Maternal Mortality in the United States: A More Comprehensive Picture to Advocate for Changes that Save Lives

In 2014, I had the opportunity to work with the Health Resources and Services Administration (HRSA) Graduate Student Epidemiology Program (GSEP). My project was focused on evaluating the maternal mortality review committee process in Georgia. Early on, most of my work consisted of becoming familiar with the global burden of maternal mortality (starting with the 2010 Amnesty International special report on maternal health care in the United States– This report criticized estimated maternal mortality ratios that gave the United States (U.S.) a subpar global ranking based on data published by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNPF), and Word Bank in 2005– despite the U.S spending more than any other country on health care), becoming acquainted with appropriate case definitions for surveillance, and reviewing various maternal mortality review data sources to gain situational awareness of the distribution and determinants of maternal mortality in the United States. Ultimately, this led me to realize that, although maternal mortality was seemingly rare and largely preventable in the U.S, the disparities that existed based on race, socioeconomic status, and quality of care were concerning.

 

As the heart of my project took off, I learned about key aspects of Georgia’s maternal mortality review committee. The committee, like others similar to it, was tasked with identifying maternal deaths using multiple data sources, reviewing medical records and death certificates to classify cases accurately (i.e. not a case, pregnancy-related, or pregnancy-associated), and evaluating which deaths were truly preventable. The process evaluation that I conducted assessed whether the review process was taking place as intended, best practices were being employed, and pregnancy-related deaths were accurately being classified. The evaluation also provided action points and recommendations that included tracking and reporting dissemination efforts intended to inform provider care, having a unified voice on the topic of maternal mortality in the state (due to conflicting local news headlines or statements made), defining process indicators, and developing a feedback loop for policy and educational changes.

 

After returning to my home state of Texas and joining the public health workforce, I remained interested in maternal mortality and learned that work was being done here too- in the form of a Maternal Mortality and Morbidity Taskforce. That was about a year and a half ago. More recently, there has been renewed media interest concerning how maternal outcomes (including maternal mortality and severe maternal morbidity) in the U.S. compares to other countries. A visit to the Centers for Disease Control and Prevention (CDC) website provided me with some background on how the CDC tracks severe maternal morbidity in the U.S. and highlighted the main risk factors or indicators for complications during pregnancy. According to the CDC, recent trends show an increase in maternal morbidity rates from 1993 to 2014 for the following indicators:

 

  • Blood transfusions at 399%.
  • Acute myocardial infarction or aneurysm at 300%.
  • Acute renal failure at 300%.
  • Adult respiratory distress syndrome at 205%.
  • Cardiac arrest, fibrillation, or conversion of cardiac rhythm at 175%.
  • Shock at 173%.
  • Ventilation/temporary tracheostomy at 93%.
  • Sepsis at 75%.
  • Hysterectomy at 55%.

 

At the same time, rates decreased or remained the same for the following indicators from 1993 to 2014:

 

  • Disseminated intravascular coagulation.
  • Air and thrombotic embolism.
  • Amniotic fluid embolism.
  • Acute congestive heart failure or pulmonary edema.
  • Puerperal cerebrovascular disorders.
  • Heart failure or arrest during surgery or procedure.
  • Eclampsia
  • Severe anesthesia complications

 

The data collected by the CDC suggests that women who are giving birth later in life or were obese before becoming pregnant/have other underlying health issues may be contributing to increases in maternal morbidity due to not being as healthy as the typical population of women that would be giving birth in the U.S. Cesarean sections are also being performed more frequently which greatly increases the risks of complications for women. On November 14th, 2017, the CDC hosted a Grand Rounds session titled, “Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States“.  William M. Callaghan presented data from the National Vital Statistics Registry which showed an increase from 1999 to 2014 in the maternal mortality rate (MMR) in the U.S (from 9.8 to 21.5 maternal deaths per 100,000 live births). America’s Health Rankings indicates that the U.S. had a rate of 19.9 maternal deaths per 100,000 live births in 2016. There was great variation across states, however, ranging from 5.8-40.7 maternal deaths per 100,000 live births.

 

Vital statistics collected by the National Center for Health Statistics (NCHS) are only one measure of maternal mortality and are limited in their ability to accurately identify cases. The Pregnancy Mortality Surveillance System (PMSS) enhances NCHS data by adding a pregnancy checkbox to maternal death certificates so that epidemiologists can link them to birth or fetal death certificates. PMSS also includes all maternal deaths occurring during pregnancy or within one year of the end of pregnancy, instead of only those that occur during pregnancy or within 42 days of the end of pregnancy. PMSS uses clinical relevance, rather than Cause of Death codes, to classify cases and the Pregnancy-related Mortality Ratio (PRMR) as its unit of measurement- MMR and PRMR have the same denominator. When comparing the MMR (which is calculated using vital statistics data) to the PRMR, there is an increase in maternal mortality but the increase is not as steep (13.2 to 17.3 as opposed to 9.8 to 21.5) and seems to be leveling off over the past few years. PRMR is more comparable to MMR when restricted to maternal deaths occurring during pregnancy or within 42 days of termination. Once this adjustment is made, maternal mortality appears to be relatively flat from 1999 to 2014. Since the PRMR incorporates clinically relevant elements, specific changes in trends can be observed. For example, between 1987 and 2013, there was a decrease in maternal deaths due to hemorrhaging and hypertension as well as an increase in maternal deaths due to heart conditions. Additional data from PMSS indicates that state maternal mortality rates ranged from ~7 to 33 maternal deaths per 100,000 live births from 2006-2013 (again showing an increase that is lower than maternal mortality rates calculated using vital statistics data). At the same, it shows that some states have 3-4 times the number of maternal deaths than other states. These differences are similar when comparing mortality across race/ethnicity- Non-Hispanic Blacks and American Indian/Alaska Natives have 3-4 times more maternal deaths than other groups. Ultimately, this paints a picture of state-level and racial/ethnic disparities that are occurring throughout the U.S.

 

Review committees and task forces like the one I evaluated in 2014 have been established in different states in order to review cases of maternal death and/or severe morbidity. However, while individual states have a better ability to implement quality improvement initiatives that are relevant to their specific needs and risk factors, it takes significant political and social motivation to pass legislation that establishes these committees. The CDC provides technical assistance to jurisdictions that desire to establish maternal mortality review committees and identify preventable deaths as well as highlight interventions that can save lives. In fact, it is information from these reviews that have led to the realization that 20%-59% of maternal deaths are preventable. The Maternal Mortality Review Information Application (MMRIA) has more recently been established to create a standardized set of best practices that have been gleaned from maternal mortality review committees across the nation.

 

So, what’s the point? My evaluation in 2014, the surveillance data that is being collected by the CDC, the committees that are being established, best practices that are being compiled, and media stories that are being written should result in the implementation of evidence-based interventions that save lives. Here are some good examples:

 

  • Earlier this year, California was celebrated as being a state that has seen a 55% decrease in maternal deaths between 2006 and 2013 due to the development of the California Maternal Quality Care Collaborative. The collaborative is a product of the review process and has put in place various toolkits, research articles, and collaborative outreach materials to improve the health of mothers.
  • A 2016 report from Saving Mothers Giving Lives, an international collaborative, has shown that countries such as Zambia and Uganda are on track to meet their 5-year goal of reducing maternal mortality by 50%

 

At the end of the day, even one preventable maternal death is one too many.

 

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Membership Roadmap: The IH Section is Ready When You Are!

In May 2015, I became a graduate student member of the American Public Health Association so that I could attend the Annual Conference and take advantage of networking opportunities. I applied for and received a travel scholarship from my university later that year.

While at the conference, I attended a variety of Student Assembly, Epidemiology, Maternal and Child Health, Community-based Participatory Research and International Health Section sessions. I also visited the Expo Center and made sure to hand out many copies of my resume as well as business cards at various booths. With my student membership, I was able to join two Sections and selected Epidemiology (my concentration) and International Health as my main groups to plug into.

Shortly after attending the Annual Conference and following up with contacts I met using email and/or LinkedIn, I had to switch my focus to finishing my practicum and graduating within the next month. In addition, I began to close out my involvement with student organizations while balancing the “job search” process. It was a busy time for me.

In February 2016, I was hired to work at a local health department as a High-Consequence Infectious Disease Epidemiologist. Since I was living ~3 hours away from where I was going to begin working, I had to find someone to take over my lease while starting the 45 min- 1.5 hour commute to work from my parents’ house. During this time, Zika virus was declared to be a public health emergency by the World Health Organization and became one of my highest priorities.

Fast forward to the end of May 2016. I received a second notification to renew my APHA membership but was weighing whether or not it would be a worthwhile investment since I wasn’t sure how APHA could benefit me. Thankfully, the Early-Career Professionals group was a great incentive for me to choose to renew my membership. Because the membership fee was reduced, funding was available, and products like the journal and newsletter could be shared within my workplace- my employer was willing to cover the membership renewal fee. These elements also played a role in me being able to attend the Annual Conference for the second time. I made a list of conference sessions that could be beneficial to my health department and solicited feedback from leadership as well as my colleagues to see what information they wanted me to bring back. I also focused on seeking out ways to collaborate and contribute to the broader public health community. This led me to take a leadership position with the International Health Section Communications Committee after seeing a Call for Volunteers in an awesome newsletter that came through my email.

Since joining the IH Communications Committee in October 2016, I have been able to post to the Section blog, create an informational video, utilize new social media outlets, review policy, serve as a proxy for a Governing Councilor at the Annual Conference, create a Membership Roadmap, assist with the Listserv as needed, share professional development opportunities, contribute to strategic planning efforts, review abstracts and much more.

So, what’s the point of me sharing all of this?! It’s never too late to get involved! Even though there were some lapses in my activity due to work and life, when more time became available in my schedule (or my circumstances changed) I was able to fall back on my membership.

If you’re looking for ways to get involved, make sure to check your emails for post-conference opportunities, read the Section blog as well as newsletter, and feel free to use the Membership Roadmap as a flexible guide!

 

roadmap

 

 

 

 

 

 

Ready or Not? A Glimpse into How Public Health Responses are Coordinated

Most of us dream of one day working for the Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO). We often envision ourselves responding to public health events around the globe and being placed in the middle of the action- whatever that action may be…

However, have you ever wondered how the response to an infectious disease outbreak or disaster is organized? Do you know how multiple agencies coordinate people and resources during a response? This blog post will provide a brief overview of functions of the National Incident Management System (NIMS), Incident Command System (ICS), Multi-Agency Coordination Systems (MACS), and Emergency Operations Centers (EOC).

Emergency management professionals are tasked at the local, state, and national level with coordinating responses to incidents- also known as events, natural or human-caused, that require a response to protect life or property, according to the Federal Emergency Management Agency (FEMA). Governmental agencies in the United States are required to follow NIMS, a systematic approach that is grounded in preparedness concepts and supports incident management for a diverse range of hazards, in order to receive preparedness grants or funding. NIMS incorporates standard resource management procedures and includes principles for information management. While NIMS is NOT a concrete plan, it supports the development of plans created by various jurisdictional players- one of the benefits of being a flexible, scalable, and dynamic approach.

The five key areas of NIMS are:

  • Preparedness– focused on planning, organizing and equipping, training, exercising, and evaluating/improving readiness to respond to an incident. Preparedness is supported by partnerships that are formed between government agencies, nongovernmental organizations, and the private sector before an incident.
  • Communications/Information Management– based on the concepts of a) Common Operating Picture, b) interoperability, c) reliability, scalability, and portability; and d) resiliency and redundancy. Communications systems should be flexible and adaptable to each incident.
  • Resource Management– serves as an accountability system for establishing current assets, identifying needs, requesting additional resources as well as organizing and tracking materials and personnel. It also allows for critical resources to be shared across jurisdictions.
  • Command and Management- consists of three organizational constructs: 1) Incident Command System (includes a management hierarchy that can be integrated into a common organizational structure), 2) Multi-Agency Coordination System (utilized when multiple agencies are involved) and 3) Public Information (processes for sharing timely, accurate, and relevant information during an incident).
  • Ongoing Management and Maintenance

Emergency Operations Centers (EOC) are used for information collection and evaluation, coordination, and priority setting. These are central locations where officials and personnel from key agencies go to meet, make decisions, and direct response activities.  Resources are coordinated at local EOCs, then at state EOCs when there are not enough resources to support an effective response. If state resources are overwhelmed then assistance from the federal government may be requested.

As stated earlier, this is just a brief overview of how a response is coordinated during an incident such as a public health event. In my next blog post, I will share my recent experience applying NIMS from a regional health department perspective.

 

Watch this video to see how the CDC responds to public health events and sets up its EOC!

 

 

 

The 9th TEPHINET Global Scientific Conference: Ending Pandemics in our Lifetime Initiative

From August 7th-11th, The Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) held its 9th Global Scientific Conference and the 23rd National Epidemiology Seminar in Chiang Mai, Thailand. I had the opportunity to listen to a panel presentation on Global Influenza Surveillance as well as the following presentation on Ending Pandemics. The overview I have provided below summarizes Mark Smolinski’s (Director of Global Health Threats at Skoll Global Threat Funds) presentation on innovations in surveillance for personal, national, and global health security. Feel free to listen to the entire presentation (1:17:00-2:16:28)!

  • Epi curves generally focus on human disease but human disease and animal outbreaks coincide or trigger one another. Additionally, bioterrorism can play a role in outbreaks and should be included in epi curves.
  • There are six main opportunities for epidemiologists/public health practitioners to intervene and reduce risk from pandemic threat:
    • Stop the threat in the animal population
    • Reduce the epi curve in the animal population
    • Find the first human cases (quickly)
    • Limit human infections and stop the epi curve in the animal population
    • Ensure strong surveillance/warning systems are in every country so disease doesn’t spread beyond country borders
    • Know and work directly with neighbors across borders so that regional security exists to stop any outbreak/prevent pandemics
  • It costs 3.4 billion dollars to prevent a pandemic by ensuring that developing countries have baseline capacity/public health systems that meet international standards. The return of investment is 10 fold. We are currently at ~450 million dollars.
  • Innovations in Surveillance – Researchers in tech as well as universities are involved in innovative surveillance methods, not necessarily epidemiologists/public health practitioners:
    • Google Flu Trends –predictive of flu and comparable to CDC flu reports (visits to providers), which were delayed by two weeks (80% of ill individuals did not visit a provider)
    • Twitter – University of Rochester developed an algorithm that can predict flu with 90% accuracy and gives an 8-day notice of when someone will get the flu (based off of tweets of others in your community/social circle)
    • HealthMap/Flu Near You – Participatory surveillance system that allows people to check off symptoms, see results on a map, and find where the closest vaccines are; correlates very well with the CDC influenza-like illness surveillance (over 5 years)
    • Epi Hacks – the idea is to bring together human, animal, and environmental health experts for one week to work with developers to come up with open source products for countries to use (for surveillance purposes); at least one has been conducted on each continent
    • PODD – uses a One Health approach as people in villages are tasked with helping find outbreaks quickly and reporting animal morbidity/mortality in real-time
    • KIDENGA – CDC and the University of Arizona are working together on vector-borne surveillance on the U.S/Mexico border, an epi hack will take place to see if they can create a sustainable way to address vector-borne diseases
    • Guardians of Health app – asked attendees to report health issues or symptoms during the World Cup, attendees received health information and program updates/information in return
    • EPICORE – retrospective analysis of public health information related to outbreaks; an automated system that epidemiologists follow-up on (after requests for information have been sent out)
  • When there are no outbreaks, public health gets no credit…
  • All countries cannot meet the International Health Regulations, even if they agree that they SHOULD be met
  • Skoll Global Threats Fund teamed up with Google and examined publicly available data at the World Health Organization (WHO) to determine how long it takes to detect, report, and respond to outbreaks; found that the global community is improving but has plateaued (due to limited data)
  • Research Paper – Finding Outbreaks Faster – Smolinski MS, Crawley AW, Olsen JM. Finding Outbreaks Faster. Health Security. 2017;15(2):215-220. doi:10.1089/hs.2016.0069.
    • There are epidemiologists in 28 countries looking at data from each outbreak to determine 6 metrics that all countries can follow (over past 5-10 years)
    • Countries had never looked closely at this issue and were able to see their strengths and weaknesses in investigating different types of outbreaks
    • Hot Spots of Emerging Infectious Disease – CORDS
      • Build friendship and trust across borders
      • Helps regional disease investigation networks share best practices, scale innovations, optimize informal networks
      • South Asia and West Africa are the most concerning for emerging infectious diseases, in a few years they may have stronger regional networks
  • Ending Pandemics Collective
    • 14 foundations and leaders of companies concerned about social responsibility want to invest in global health, share ideas, coordinate funding for projects, break down barriers in the foundation world
      • Smithsonian Museum of Natural History wants to do a 2-year exhibit called outbreaks, collectively a great chance to improve the knowledge base of people that visit the exhibit (~7 million people)
      • In 10 years the collective sees a world where:
        • Every outbreak is detected within 3 incubations periods of the index case or cluster
        • Every country’s Emergency Operations Center is utilizing an integrated, event-based detection system being used simultaneously by the WHO and G20
        • Human, animal, and environmental health volunteers are verifying rumors or suspected threats within 24 -48 hours through EpiCore
        • Participatory surveillance is engaging communities directly to detect and respond to outbreaks in every disease hotspot across the globe
        • Field epidemiologists in every country are using the latest technology to detect, verify, and respond to outbreaks faster
  • At the end of the day, pandemics can be prevented because “no community is too hard to reach, no community is too poor to innovate, and curiosity outshines fear!” 

13 Years to Eliminate Morbidity and Mortality due to Viral Hepatitis- Global Partners Believe It Can Be Done!

The liver processes nutrients, helps to fight against infection, and aids in cleaning the blood in our bodies. Inflammation of the liver is generally known as hepatitis. Although hepatitis can be caused by autoimmune disorders, occur as a result of excessive alcohol consumption, or become induced after a toxin is introduced into the liver, the hepatitis of most concern has a viral origin. While there are 5 main viruses (Hepatitis A-E), Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) are responsible for the majority of morbidity and mortality cases associated with viral hepatitis infections globally- this is comparable to HIV/AIDS and TB, killing 1.34 million people a year. Hepatitis can either be acute (i.e. a short-term illness within 6 months of infection) or chronic. 75-80% of individuals infected with HCV will develop a chronic infection. The likelihood of HBV becoming chronic largely depends on the age at which infection occurs. According to the Centers for Disease Control and Prevention (CDC), 90% of infants, 25-50% of children between 1-5 years of age, and 6-10% of individuals over 5 years of age will develop chronic HBV. Although the majority of individuals are diagnosed at a young age, younger age groups are less likely to show symptoms.

Currently, there are 240 million people living with chronic HBV and 130-150 million people with chronic HCV around the world.

Risk factors for HBV and HCV include:

According to the World Health Organization (WHO), there are differences in global burden of disease trends for HCV and HBV:

  • HCV: Affects all regions although there are significant differences between and within countries. The WHO Eastern Mediterranean Region and the European Region have the highest reported prevalence of HCV.
  • HBV: Mostly affects the WHO African Region and the Western Pacific Region

The number of cases of hepatitis that are diagnosed increases every year as well as deaths, which have increased by 50% over the past 20 years. Even worse, most people with hepatitis are asymptomatic in the acute stage and the beginning of the chronic stage- those with symptoms may have fever, jaundice, loss of appetite, grey stools, dark urine, and abdominal pain.  Although a vaccine is only available to protect against HBV, effective treatment options exist for both chronic HBV and HCV. This is an important reality since therapy and proper case management can reduce the risk of complications such as cirrhosis, liver cancer, and premature death that are caused by chronic hepatitis infection. Access strategies supported by the WHO in 13 countries have helped more middle-income countries receive necessary medications such as Directing Acting Antirals (DAA). These drugs have a cure rate of over 95% within a 3-month timeframe, for HCV, and less side effects than other drugs- but 80% of HCV cases still have difficulties accessing the treatment and case management they need because it can be expensive. The WHO released the report, “Global Report on Access to Hepatitis C Treatment: Focus on Overcoming Barriers,” which discussed the importance of political mobilization, advocacy, and pricing negotiations on increasing access to necessary medications in low-middle income countries. Local, more cost-effective medications have even been manufactured in a few countries. In order to address the 80% of people still in need of help, in May 2016, at the World Health Assembly, 194 countries adopted the Global Health Sector Strategy on Viral Hepatitis with the goal of eliminating hepatitis by 2030. DAAs were also added to the List of Essential Medicines.

Information from the global strategy is incorporated into World Hepatitis Day activities. World Hepatitis Day occurs on July 28th every year and is focused on raising awareness about the global burden of viral hepatitis as well as the prevention and treatment options that exist. Watch these short videos to learn more about the WHO’s global strategy and the theme for this year!