A Commitment to Saving Mothers' Lives
Despite advances in technology and obstetric care, the maternal mortality rate has actually more than doubled, rising from 7.2 pregnancy-related deaths per 100,000 live births per year in 1987 to 16.9 in 2016, according to the U.S. Centers for Disease Control and Prevention. There are also considerable disparities, with the death rate more than three times greater for black non-Hispanic women versus white non-Hispanic mothers. Many of these deaths are preventable. NewYork-Presbyterian's ob/gyn departments have launched multidisciplinary initiatives to better understand, reduce, and prevent maternal mortality.
The Safe Motherhood Initiative
More pregnant women in the United States today have chronic health conditions such as hypertension, diabetes, and heart disease. Indeed, while the contribution of hemorrhage, hypertensive disorders of pregnancy (i.e., preeclampsia, eclampsia), and anesthesia complications to pregnancy-related deaths have declined, the impact of cardiovascular disease, cerebrovascular accidents, and other medical conditions has risen. NewYork-Presbyterian/Columbia University Irving Medical Center and NewYork-Presbyterian/Weill Cornell Medical Center are both actively involved in the Safe Motherhood Initiative of the American College of Obstetricians and Gynecologists District II.
Hospitals that participate in this program learn and implement guidelines to reduce obstetric hemorrhage, hypertension of pregnancy, and venous thromboembolism. "When obstetric emergencies happen, it's helpful to have standardized protocols as well as checklists to ensure that nothing is overlooked," noted Robin Kalish, MD, Vice Chair of Obstetrics at NewYork-Presbyterian/Weill Cornell. "We are constantly following it and looking at how our cases are managed to improve outcomes."
"This is an important multidisciplinary approach taken by all staff members, including nurses, residents, fellows, and physicians involved in obstetric care, with the goal of reducing maternal mortality," added Lynn Simpson, MD, Chief of Maternal Fetal Medicine at NewYork-Presbyterian/Columbia.
Excellence in Accreta Management
NewYork-Presbyterian's maternal-fetal medicine teams are widely sought for their expertise in the management of placenta accreta, a cause of obstetric hemorrhage and premature birth. NewYork-Presbyterian is known as a referral center for this condition. Women with placenta accreta are monitored closely and receive a tailor-made delivery plan that brings together ob/gyns, maternal-fetal medicine specialists, obstetric anesthesiologists, gynecologic oncologists, interventional radiologists, urologists, nursing, NICU staff, and OR technologists who meet regularly to discuss and plan for each patient's delivery, which brings together all team members in the OR. "Getting together around a table for an hour accomplishes so much more than two weeks of shared emails," said Dr. Kalish, speaking about the regular accreta team meeting at NewYork-Presbyterian/Weill Cornell.
The Power of Simulation
Simulation provides trainees with the opportunity to encounter and address less common but potentially fatal patient scenarios in a safe environment. Both NewYork-Presbyterian/Columbia and NewYork-Presbyterian/Weill Cornell have simulation programs that bring together all the staff who would be needed to manage a maternal code, for example, as well as other challenges such as maternal hemorrhage and shoulder dystocia. "These simulations have gone a long way to help us coordinate the necessary components of care that help to improve patient outcomes," explained Dr. Simpson. At NewYork-Presbyterian/Weill Cornell, the Director of Labor & Delivery is using simulation to train staff on rare events like maternal code as well as new communication methods for routine aspects of care, especially given the vastly expanded footprint in the new Alexandra Cohen Hospital for Women and Newborns — scheduled to open in summer 2020. This new hospital will have a dedicated simulation suite for obstetrics and the NICU.
The Mothers Center: A Model of Outpatient Maternal-Fetal Medicine Care
The Mothers Center at NewYork-Presbyterian/Columbia is a first-of-its-kind space dedicated to providing coordinated care to pregnant women with complications requiring specialized care. Maternal-fetal medicine experts and specialists across various medical and surgical subspecialty areas, such as cardiology and psychiatry, collaborate to customize treatment plans for each patient. Services include coordinating appointments with specialists, providing counseling — including preconception counseling — and establishing a plan to manage care in the best way possible.
Mothers Center staff optimize the health of patients before, during, and after pregnancy, including patients with heart disease, placental disorders, kidney disease, blood disorders, pulmonary disease, neurologic disease, endocrine disease, and organ transplants. The Mothers Center is the only such comprehensive care center in the country and serves as a national model for the care of medically and surgically complex pregnant women. The team is also conducting research to improve care and education.
To efficiently utilize regionalization, NewYork-Presbyterian/Weill Cornell has launched a weekly preconception consultation clinic to allow care coordination for women with complex diseases and to determine if some of them can deliver at their community hospital, such as NewYork-Presbyterian Lower Manhattan Hospital.
Preventing Cardiac Deaths
Responding to the increased risk of heart disease during pregnancy, NewYork-Presbyterian brings together doctors from obstetrics, maternal-fetal medicine, cardiology, obstetric anesthesiology, and obstetric nursing to care for mothers with acquired or congenital cardiac disease, who have nearly 100 times higher mortality than pregnant women without cardiac disease. Interventions may include ensuring patients take their medications as prescribed, modifying certain activities, and seeing their cardiologists more frequently during pregnancy.
NewYork-Presbyterian maternal-fetal medicine specialists are investigating death certificate data to research deaths from any causes occurring among mothers who may have sought care at the hospital at some point in their lives but who died elsewhere. They are seeking to identify preventable deaths and touchpoints of care to determine if there is anything NewYork-Presbyterian doctors could do differently to reduce the risk of maternal death.
NewYork-Presbyterian/Weill Cornell's team of laborists — staff ob/gyns in the hospital 24/7 — is growing, with more physicians available to focus on the care of women who are either unregistered for prenatal care prior to delivery or women who are seen in a resident clinic, as they tend to be quite complex. The Cohen Hospital will also have obstetric critical care nurses on the unit around the clock. All ob/gyn staff are also undergoing half-day "implicit bias" training to acknowledge how personal biases can affect the care that they render. In addition, this training will improve cultural competence as staff members care for a diverse population of women.
For example, women with certain social determinants of health like homelessness or particular cultural practices may be unwilling to access emergent postpartum visits. This could lead to preventable mortality, since about 30% of maternal mortality occurs after delivery. Being prepared for these issues by providing individualized culturally appropriate care could reduce maternal mortality disparities. Said Dr. Kalish, "With this training, staff members park their biases at the door and learn to respect differences, appreciate diversity, and gain a better understanding of our patients."