AGOS Annual Meeting AGOS Annual Meeting September 14, 2012 Putting the “M” Back in MFM.

AGOS Annual Meeting AGOS Annual Meeting

September 14, 2012

Putting the “M” Putting the “M” Back in MFMBack in MFM

Global Maternal Health:A Call to Action

THE LANCET, JULY 13, 1985

Maternal Health

MATERNAL MORTALITY—A NEGLECTED MATERNAL MORTALITY—A NEGLECTED TRAGEDYTRAGEDY

Where is the M in MCH?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 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

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

Hogan MC, et al. Lancet 2010.

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. Obstet Gynecol 2010, Callaghan WM, Semin Perinatol 36:2-6

Calling Attention to Maternal Mortality in

the US

Amnesty International Report, 2010: Maternal Mortality Ratio

in 2005

38.7 per 100,000 for non-Hispanic,

African-American women

vs. 10.7 per 100,000

for white women

The Joint Commission 2010:

Preventing Maternal Death

Calling Attention to Maternal Mortality in

the US

Initiatives to decrease maternal mortality • case reporting and review• team training and drills• thromboembolism prophylaxis

Safe Motherhood Initiative

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 yearCallaghan WM et al. AJOG 2008.

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 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

Hemorrhage

Thrombotic p

ulmonary

embolism

Amniotic fluid embolis

m

Cardiomyopath

y

Hyperte

nsive diso

rders

of pregn

ancy

Anesthesia

Cerebrovascu

lar

accident

Cardiova

sular

conditions

Noncard

iovascu

lar

medical c

onditionsInfecti

on0

25

35

30

20

5

15

10

Berg CJ et al. Obstet Gynecol 2010.

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

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

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?

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 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

A Call to Action

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

"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?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 Participants

Sponsor:

MFM Think Tank 2012: The Participants

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

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

Advances in medical knowledge

Accelerating adoption of technology

Increasing restrictions on resident duty hours

MORE TO LEARN IN LESS TIME

Current MFM Fellowship

Requirements

12 months clinical rotations

18 months research activities

6 months elective time

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”


ABOG's Response

Modified 2013 requirements to increase requirements for:

Clinical rotations - 15 months• 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”


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


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


Annual Birth Volume in U.S. Hospitals, 2008

NU

MBE

RS O

F H

OSP

ITAL

S

n = 3,265Simpson KR, JOGNN 40, 2011

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

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

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


Preeclampsia

ACOG Presidential Initiative 2011-2012

• Summarize the current state of knowledge

• Develop practice guidelines and checklists for “Best Practices”

• Identify the most compelling areas for research

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

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

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 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

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 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

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

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


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

1. Develop standardized methods for national surveillance of maternal mortality

2. Define significant maternal morbidity and “near misses”

3. Determine appropriate patients for transfer to level III care

4. Research impact of adverse pregnancy outcomes on long-term maternal health

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

28% - 40% of pregnancy-

related deaths potentially

preventableClark SL, Am J Obstet Gynecol 2008

Berg CJ, Obstet Gynecol 2005,

Organized National Response

“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

AGOS Annual Meeting AGOS Annual Meeting

September 14, 2012

Putting the “M” Putting the “M” Back in MFMBack in MFM

AGOS Annual Meeting AGOS Annual Meeting September 14, 2012 Putting the “M” Back in MFM.

Documents

Transcript of AGOS Annual Meeting AGOS Annual Meeting September 14, 2012 Putting the “M” Back in MFM.