[Iskander] Hello, I'm Dr. John Iskandar welcome
to CDC Beyond The Data.
I'm here today with Dr. Michael Lu professor
and senior associate dean of public health
at George Washington University.
Welcome Dr. Lu.
[Lu] Thank you for having me.
[Iskander] So we heard today about the issue
of maternal mortality in the United States,
and many people may think of this as an issue
from a bygone era but how large is this problem
in the United States?
[Lu] I think a lot of people don't know about this.
That every year in the United States more than 700 women die
from complications during pregnancy and childbirth.
I think that is 700 too many,
and more than 50,000 women suffer a life-threatening
complications or what we call severe maternal morbidity.
We are the richest nation on earth, and yet,
we've now rank last, dead last among developed nations
on the total mortality.
I think this is a national disgrace.
I think we can do better as a nation.
[Iskander] So those numbers I think should shock people,
but how confident are we in the accuracy of those numbers?
And is that part of the problem?
[Lu] It is part the problem.
I think we're getting better,
but I think there's still a lot more work to do.
So when it comes to counting maternal deaths,
there are basically several ways.
Three ways that we can do this.
There is the maternal mortality ratio, which it captures deaths
up to 42 days after pregnancy, and it's based
on a pregnancy checkbox on the death certificate
which could lead to a lot
of false positives and false negatives.
And because of that, the CDC developed the PMSS
that Dr.Calahan talked about earlier today,
and that's the pregnancy related mortality rates
and that I think improves upon on the patrol mortality ratio.
It has more information, and it goes up to one year
after the end of pregnancy.
But it still has its limitation because it's still vastly based
on vital statistics and that's why I think what CDC
and others are doing right now are working with the states
to really promote maternal mortality review
that really dives deep into the clinical causes
of maternal death.
I think that's critically important because if we want
to know how to prevent maternal mortality we really need good
data about causes about prevention
and about whether what we're doing is working or not.
[Iskander] So Dr.Olea today spoke at some length
about maternal mortality review committees
in states or in hospitals.
It's a kind of bureaucratic sounding name,
but what do they do and how can they help prevent
maternal deaths?
[Lu] Well, I think these maternal mortality committees do
such important work in terms of looking at every maternal death
and try to figure out what could have caused it
and whether the death could have been prevented.
And that information goes a long way in terms
of helping this bring about either practice change
or policy change that could potentially avert another death.
[Iskander] So one of the information that can be gleaned
from that is what proportion of deaths might be preventable,
and what are in fact the leading causes
of death regardless of what data source?
What kind of information do we know about that?
[Lu] Well, we do know that the leading causes
of maternal deaths are hemorrhage, preeclampsia,
or toxemia, and embolism, but we also know
that cardiovascular diseases including postpartum
cardiomyopathy are becoming increasingly important causes
of maternal death.
Statistics vary, but a number of studies show that can more
than half of these maternal deaths are preventable.
[Iskander] Now, as we are facing an older population
but also even in our younger population,
an increasing burden of chronic diseases.
Does that have an impact on maternal mortality,
and are there steps we could take to impact that?
[Lu] Absolutely, so we know that the demographics
of childbearing is changing in the United States.
Women are older when they get pregnant.
Women are also entering pregnancy
with more chronic conditions like hypertension, diabetes,
heart disease as well as obesity which are major risk factors
for maternal mortality and severe maternal morbidity.
So I think if we really want to move the needle
on maternal mortality in this country there are two things
that we have to do.
We have to improve women's health before
that they get pregnant, and we have to improve the quality
and safety of maternity care in this country.
[Iskander] So related to that second issue, the quality
and safety of maternity care, Dr. Olea introduced us
to the concept of a safety bundle and some
of our audience may have heard
that in other public health context.
What is a safety bundle?
What's an example of one, and how does that help save a life
in the hospital context?
[Lu] So a safety bundle are best practices
or other resources including tool kits that's all bundled
up to really improve the quality and safety of maternity care.
A number of these safety bundles have been developed
over the last few years to address some
of the most common causes maternal death including
hemorrhage thromboembolism, as well as, preeclampsia
and a number of other bundles are
under development including one for cardiovascular diseases
as well as opioid misuse during pregnancy.
And I think these bundles really get at the 4R's: Readiness,
you want to be ready before a complication occurs;
Recognition, you want to be able to recognize
when the complication is happening really early
on because the longer the delay the worse the outcome.
You want to be able to respond in the most effective way,
and most importantly, you also want to be able to report back
and then really learn from this experience
so that you can continue to drive improvement
in your clinical practice.
So I think these bundles really help support clinicians
and hospitals to improve the quality and safety
of their care through the four R's.
[Iskander] Okay, so Dr.Lu, you're trained as an OB/GYN.
You have a long career as a senior leader
in maternal and child health.
I'd like to ask you to reflect on kind
of your personal perspective on maternal mortality.
What issues does it raise for you?
[Lu] Well I think that we have come such a long way.
We have such a great momentum going on right now
in maternal mortality.
This problem has been going on for decades.
I remember reading about the problem with maternal mortality
in the United States when I was in medical school,
and the problem just seems to get worse and worse to a point
where there was one point maybe we thought that there is nothing
that we could really do about maternal mortality.
I think the experience that I had
in California can really change my view about this.
That, in California, I saw a network of doctors, nurses,
public health professionals that was trying to spread quality
and safety across all the hospitals in California
by implementing these early versions
of these safety bundles, and they just went door-to-door.
They provided in-service for labor and delivery staff.
They did grand rounds.
They engaged hospital CEOs and OB Chairs, and they started
to change practice and policies hospital by hospital.
And then when you look at the data in California,
up until about 2006 California was trending with the rest
of the United States,
that maternal mortality rate just kept going up,
but between 2006 and 2012 maternal mortality decreased
by more than half in just six years and that's
with the implementation of the safety bundles.
So that's what I think.
That if we could replicate the success
in California throughout the rest of the United States,
and that's really the genesis of the AIM project
that was mentioned earlier today,
I think we can really move the needle over the next few years
of maternal mortality in this country.
[Iskander] Thank you very much Dr.Lu, and thank you for ending
on that optimistic note.
[Lu] Thank you John.
[Iskander] Please join us next month for Beyond The Data.