Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions
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1. Introduction
In response to these recommendations, the VA launched a maternal mortality surveillance committee to review all pregnancy-associated deaths among veterans who received VA maternity care benefits to cover their costs with community providers. These individuals received their maternity care from diverse providers and institutions across the United States (US) but continued to access primary, mental health, emergency, and specialty care at the VA.
2. Materials and Methods
This retrospective analysis included all pregnancies and pregnancy-associated deaths among veterans using VA maternity care benefits from fiscal year 2011–2020. Each mortality case underwent individual medical record review.
Identification of mortality cases. Inclusion criteria for this evaluation of pregnancy-associated mortality among veterans between FY 2011–2020 included:
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Eligibility for benefits in the Department of Veterans Affairs (VA);
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Enrollment in VA;
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The use of VA maternity care benefits (as opposed to a third-party payer, such as Medicare or private insurance through an employer or spouse).
Exclusion criteria included:
Encounters from all veterans during the specified time period with evidence of pregnancy outcomes were extracted from VA billing data using international classification of disease (ICD)-9/10, diagnosis-related group (DRG), and current procedural terminology (CPT) codes. This included any pregnancy outcome (pregnancy loss and live births at any gestational age). Billing data, derived from claims submitted from non-VA providers and hospitals for services rendered to veterans, were also used to identify pregnancy outcomes. After limiting by inclusion and exclusion criteria, deaths were identified using the VA Vital Status Mast File (VSF), which includes national data from the Veterans Benefits Administration Integrated Benefits System (IBS) Death File, Medical Inpatient Datasets, the Social Security Administration (SSA) Death File, and the Medicare Vital Status File. A second VA-based research group was approached to validate the algorithm for identifying pregnancy-associated deaths developed by the first group. The results of this assessment were largely concordant. The mortality identification algorithm was subsequently revised to include search strategies from both groups.
Mortality Review. All deaths identified between FY 2011–2020 received an in-depth review by a clinician-researcher trained to ascertain the cause and timing of death. To calculate the maternal mortality ratio (which specifies death must be pregnancy-related), deaths identified during pregnancy or within the first 42 days postpartum underwent a confirmatory review by a second trained clinician to determine if the death was related to pregnancy or from an incidental or accidental cause. If the cause of death could not be identified solely from the medical record, further information was sought through the National Death Index or via local medical examiners’ offices.
The individual review was completed using a chart abstraction template that was based on the CDC mortality review guidelines with additional veteran-specific factors. Charts were accessed through Joint Longitudinal Viewer (JLV), VA’s VistAWeb chart review tool, which allows for the review of data generated from the VA, the Department of Defense, and community care records.
Social determinants of health were assessed during individual chart review based on findings during the year prior to pregnancy, through pregnancy, until the time of death. Housing status was determined by (1) any mention of being unhoused or experiencing unstable housing in the medical record or (2) participation in the Housing and Urban Development VA Supportive Housing program (HUD-VASH), a collaborative program designed to meet the housing needs of veterans. Exposure to community violence or exposure to domestic violence was assessed via individual chart review and/or results of intimate partner violence screening in the medical record. Financial insecurity was assessed based on the mention of financial needs relating to transportation, nutrition, or childcare in the medical record.
Multidisciplinary Review Committee. A multidisciplinary maternal mortality review committee was developed to systematically review cases with a special focus on care provided by VA-based providers in the year prior to pregnancy, through pregnancy, and until the time of death, in addition to scanned records from maternity care providers in the community which are archived in the medical record. The committee systematically evaluated mortality cases to identify strengths and opportunities for care improvements in VA care. Each aspect of care provision (e.g., primary care, pharmacy services, and mental health care) was evaluated to determine if care deficits contributed to preventable mortality. Finally, a summative evaluation was done to identify prominent areas for improvement and successful practices that should be continued at the provider, institution, and healthcare system levels. The team included 10 individuals with expertise in obstetrics and gynecology, primary care, psychiatry, outreach and care coordination, social work, and maternal mortality. Reviewers were either exclusively based at the VA or dually appointed to academic institutions and the VA.
3. Results
Maternal mortality and pregnancy-associated mortality: Between VA Fiscal Year 2011–2020, a total of 39,720 pregnancies were evaluated; among them, 32 pregnancy-associated deaths were identified. The overall pregnancy-associated mortality ratio (PAMR) was 80.6 deaths per 100,000 live births among veterans using maternity care benefits paid for by the VA. Sixteen deaths occurred either during pregnancy or within the first 42 days postpartum. Fifteen of these were identified as cases that related to or were aggravated by the pregnancy but not from accidental or incidental causes. Thus, the maternal mortality ratio was 37.8 deaths per 100,000 live births.
Social Determinants of Health. Social determinants of health with the potential to affect pregnancy outcome (being unhoused or with unstable housing, exposure to violence at home or in the community, and financial instability) affected half of those who died (n = 16, 50%) and were more likely to affect those who died in the late postpartum period between 43–365 days postpartum (n = 10, 63%).
Care Coordination: Of the 32 veterans who died in pregnancy-associated events, 13 (41%) had contact with a VA Maternity Care Coordinator. The frequency of involvement varied as some individuals had many points of contact throughout the pregnancy, while others had initial outreach only.
4. Discussion
The VA maternal mortality review committee, established within an organization that does not directly provide obstetric care, is an effective strategy for collecting data, providing ongoing surveillance, and developing recommendations for the non-obstetric care team, including primary, mental health, emergency, and specialty providers. It has provided insights into opportunities for care at the provider, institution, and system levels. Clinical implications identified by the maternal mortality review process are detailed below.
Implications of demographics and access: Veterans from minoritized racial groups, including Black/African American, American Indian/Alaska Native, Asian, and Native Hawaiian/Pacific Islander, had a significantly higher pregnancy-associated mortality ratio as compared to Whites in our cohort, even though the maternal mortality ratio was relatively similar between the two groups. Because numbers are small, it is difficult to draw definitive conclusions. However, the difference may reflect that minoritized individuals in this cohort were temporally more likely to die in the late postpartum period when adverse social determinants of health were also more likely to impact outcomes. This underscores the important role primary, mental health, and other non-obstetric care providers can play during the late postpartum period to address broader reproductive health issues and social determinants of health. At the institutional level, it reinforces the need for substantive support to alleviate adverse social determinants of health, such as housing and transportation, and ongoing efforts to address systemic racism, such as hiring culturally concordant providers and ensuring equal access to care.
Implications of timing of death and social determinants of health: In our cohort, half (50%) of deaths from any cause and nearly all deaths by homicide, suicide, or overdose occurred in the late postpartum period (43–365 days postpartum) after maternity care in the community had ended. These findings reflect the vulnerability of the entire first year after birth as individuals adapt to new responsibilities and changing family structures. As mentioned, adverse social determinants of health, including housing instability, exposure to violence, and financial constraints, were also more likely to affect those who died in the late postpartum period. Primary care and mental health care providers who resume care after patients transition away from their maternity care providers may not be aware of pregnancy complications and may lack protocols that identify the full postpartum year as a time of elevated risk. It is crucial that healthcare providers understand the risks of the entire postpartum year as well as the social challenges faced by patients and implement increased surveillance and support, including referrals as needed between primary, specialty, and mental health care.
5. Limitations
It is essential to consider the limitations of the data when interpreting these results. All case review information was derived from medical records archived within the VA electronic health record, including scanned documents from community care providers. These documents from community providers were requested for billing rather than clinical purposes and were submitted on a voluntary rather than mandatory basis. Thus, community care records were not consistently available. Our findings incorporated both ICD-9 and ICD-10 CM/PCS; thus, there may be limitations related to disruptions caused by this coding transition. Finally, because pregnancy-associated death is rare and this study is restricted to only veterans using VA maternity care benefits, our final sample size of 32 deaths is small. This limits any ability to draw definitive conclusions about associated risk factors and compare mortality ratios. It is also not possible to generalize these findings to other populations, including veterans who are not enrolled for care at the VA or those who use other coverage.
6. Conclusions
The findings of this VA-based maternal mortality review of non-obstetric care underscores the need for services tailored to veterans before, during, and after pregnancy. Improved integration of VA-based and community-based care would improve treatment continuity and access to veteran-specific care, especially in the area of mental health, which is by far the leading underlying pregnancy complication for individuals who die in pregnancy-associated events. The VA also has a significant opportunity for preconception care in the management of chronic conditions such as hypertension, obesity, mental health conditions, and substance use disorders. Patient education, preconception counseling, contraception management, and pregnancy options counseling are all important clinical foci for primary, mental health, emergency, and specialty care providers as the number of reproductive-age veterans continues to grow at VA. Ongoing surveillance by the multidisciplinary VA-based maternal mortality review committee will continue to provide policy and practice recommendations. Systematic surveillance and review of maternal deaths in institutions that do not provide maternity care is a productive means to develop and refine care interventions that strengthen the healthcare safety net and improve maternal outcomes.
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