal quality collaborative. And one of the initiatives, for example, is called the postpartum access and continuity of care, so PACK because Deb pointed out very early. There's a significant proportion of maternal deaths that occur in the postpartum period. So, patients no longer in the acute care arena.
What can we do to improve that? So, with the PACK we had a participation of 75% of the hospitals in the state, and that's a pretty noteworthy statistic. When selecting initiatives for the statewide maternal health bundles, we use the statewide maternal health statistics as one of the considerations. So again, harsh, but why are our moms dying? Because in our state, if it looks a little bit different than other states, then let's address our issues.
And you're seeing the rise of that in many states as Deb already mentioned. You see maternal morbidity, they typically are called PAMR, where they're reviewing literally case by case the deaths in that state to see where our stats are coming from. Is it from opioid OD? Is it from postpartum? Is it from intrapartum complications?
So, our stats in the state demonstrated that 75% of our maternal deaths occur in the first 60 days after discharge, and 2/3 of them again sobering are considered preventable. So, our PACK initiative is scheduled to run through 2024, and we're already seeing improvement. We've seen improvement in the areas of the percentage of patients scheduling early postpartum follow-ups with a qualified clinician.
We're seeing improvement in all of the patients getting education before leaving the hospital about the postpartum warning signs. And we're seeing an improvement in the evaluation of postpartum discharge vital signs and literally just that, are we taking a set of vital signs before a patient leaves the hospital to make sure at right now is appropriate for that patient to be going?
Nurses are key to the success and impact of these initiatives. And they're doing the heavy lifting day in and day out and the hard work of championing these and improving outcomes.
DEBBIE KETCHUM: I'm so glad you highlighted that, Karen. Our nurses and providers are working really, really hard and diligently to make an impact on these initiatives.
JOAN PORCARO: Thank you both. So, I want to take a moment really to talk about data collection. And as a risk management professional for a few decades, to me or for me, how we are collecting data is just as important is actually collecting the data. So, the how is good if you're asking the right questions.
Are we in a place where data is being consistently collected and tracked and trended?
DEBBIE KETCHUM: Joan, we're not yet at a place where our data is being consistently collected, and that is unfortunate. Though we do have some data consistently collected or consistently tracked and trended, but we do know that the data and research are fundamental to identifying these areas for opportunity and measuring our outcomes. And the White House Maternal Health Blueprint reinforces studies that our data collection does remain fragmented.
It is unstandardized, it's non-transparent, and it's irregular. The inconsistent data collection makes it more difficult to effectively quantify mortality rates, but we are focused on improving in this area. There is work being done on improving the data collection within the CDC and state, territorial or local health departments with their joint research project called the Pregnancy Risk Assessment Monitoring System, you may know it as a PRAMS, as well as the maternal mortality review committees that state and local levels to review the deaths of women during or within a year.
It is really sad to say that not all of our states do participate in the maternal mortality review committees at this time, but there is a push to continue to encourage all states to participate for the benefit of our patients.
JOAN PORCARO: So basically, what I'm hearing is, and as we well know, healthcare, we collect a lot of data, we really do. But what I'm hearing you say is, we're beginning to feel better about how we're using that data to actually put the focus on reducing risk and injury and maternal mortality. Do you agree? Do you feel like that's the direction we're going?
DEBBIE KETCHUM: I do agree. I 100% agree. You summed that up very well. We do have a focus on consistency and just data collection overall for our patients.
KAREN KOLEGA: I'd love to add that-- I sometimes word it as I often have to think backwards. And I think that's what was done here. I think that when we started to aggregate this data, we realized that from state to state, there were not only inconsistencies, pretty massive inconsistencies.
And so, I think we're working backwards to realize until we rectify that issue, then we're not going to be able to get aggregate statistics that have the rigor that you need for the work that needs to be done that you've mentioned, Joan, to really look at an aggregate level and be able to say, here's the areas for improvement. Here's where we can help mitigate risk and improve that care and outcome for moms and birthing families and babies. So great question, Joan.
DEBBIE KETCHUM: I'm glad you added that too, KK, because it is very sensitive and emotional. The data is not just data. They're not just numbers. They're people, they're family. And getting to a place where we're comfortable talking about our maternal deaths and morbidity has really progressed over time. But it is really sensitive information that makes it hard to just deep dive right in worldwide.
KAREN KOLEGA: Great point, Deb. And I have to tell you, I don't think you think about those details sometimes, that in order for those maternal mortality review boards to occur, there's people sitting at a table talking about it, and that's a hard day. And we really have to commend our colleagues who are doing that work because it's very emotional. It is. I mean, I've done it. I'm sure you've done it.
And my family would know, be kind to me when I come home because you're pretty worn out because you've dedicated a career to this. And these outcomes just are heartbreaking. They really are. But you have to pick yourself up and say we got to keep moving forward. We have to use this and honor those who lost their lives, so that this doesn't happen.
DEBBIE KETCHUM: Absolutely.
JOAN PORCARO: So, Karen, and Deb, as we well know, healthcare collects a tremendous amount of data. We deal with a lot of data in our day-to-day. So, what I'm hearing you say is that we can use that data, and we should use that data to reduce the risk of injury and maternal mortality. Is that a correct assumption?
KAREN KOLEGA: Absolutely. It's a great assumption. Data is data. But when we apply it and use it for improvement, it's so powerful. So, it makes me think about a recent study that really got me excited, and it was published in the Journal of the American Medical Association, JAMA, we all refer to that. And JAMA is a very respected peer-reviewed publication.
And the study looked at almost 12 million deliveries. So, from an academic standpoint, that's going to get a lot of attention because that's a really big cohort. And when you have those size studies, and you really can get some great statistics that have the rigor behind it. So, 12 million delivery related hospitalizations between 2008 and 2021.
We have that data available now because of the advancements in healthcare and a lot of it because of the universal EMR. So, I believe it's 85% to 95% of hospitals are using the EMR, so we can gather all that data. But do keep in mind with this study, when we talk about our maternal outcomes, it looked at in-hospital care. And a lot of maternal deaths occur in the postpartum, so we're not going to capture that in this study.
But the study findings include a decrease in delivery related deaths in the United States in our hospitals for all racial and ethnic groups, all age groups, and all modes of delivery during that time period. It went on to include that this is likely due to the impact of the national strategies, those bundles that we talked about, that are focused on improving maternal quality of care provided during delivery related hospitalizations. So that to me is such a hopeful study that those bundles that we're implementing for quality improvement are impacting care in a positive way.
And the takeaway for me is that our maternal quality improvement bundles really, we need to look at extrapolating the success of that to those other points of care, like prenatal and postpartum. Because anytime you have a win, let's look at where can we use that to continue improvement across the continuum for our moms or birthing families.
JOAN PORCARO: Well, thank you, Karen. So, we're coming to a close for our session today. And when we're thinking about patient safety and reduced liability, for our listening audience, if each of you could just pick one point, what is that one takeaway you'd want to leave with our listeners?
KAREN KOLEGA: So, Joan, in closing, I have to tell you, I am a bit of a geek. And so, I do believe in smart goals because I think to make them measurable and attainable is really important because we all like to check things off our list. But one important thing that our listeners could do, and I think we have a broad array of listeners, is take the time this week, take 15 minutes, do an online search, and learn about the CDCs. HEAR HER Campaign. So that's the Centers for Disease Control, the CDC.
And they've had a campaign ongoing for a while called the HEAR HER Campaign. It has a ton of information for everyone to learn more and spread the word about this issue. Your awareness, our awareness, everybody's awareness is key to improving this. We have a history of successful public awareness campaigns in this country. Look what we've done with strokes, the improvement is immense. Let's do the same for our moms and birthing people. I know together that we can do better.
DEBBIE KETCHUM: Absolutely. So true. And so many of us are coming together across our world to do better. Now that we know better, we're doing better, we want to make improve our outcomes. And now more than ever, there's a devotion and focus by organizations, legislation, skilled expert, care teams, states, and nations to evaluate and accelerate the progress with improving our outcomes with maternal morbidity and mortality. And I really want to applaud everyone who devotes their attention on this focus.
JOAN PORCARO: Well, I want to first thank, Karen, for joining us today. Thank you, Karen.
KAREN KOLEGA: Joan, it's been such a pleasure. Thank you for having me.
JOAN PORCARO: And as always, Deb, I appreciate your time and your expertise. Thank you also for joining us today.
DEBBIE KETCHUM: Thank you very much, Joan. It was wonderful to be here too with KK and you to talk about such an important topic.
JOAN PORCARO: And in closing, I want to thank our audience. And those who have tuned into our discussion, I hope you'll be joining us for future discussions in the coming weeks. And again, thank you for listening to our podcast, WTW Vital Signs.
SPEAKER: Thank you for joining us for this WTW podcast, featuring the latest thinking on the intersection of people, capital, and risk. WTW hopes you found the general information provided in this podcast informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us.
In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast Incorporated in the United States and Willis Canada Incorporated in Canada.
