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Putting the “M” Back in MFM. AGOS Annual Meeting September 14, 2012. Global Maternal Health: A Call to Action. THE LANCET, JULY 13, 1985. Maternal Health MATERNAL MORTALITY—A NEGLECTED TRAGEDY Where is the M in MCH? ALLAN ROSENFIELD DEBORAH MAINE

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slide1

Putting the “M”

Back in MFM

AGOS Annual Meeting

September 14, 2012

global maternal health a call to action
Global Maternal Health:A Call to Action

THE LANCET, JULY 13, 1985

Maternal Health

MATERNAL MORTALITY—A NEGLECTED TRAGEDY

Where is the M in MCH?

ALLAN ROSENFIELD DEBORAH MAINE

Center for Population and Family Health, Faculty of Medicine,

Columbia University, 60 Haven Avenue, New York,

NY 10032, USA

international movement to reduce maternal mortality
International Movement to Reduce Maternal Mortality
  • 1987, Global Safe Motherhood Conference,

Nairobi, Kenya

  • 2000, United Nations' 8 Millennium Development Goals

Target #5: Reduce the maternal mortality ratio ratio by 75% from 1990-2015

World Bank

United Nations

United Nations General Assembly. United Nations millennium declaration. A/RES/55/2. New York (NY): United Nations, 2000.

global maternal mortality progress
Global Maternal Mortality: Progress
  • Comprehensive analysis funded by Bill and Melinda Gates Foundation
  • Estimates of global maternal deaths: 526,300 in 1980  324,900 in 2008
  • Yearly rate of decline of global MMR since 1990 was 1.3%
  • Gates' pledge of $1.5 billion toward maternal, newborn, and child health over 5 years

Hogan MC, et al. Lancet 2010.

yearly rate of change in maternal mortality ratio 1990 2008
Yearly Rate of Change in Maternal Mortality Ratio,1990–2008

Hogan MC, et al. Lancet 2010.

us maternal mortality ratio what is the trend
US Maternal Mortality Ratio: What is the Trend?
  • Several other reports indicate that the maternal mortality ratio in the US is increasing.
    • Maternal mortality ratio rose from 10.0 to 14.5 per 100,000 between 1990 and 2006
    • Changes in the National Vital Statistics System may have improved ascertainment of maternal death
  • Maternal mortality is NOT DECREASING in the US, despite advancements of modern medicine

Berg CJ et al. ObstetGynecol 2010, Callaghan WM, SeminPerinatol 36:2-6

calling attention to maternal mortality in the us
Calling Attention to Maternal Mortality in the US

Amnesty International Report, 2010:

  • Maternal Mortality Ratio in 2005

38.7 per100,000

for non-Hispanic,

African-American women

vs.

10.7 per100,000

for white women

slide8

Calling Attention to Maternal Mortality in the US

The Joint Commission 2010:

Preventing

Maternal Death

  • Initiatives to decrease maternal mortality
    • case reporting and review
    • team training and drills
    • thromboembolism prophylaxis
morbidity during delivery hospitalizations
Morbidity During Delivery Hospitalizations
  • Reviewed national hospital discharge survey 1991-2003
    • 432,000 records representing 50.6 million deliveries
  • Severe morbidity 5.1 per 1,000 deliveries
    • Hysterectomy, transfusion, or eclampsia
    • Risk factors: Extremes of age, black race
    • Severe morbidity 50 x more common than death
  • Impacts 20,000 - 30,000 women each year
  • Callaghan WM et al. AJOG 2008.
the burden of maternal morbidity
The Burden of Maternal Morbidity

“A review of the more common causes of severe maternal morbidity is likely to provide a more clinically relevant measure of the standard of maternal care.”

Professor Thomas F. Baskett, MB

Best Prac Res in Clin Ob Gynaecol, 2008

factors increasing maternal mortality and morbidity
Factors Increasing Maternal Mortality and Morbidity
  • Maternal age
  • Obesity
  • Cesarean delivery
  • More pregnancies in women with significant chronic medical conditions
    • Hypertension
    • Pregestational diabetes
    • Congenital heart disease
    • Organ transplant
us pregnancy related mortality
US Pregnancy-Related Mortality

35

Mortality (%)

30

25

20

15

10

5

0

Infection

Cardiovasular

conditions

Cerebrovascular

accident

Hemorrhage

Anesthesia

Noncardiovascular

medical conditions

Thrombotic pulmonary embolism

Amniotic fluid embolism

Hypertensive disorders

of pregnancy

Cardiomyopathy

Berg CJ et al. Obstet Gynecol 2010.

mfm the historical perspective
MFM: The Historical Perspective
  • 1970: MFM is a subspecialty of OB/GYN
  • 1974: The first MFM board certification exam
  • 1977: The Society for Perinatal Obstetricians (now SMFM) was founded
  • Today: SMFM consists of more than 2,300 active members and ~ 100 MFM fellows graduate each year
advances in fetal and neonatal medicine
Advances in Fetal and Neonatal Medicine
  • Prenatal diagnosis and screening programs
    • Genetic disorders and congenital anomalies
  • Near eradication of Rh disease
  • Therapies for women at high risk for PTB
    • steroids, antibiotics for PPROM, magnesium
  • Progesterone to decrease recurrent PTB
  • Reduction of stillbirth
  • Fetal therapy
    • TTTS, NAIT, myelomeningocele
changes in modern obstetrical practice
Changes in Modern Obstetrical Practice
  • Significant decrease in rate of operative vaginal deliveries
  • Near-extinction of vaginal breech deliveries
  • Generalists and laborists managing labor and delivery
  • Increased reliance on medical subspecialists to manage chronic disease in pregnancy
  • Increased utilization of GYN oncologists to assist in complicated obstetrical surgery
  • 7 MFMs certified in critical care
where are the mfms

Where are the MFMs?

  • There appears to be an increase in the popularity of consultative MFM practice
    • Predictability of hours and part-time availability
    • Reimbursement differential between fetal and maternal medicine
    • Wide differential in malpractice burden between outpatient and inpatient services
measuring generalists satisfaction with mfm specialists
Measuring Generalists' Satisfaction with MFM Specialists
  • Majority (68%) report satisfaction
  • Majority would consult or co-manage with MFM specialist for 26 of 38 specific maternal, fetal & obstetric diagnoses/complications
  • 31% reported dissatisfaction with MFMs:
    • Lack of availability (49%)
    • Lack of daytime availability (26%)
    • Lack of nighttime availability (35%)
    • MFM practice limited to diagnostic testing (32%)

Wenstrom K, Am J Perinatol 2012

slide20

What are we doing to reduce maternal mortality and morbidity in a maternal population with an

increasing incidence of

chronic disease?

D’Alton ME, Obstet Gynecol 2010;116:1401–4

where is the m in mfm feedback
Where is the M in MFM?Feedback

"Residency programs should have more practicing CLINICIANS to teach the young residents obstetrics, and not MFM consultants, who spend the entire day in the office doing sonos. We are good in detecting anomalies but when it comes to everyday obstetrics we have lost our common sense!"

Louis Kokkinakos, MD, Columbia, MD

where is the m in mfm feedback1
Where is the M in MFM?Feedback

"I wonder what will happen in another decade when it will be very rare to have hospital-based MFM physicians and most are office-based, consultative physicians who are not skilled or available in the middle of the night. If we are to put the ‘M’ back into MFM, I think it has to start with the academic leaders and we need to select fellows who will be committed to this approach…”

Dana P. Damron, MD, MFM, Billings, MT

mfm think tank 2012 the participants1
MFM Think Tank 2012: The Participants
  • Richard Berkowitz
  • Clarissa Bonanno
  • Haywood Brown
  • Josh Copel
  • Gary Cunningham
  • Mary D’Alton
  • Tom Garite
  • Larry Gilstrap
  • Bill Grobman
  • Gary Hankins
  • John Hauth
  • Brian Iriye
  • George Macones
  • Jim Martin
  • Stephanie Martin
  • Kate Menard
  • Dan O’Keefe
  • Luis Pacheco
  • Laura Riley
  • George Saade
  • Cathy Spong
mfm think tank 2012 the objectives
MFM Think Tank 2012: The Objectives
  • Organized, national approach to decrease maternal mortality and morbidity in the US
    • Enhance the training in maternal care for residents and fellows
    • Improve medical care and management of pregnant women
    • Address the critical research gaps in maternal medicine
evolution of mfm training
Evolution of MFM Training
  • 1970s: inception of 2-year Fellowship training program
  • 1996: Expansion of MFM Fellowship to 3 years to include mandatory research training
  • Residency work hour restrictions
    • 80 hours week (2003)
    • 16 hour shifts (2011)
challenges in ob gyn residency training
Challenges in Ob/Gyn Residency Training

Advances in medical knowledge

Accelerating adoption of technology

Increasing restrictions on

resident duty hours

  • MORE TO LEARN IN LESS TIME
current mfm fellowship requirements
Current MFM Fellowship Requirements

12 months clinical rotations

18 months research activities

6 months elective time

mfm fellowship training recommendations
MFM Fellowship Training:Recommendations
  • Modification of MFM Fellowship requirements to include:
    • 18 months of CLINICAL rotations
    • 12 months research
    • 6 months elective
  • Inclusion of mandatory rotations
    • Labor and Delivery/Inpatient Obstetrical Services 4 months
    • Intensive Care Units 2 months

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

mfm fellowship training abog s response
MFM Fellowship Training:ABOG's Response

Modified 2013 requirements to increase requirements for:

  • Clinical rotations - 15months
    • L& D/Inpatient Services rotation - 2 months
    • ICU rotation - 1 month
  • Research - 12 months
  • Elective - 9 months

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

mfm fellowship training recommendations1
MFM Fellowship Training:Recommendations
  • Increase in simulation and case-based learning methodologies
  • Certification in Advanced Cardiac Life Support (ACLS)
  • Development subspecialty-specific, in-service exam for fellowship trainees

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

mfm think tank 2012 obstetrical care and services
MFM Think Tank 2012:Obstetrical Care and Services
  • High risk women:
  • Timely identification and referral of patients for tertiary care
  • Low risk women:
    • Comprehensive national effort to educate all providers on the prevention and treatment of obstetrical complications

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

annual birth volume in u s hospitals 2008
Annual Birth Volume in U.S. Hospitals, 2008

NUMBERS OF HOSPITALS

n = 3,265

Simpson KR, JOGNN 40, 2011

direct deaths per million maternities by cause uk 1994 2008
Direct Deaths per Million Maternities by Cause - UK 1994-2008

Saving Mothers’ Lives 2006-2008, National Launch, March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG

comprehensive national effort

Comprehensive National Effort

  • Standard protocols
  • Saving Mothers Lives, U.K.

Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. Eighth Report, Confidential Enquiries into Maternal Deaths in the United Kingdom, BJOG Volume 118, Issue Supplements 2011

    • National confidential enquiry system into maternal deaths published every 3 years
    • Goal to identify remediable factors to address in guidelines created by national organizations
recommended guidelines

Recommended Guidelines

  • Urgent development of national management guidelines:
  • Hypertensive disorders in pregnancy
  • Postpartum hemorrhage
  • Prevention of venous thromboembolism
  • Diagnosis and management of placenta accreta
  • Management of the obese obstetrical patient
  • Management of cardiac disease in pregnancy

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

acog presidential initiative 2011 2012
Summarize the current state of knowledge

Develop practice guidelines and checklists for “Best Practices”

ACOG Presidential Initiative 2011-2012
  • Preeclampsia
  • Identify the most compelling areas for research
coming soon from acog

Coming Soon From ACOG

  • Executive summary of Hypertension in Pregnancy Working Group
    • Upcoming in Obstetrics & Gynecology
  • Downloadable protocols
  • Updates on new research findings
  • Efforts at global consensus guidelines
the relevance of protocols

The Relevance of Protocols

  • National Protocols for Maternal Medicine
  • Should be derived from evidence-based data
  • Define the standard of care
  • Minimize variability
  • Reduce the need to rely on memory
  • Enhance patient safety
  • Reduce duplication of effort
obstetrical care and service

Obstetrical Care and Service

  • Toward Improving the Outcome of Pregnancy 1976: Recommendation for the Development of Maternal and Perinatal Health Services
    • Stratified maternal and neonatal care into 3 levels of complexity: Basic, Specialty & Subspecialty

“. . . it was recognized that to make optimal maternal, fetal and perinatal care appropriate to the needs of each patient available to all, the systems approach is essential.”

obstetrical care and service1

Obstetrical Care and Service

  • Toward Improving the Outcome of Pregnancy II, 1993: Perinatal Regionalization Revisited

March of Dimes

  • Toward Improving the Outcome of Pregnancy III, Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives, 2010, March of Dimes
regionalized perinatal care

Regionalized Perinatal Care

  • Became synonymous with Regionalized Neonatal Care
  • Priority became transfer of women at risk for delivering neonates with higher care requirements
  • Erroneously assumed that institutions with Level 3 NICU capabilities were equipped to care for any maternal medical condition
obstetrical care and service recommendations
Obstetrical Care and Service: Recommendations
  • Establish a system for "levels" of maternal care
  • Levels of care designated nationally by a single entity
    • Facilitate consistent definitions and standards at each level
    • More informative for physicians and patients making health care decisions
    • Better comparisons of outcomes, resource utilization, and cost

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

role of mfm physicians

Role of MFM Physicians

  • MFM Physicians must take the lead in caring for medically compromised obstetrical patients
  • MFMs have unique expertise in medical and surgical complications as they relate to pregnancy and the fetus

To lead the care team,

MFM physicians must be available for inpatient service

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

maternal medicine physicians

Maternal Medicine Physicians

  • Majority of time spent in caring for obstetrical patients with medical problems.
  • Act as consultants
  • Lead teams that focus on multidisciplinary care, practice guidelines for safety and quality related to maternal care
  • Be role models for MFM fellows in training

“Putting the ‘M’ Back in Maternal-Fetal Medicine”

obstetrical care and service recommendations1
Obstetrical Care and Service: Recommendations
  • Incentivize MFM physicians to care for pregnant women with medical problems:
    • Recognition of the importance of maternal experts by the medical community
    • Offer training in practice management and leadership skills
    • Creation of pathways for academic promotion
    • Provision of adequate financial compensation
research recommendations

Research Recommendations

  • Develop standardized methods for national surveillance of maternal mortality
  • Define significant maternal morbidity and “near misses”
  • Determine appropriate patients for transfer to level III care
  • Research impact of adverse pregnancy outcomes on long-term maternal health
nichd mfm units networks

NICHD MFM Units Networks

Fourteen U.S. university-based clinical centers focus on clinical questions in MFM and obstetrics, in particular the continuing problem of preterm birth.

the gap between knowing and doing
The Gap Between Knowing and Doing

“Between the health care we have and the health care we could have

lies not just a gap,

but a chasm.”

Crossing the Quality Chasm, IOM, 2001

28% - 40% of pregnancy-related deaths potentially preventable

Clark SL, Am J Obstet Gynecol 2008 Berg CJ, Obstet Gynecol 2005,

Organized National Response

slide51

Putting the “M”

Back in MFM

AGOS Annual Meeting

September 14, 2012