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Join us as we dive deeper into the rising severe maternal morbidity and maternal mortality rates in the United States through a data-driven, quality improvement lens. Each episode will foster discussion with those committed to improving maternal health outcomes and saving lives.
Christie - 00:00:04:
Welcome to AIM For Safer Birth. I'm your host, Christie Allen, Senior Director of Quality Improvement and Programs at the American College of Obstetricians and Gynecologists, or ACOG. On this podcast, we dive deeper into the rising severe maternal morbidity and maternal mortality rates in the United States through a data-driven quality improvement lens. In this season, I'm talking with maternal health innovators about charting a course for high-quality maternity care, and I'm excited to talk with Dr. Elliott Main, a leading expert in maternal health. Dr. Main was the founding medical director of the California Maternal Quality Care Collaborative and chaired the California Pregnancy Associated Mortality Review Committee, serving both for 17 years. He is currently the professor of obstetrics and gynecology at Stanford University and the principal investigator of two large NIH grants on maternal quality improvement. Dr. Main has been instrumental in numerous state and national initiatives to improve maternal care and reduce maternal mortality, and currently serves as a National Implementation Advisor for the Alliance for Innovation on Maternal Health, or AIM. So please welcome Dr. Main, and thank you for joining me.
Elliott - 00:01:06:
Thank you, Christie. Always a pleasure to chat.
Christie - 00:01:09:
I'm kind of laughing as I read this off and talk about your background because I feel like a lot of our listeners may already know who you are and have maybe heard you talk in the past. You do certainly get around and have made the rounds.
Elliott - 00:01:23:
Well, I think I've... I counted up the other day, I think I've been to 42 states, either in person or by Zoom. For the last three years, it's been by Zoom, of course.
Christie - 00:01:36:
We need to get the list of the other remaining and make sure we get you there in the next few years. So I was kind of hoping to talk to you today mostly about the history of AIM. AIM as a program, I know you've been engaged with since before it existed, and you're part of the reason it exists. I'll call that out in case you don't. But I had the pleasure of joining the work of AIM in 2019, which was well after it was underway. And I was just kind of hoping you could talk a little bit about how we got where we are today. I think a good place to start might be sort of the work that led to the idea of AIM, if that makes sense. Preconception, if you will.
Elliott - 00:02:17:
There was a lot of preconception work here. And it sort of centered around Some of the early maternal mortality reviews. I developed and started the Maternal Mortality Review Committee in California, as you mentioned, in 2006. And we got it underway, and it was very clear that there was a group of deaths that were clearly preventable. In fact, it was a fairly large number of deaths, and they clustered around obstetric hemorrhage and severe hypertension. And there were themes that we could clearly identify in terms of preventability that were denial, not wanting to admit that someone was really sick, denial, delay. Delay can be due to denial, but it's also delays in identification, delays in treatment. And dismissal. Not listening to the patient. Those three Ds were really, really important, and they were present. In all the major causes of maternal mortality, when we looked at whether it was obstetric hemorrhage or hypertension or... Venous thromboembolism or sepsis. Or cardiovascular disease. Things were missed. Things that shouldn't have been missed, put it that way. And so that was an aha moment. And this was really at the time. This was in the late 2000s, like 2006 to 2009. This is the same time that there was growing attention to the national maternal mortality rate. Which was clearly not what it should. It was clearly higher than it had been in the past, clearly higher than other... Uh... Well-resourced countries around the globe. And so we started thinking about What should we do to make this change? We really wanted in a maternal mortality review in my state and others to not just count the deaths, not just report on the causes, but to really identify interventions. What can be done to change the outcomes? And that was really the genesis is people who were working in this area getting together. In a call to action with Mary Dalton and Kate Menard and myself did this in obstetrics and gynecology. And really, Mary Dalton led the big push to put the M back into maternal fetal medicine. And we had a very sympathetic ear in Michael Lu, who was one of the very first obstetrician to direct the Maternal Child Health Bureau in HRSA. And he was pushing to put the M back in maternal child health on the public health side. And so at the same time, there was... Work on quality improvement in general, in medicine in general, from CMMI. CMMI is Center for Medicaid and Medicare Innovation. And they had hospital engagement networks. And we approached them with the idea that they really needed to work on maternity, not just on internal medicine subjects. And we got them engaged. Three bundles in three years was our pitch for hypertension, for hemorrhage, for hypertension, and for venous thromboembolism. And ACOG led the charge on that. So I remember meeting in Washington, D.C. Jane Mahoney was the lead person at ACOG. And that got the attention of Michael Lu then in Maternal Child Health as a funding source. This was after we had done some preliminary work in California and in New York, ACOG District 2 in particular. To do some pilot work. And for any QI project, you need pilots to show that what you're talking about has validity. And so each of us, particularly New York and California, had done small collaboratives and could show some benefit from that. So that was the foundation work for AIM to form.
Christie - 00:06:40:
So it sounds like, it's not coincidental, so I don't want it to sound like that, but it sounds like things sort of came together in a way. It sounds like some advocates, passionate clinician and patient advocates came together. It started on your side with the clinicians, obviously. There were some publications. I'm just thinking of it like a change model because I think of everything like a change model or a QI model. But it took sort of a clinician, public partnerships and advocacy, but the recognition was really the key that it was even an issue. And I think that to me was interesting because I was working in OB care as a nurse at the bedside. And a dialogue started. And it sounds like you all sort of... Built that dialogue through a variety of methods. So you mentioned some people and sort of the changes that were needed to start that dialogue. What for you kind of led to the next steps and the vision and motivation behind it?
Elliott - 00:07:40:
Well, to create change at scale, there are a couple of principles that we identified pretty early on. One is to have... A good reason to change. No one wants to change their clinical practice just because, you know, someone else says that you should do it. You have to have a good incentive. And the incentive here was clearly identifying maternal mortality as a national issue and the fact that severe maternal morbidity was being published now and showing that it also had increased markedly in the last decade. And so this put a lot of attention to it. And at the same time, NPR and ProPublica came out with a series of articles that were really drawing attention to the issue with personal stories, including one that I think resonated with a lot of clinicians, which was the story of a nurse who died in her own hospital. She was a NICU nurse who delivered at her own hospital and passed away in her own hospital, even though she was a healthy person. And that was one that everyone could identify with as their, but for the grace of God, my go-I. Together with a lot of other stories that resonated with other groups, but that was one that was a particularly important one for clinicians. So you have to have an incentive, and you have to have some data, and you have to have a change package. I... What are you doing together? And that was really the next step here, I think, was to establish bundles. And toolkits, which are, I can explain in a moment the difference, it was really important how these change packages were developed. And the key issue here is that they were multidisciplinary. One of the key steps was for ACOG to establish the Council on Patient Safety, which involved every major group. Physician, nurses, midwives, public health leads, anesthesia, family medicine. Every major organization around the country interested in maternal health was involved. He met twice a year. And really was the lead for developing what became the AIM bundles. In these, in AIM bundle, It was not a detailed description of what you had to do, but it was a list of things that every hospital in the country should look into and have, with the details often being completed or filled in by a toolkit. And there were several different toolkits done around the country. We developed those at California Maternal Quality Care Collaborative. New York had different versions. Illinois had different versions. And many other states did. And that was totally appropriate because you want to modify the content to meet the more localized resources and needs. And indeed, that was the principle for the patient safety bundles, that this was basically a checklist of items that every hospital should look at, such as, for example, for hemorrhage, that every hospital in the country have a hemorrhage cart. Full of the resources that are needed. And can be rolled into the patient room at the time of a hemorrhage. That you have a standardized protocol, that you have a standardized way of measuring blood loss. And that you have a strong engagement with your blood bank. And that you have ways of debriefing and learning after each events. And so that there's learning that is ongoing.
Christie - 00:11:42:
So to pause you just for a minute, what's interesting to me as you're talking about this is these seem like common sense. And I can't tell if that's because I've been working in the space or if we just needed to pull these pieces together for folks.
Elliott - 00:11:59:
It's an interesting comment because it is kind of common sense that emergency response should have a standardized approach. And indeed, when you think about a code blue in a hospital. There's a crash cart involved and there is a very standardized protocol for how you do a code loop. We've never really gone there in obstetrics. We all think we know what to do in the case of an emergency, but the reality is we don't. We didn't. And we need to really review what we've done and to do it in a more formal way, which is not to say that every single case has to be managed in the same way. It's that you have a standardized approach that is also balanced with variation based on the clinical differences of the patient. But you have to start from a standardized base.
Christie - 00:13:01:
That makes a lot of sense. And I think when you think about humans, which providers, clinicians, multidisciplinary groups are, you know, we like to think that our competency overrides potentially anxiety or a panic response. Even when you've been doing this for a while, I think because we care about the work we do, maybe some of that goes out the window when you're having an adrenaline response. And I can see why that was in its way revolutionary. I remember running around for supplies when I worked in labor and delivery. So the concept of a car is really, like most big concepts in QI, it's simple, but it's a game changer.
Elliott - 00:13:39:
It is interesting that he's... A standardized approach. Was resisted initially by terms like cookbook medicine and so forth. But as soon as people started working together on this and realized the really important benefit of having the nurses and the whole team trained to a common response, that it would make a difference. I remember in my hospital, you know, when we introduced the hemorrhage, which... Toolkit that we would celebrate each hemorrhage that we did well. And it was really a sense of accomplishment that you could make a difference.
Christie - 00:14:23:
There's nothing worse than leaving and hoping you could have done it better when it comes to patient care, I think. And frankly, I'm going to point out, too, cookbooks exist for a reason, because recipes lead to successful cooking when they followed without too much variation.
Elliott - 00:14:38:
Well, what we saw was that it was really important to break through the barriers that I mentioned earlier of denial and delay. Because those were so prevalent in all the deaths that we reviewed that one of the key steps to overcome those was to have some standardized approach for our emergencies. I can't tell you how many cases of... Deaths from hypertension, from severe preeclampsia or eclampsia that we reviewed, in which everyone was sitting around watching blood pressures that were off the wall and not being treated. And it was just really disturbing. And so that was one of the key things for that bundle was to really have that be a hard and fast rule that you treated emergently. Every blood pressure that was confirmed, that was over 160 or 110 diastolic. And almost all the deaths that we had in California were not treated in a timely way with severe range blood pressures. As follow-up, kind of, as we've followed the deaths over the following decade, the deaths from hypertension fell markedly. And indeed, they were relegated now to postpartum deaths rather than intrapartum deaths.
Christie - 00:16:02:
The next frontier, if you will.
Elliott - 00:16:03:
Indeed.
Christie - 00:16:04:
So we're going to touch on that for sure. And I think that it would be helpful maybe before we talk about the evolution of AIM to talk about sort of the rapid growth and evolution of AIM early on. I know that looking back, so I only have documents to work on. You lived it in real time. The initial goal was for a few states to join AIM to implement these patient safety bundles, correct?
Elliott - 00:16:30:
So even sort of as a precursor for AIM was the development of state perinatal quality collaboratives. Which was a mechanism for translation of national bundles into all the hospitals in your state. We weren't really very organized for this, except if you were a big system like a Kaiser. Or some of the other big systems around the country. But having the state-parenting equality collaborative was a really big step here. Some of the earliest ones were in California, in Illinois. Ohio. In Florida, and these allowed the introduction of data and feedback into the system. Data ends up being a really important driver of change, getting feedback on to what you're doing and having that piece involved and having the peer pressure of all the hospitals in the state working on the same subject was very important. So state perinatal quality collaboratives got a kickstart also by some initial funding from the CDC. This was also started in the early 2010s. The first three states were California, New York, and Ohio. And then Illinois in Florida entered soon thereafter. And so there were a handful of states with perinatal quality collaboratives. That was then expanded greatly. And into three or four more, which joined AIM. And then there were five and then there were 15 and now there are 43. Now there are 49 plus the DC. So it sort of grew exponentially. Every double, you know, one of these situations doubles every two years. And so all of a sudden, it's going to eat Chicago.
Christie - 00:18:32:
So question for you around that, because some of our listeners may not be as familiar. And I'm going to use the acronym PQC for Perinatal Quality Collaborative, which you were discussing. We know they're funded in a variety of ways you mentioned through the CDC. When you say that, I think people may who aren't involved in the work, a vision like a bricks and mortar, like it's an institution or an organization. Can you talk a little bit about the structure of perinatal quality collaboratives?
Elliott - 00:19:00:
So they vary from state to state. Some are based in academic institutions. Ours in California is based at Stanford. Some are based in public health departments, others in independent organizations. But they are collaboratives, i.e. They have a limited central structure of people, but it's mostly about getting people together from all around the state to agree to do things and to help share and educate, share data and educate through webinars locally. It is so important to be able to give them their own data back. And to be able for hospitals to compare themselves against others, particularly with standardized metrics. That have a degree of risk adjustment. And hospitals in the past had no idea about how they compared to others. This has been a really, really important tool.
Christie - 00:19:59:
I think I've always said this, and I actually think I've said it before, even maybe this season in the podcast, but nobody believes something's possible until they see other people doing it. And I think some of the things you're describing are, you know, the PQC formation and function are the core concepts of quality, a shared mental model, aligned values, data. And I love that. I think the PQC is the best representative of that. So the PQCs are the action arm of AIM, as I see it. They're the ones doing the work on the ground, supporting facilities or are parts of the facilities that are actually sort of, I'm making air quotes here, but doing the bundle. And I think that is important when we talk about it. But the goal isn't the bundle, right?
Elliott - 00:20:41:
The goal is the action, is the change in the process and to be able to show some actually change in outcomes. So it's about changing people's practices on the day to day, which is not easy. It takes more than a village to make these kinds of changes. And that's why you want to go in with a lot of support. One of the keys is to have support from your national professional organizations. So, you know, when I work with all the hospitals, I work 220, all the hospitals in California, it is critically important that I go in not just talking about what I think, but that this is national. This is ACOG supported. This is AWAN supported, ACNM supported. All the key organizations that are in maternity care are supporting these bundles and helped write them. And so that goes a huge long way to help convince people. And indeed, when you're working on quality improvement in the hospital and labor and delivery, The folks who carry out the bulk of the burden are the nursing staff. And so we have... Really worked hard to engage nursing. And to celebrate nursing achievements as we make all the changes that we have to do for safety on labor and delivery.
Christie - 00:22:10:
You mentioned the professional member organizations, and I know in different iterations of AIM, we are in our third cycle of funding now. And I know that we've worked with partners in different ways, but pretty consistently when you get down to the foundations. And I know that those foundations include sort of building both resources to support the bundles. You mentioned toolkits. We call them resource kits or other resources. And the bundles themselves with experts that are recommended to us. How did you all decide to do that in the first place?
Elliott - 00:22:42:
Well, you have to have a template to work from. You have to have basically the basic educational documents to support the bundle elements. You know, you have to, you know, so you have a toolkit. Excuse me, you have a... So if you're going to introduce a cart, a hemorrhage cart, you know, what's in the cart? What are examples? It makes it so much easier if you can provide hospitals two or three different examples of how it's done. And that's what goes in in the resource kits or the toolkits that have been developed for these purposes. And that jumpstarts the change process. You know, and it's... All these things are really important to have. Experience testing them and to have some publications on them. And so one of the keys in the introduction of AIM, I think, was to have some of the early states. Actually publish their results and then show benefit from them.
Christie - 00:23:47:
I'm going to shift a little bit to talking about sort of the, maybe the evolution of the bundles and some of the work of AIM, because I think folks have sometimes seen it over time. Sometimes they know the background and sometimes they don't. So we went through some changes in AIM as bundles sort of, bundles became, they proliferated rapidly. That bundles are very popular and for a reason, because people started to see data and started to see the sense of them. And I know that we have now what we refer to as the core patient safety bundles. And I'm happy to talk about how we got to the core, but I think you have the data pieces of having seen the implementation over time. And why are the core bundles, the core bundles in AIM now?
Elliott - 00:24:30:
The core bundles of hypertension, hemorrhage, C-section, And I forgot.
Christie - 00:24:37:
Cardiac conditions. Let's see. Substance and obstetric care. Postpartum discharge transition.
Elliott - 00:24:45:
Why don't you name the core ones?
Christie - 00:24:48:
The core ones. Okay. So the core patient safety bundles are obstetric hemorrhage, severe hypertension in pregnancy, sepsis and obstetric care, cardiac conditions and obstetric care, postpartum discharge transition, which is a time period to be clear and not a clinical condition. And we can visit that if we need to. Care of the pregnant and postpartum person with substance use disorder and perinatal mental health conditions. I believe the last is safe reduction of primary cesarean. I think I got all eight.
Elliott - 00:25:20:
So they... They did proliferate because maternal mortality is not a single issue. And you have to really... Uh... Address the underlying causes. And that was really one of the key things in doing a review is to say, okay. You know, what are the leading underlying drivers of maternal mortality? How can we address them, you know, from a clinical and then from a non-clinical standpoint? And we'll get into that in a moment, too. Oh. And then what are the most preventable ones? So we started off with the most preventable ones that also drive severe maternal morbidity. When you look at severe maternal morbidity, it far and away is driven by hemorrhage and hypertension. So those are the first two bundles. And then sepsis is up there as well as the others as important drivers. Oh. And they all need attention. But sometimes you can have too many bundles. There can be, you have to make certain that you have the change for the first bundle well established before you go on to the next.
Christie - 00:26:35:
And they have overlapping components, correct? You know, there's some best practices, right?
Elliott - 00:26:41:
Yes. They all have a very similar structure that we developed with the very first bundle, which was obstetric hemorrhage. Which I had the honor of working with Deena Goffman and Lisa Kane Lowe, among others, to develop, I think, in 2015. We started off with a 4R model of... Of readiness, recognition, response, and then reporting or system learning. Which is really the four stages of care. You want to have stuff all established and training and so forth to start with, and you have to be able to recognize, i.e. Diagnose, and you have to be able to respond to treat quickly, and you have to learn from it. We've realized after several years that we were missing a really important part, which was respectful care. And that's become the fifth R. Oh. But we then also learn that you want to put that fifth R throughout the other four R's rather than have it be a separate R. And that's been an important evolution of how the bundles have worked. And so now every bundle has five R's, with that fifth R being trying to permeate throughout the rest of the bundle.
Christie - 00:28:06:
I think that really speaks to the three Ds you were talking about. We've got five R's, three Ds, a whole alphabet soup. But I think the five R's are really meaningful in that framework. And a lot of AIM's work now revolves around those because they so well cover it. I think the concept of respectful care, too, came to a fore and more and more as we've recognized disparities in outcomes related to inequities. And you touched a little on, you know, things outside the hospital unit. And I think the focus very appropriately in the beginning was very labor and delivery unit or birthing facility focused. Can you talk a little bit about why and how some of that extends out past that level?
Elliott - 00:28:48:
As we've learned more and more about maternal mortality and looked at pregnancy-related mortality, which is a different definition, and it goes out to a year after birth, and there's a clear recognition that there are a lot of pregnancy-related deaths that aren't occurring in the hospital, but particularly in that postpartum period. Postpartum, you know, to 42 days has been the classic term, but even beyond that, particularly for conditions like cardiovascular disease or cardiomyopathy. Is heavily weighted for the post-delivery period, up to a year. We've We've seen the overlap of the other big epidemic in America, which is... Substance use, opioid use, and drug overdose deaths. And our obstetric population is in that same demographic that has been hit very hard by that. And so not to mention mental health, which is also heavily in the postpartum period, particularly the later postpartum period. And so if you're going to be looking at improving maternal health and maternal mortality in the big picture, you have to look beyond the hospital. In fact, I think we've been doing pretty well over the last decade with improving care in the hospital. But we haven't really, or just now beginning the work in the postpartum period, which opens all kinds of different challenges, to be honest. It is not that it's ever been easy, but it is a little more straightforward to deal with the hospital setting where you have a lot of staff. Data collection and a focus. Was when she got outside the hospital walls, it gets much trickier, much more challenging, and because the care is less diffused, less organized to begin with.
Christie - 00:30:50:
So we've talked in previous season, we talked about the integration of equity with quality, and we talked about the fractured nature of sort of the maternal perinatal time period in that care that it's outpatient, then it's inpatient, then it's outpatient again. There's different providers. Things don't talk to each other. And I don't necessarily mean providers. I mean EHR and EMR, which is something we've talked about. And it's exacerbated, right, for folks that already are facing challenges being part of marginalized communities or rural locations.
Elliott - 00:31:23:
It- You know, the... Spent my whole career in the medical system only to realize that we don't really have a system. And it's very distressing to really understand that. You know, I feel like I can make saves in the hospital only to have backtracks outside the hospital. And it's the nature of where we are right now that we have to start really thinking of different models of care, having care navigators, people who can pull together all the disparate parts of a system to make it more manageable for a patient. And we're just learning about some of the best practices. This is where doulas can play a role. For marginalized communities. This is where all kinds of other Folks could play roles. But how to integrate them, how to pay for them, how to support them and how to integrate them with the other parts of the system, you know, in terms of communication, as you mentioned earlier, everybody needs to know what the story is to make it work right. And that's still a work in progress right now.
Christie - 00:32:38:
I would say that I am optimistic about that, although I would offer that anyone who works in quality improvement is essentially an optimist. We believe it can be better. We believe it can be better. So I believe that this is getting better, and I'm encouraged by the commitment I see. I think one of the other evolutions I've noticed is, as we've extended, we've recognized that people exist as whole people in communities. And there has been increasing patient with lived expertise engagement, community engagement, and that kind of feeds my... If not optimism, at least hope. And I really appreciate your focus on those pieces. We've talked a little bit about past and a little bit about current state, a little bit about future. I'd love to talk about data in the context of all of that. And when I say data, I want to be clear that I'm not talking about, you know, I don't want to seem like I'm talking about like Mrs. Smith in Texas had X outcome. It's different than that in quality improvement, correct?
Elliott - 00:33:33:
When calling improvement, you're looking at the outcomes of a population. Where the individuals, but the sum of the individuals equals the outcome of a hospital, and the sum of the hospitals is the outcome of a state, et cetera, it's building up. Some states are interested in sharing data internally with other hospitals and sharing data publicly, where other states aren't the hospital level. And so that's a challenge that we're facing around the country is the openness of sharing outcome data. And I think that's an important public service, to be honest, is to be able to understand more about. The data locally, and that's how you learn. And that's how you change, is to have that. So when we look at... Quality improvement data, we're looking at outcomes, which would be morbidity, mortality, which is very, very rare at the hospital level, to be honest, we're talking about. You know, one in 10,000 births typically or less in the hospital. But we're really looking at morbidity measures as outcomes. But then we're looking at, to drive change, you have to have structure, process, and outcome measures in the typical models. And so most of our QI projects have involved a limited. Selection of of measures of structure. Have you implemented this? Have you implemented that? Sort of as yes, no questions, together with a limited set of process measures, which is measuring the proportion of women who were treated with severe hypertension within the hour as a typical process measure. Those all then will lead up to outcome issues that can be collected locally.
Christie - 00:35:25:
So when I hear you talk about the data, I hear you talking about how it needs to be used and how it is being used. So we're not collecting data to do research here.
Elliott - 00:35:35:
So this is data for QI, for quality improvement. And that's what a state perinatal quality collaborative does. That's what AIM does. But at the end of the day, you want to be able to publish it, if you have outcomes, to be able to show benefit. So that's been... Something we've done a lot of work on. You know, in California, we have a very large data system that... I felt was really critical to driving QI in such a large state. And that has actually... Allowed us Uh, to publish a number of articles showing the benefit of particularly in hemorrhage, of introducing the toolkit, the bundle, and showing that we could reduce morbidity for all mothers, actually for all races and ethnicities. And we reduced but did not close the gap between black and white mothers. And that's one of the things. This led us to expand where we are. You know, we've done a lot of work on C-sections. We were able to reduce for all mothers, but not fully close the gap. Between black mothers and white mothers. And again, that's leading us to do much more community engagement, much more patient engagement with outreach in that fourth and fifth hour. Of respectful care has really been a key part of what we're doing.
Christie - 00:37:08:
So I want to acknowledge something, which is you're talking about sort of the two purposes of the data, one to inform the actual quality improvement work you're doing, and then the other to basically inform quality improvement efforts, sort of generally, nationally, statewide. Very important concept that I think sometimes gets conflated as we talk about the work. And I also hear you touching on, but what do we do about it, right? So we recognize the problem, we're working on it, and you touched a little on sort of the community engagement pieces and some of the models and navigators. What else do we need to make progress in maternal health? And a little, maybe how do we define that progress?
Elliott - 00:37:50:
For maternal mortality, It is a controversial number. Let me just start off by saying that right now. It's surprisingly hard to collect accurately. You would think a death is a death, but is it related to the pregnancy? Do we know, was it within a year of a pregnancy? I mean, those are not necessarily easy things to do. And there's judgments involved, very unlike infant mortality, which is just did a baby die within a year of birth? That's it. No judgments. For maternal mortality, it's very uncommon to begin with. We're talking about 1 in 10,000, 1 in 2 in 10,000 births. And that goes all the way out to a year. But there are all these judgments involved. And if you ever sit in the committee trying to make these kind of judgments, you can see that it can vary from committee to committee based on the people involved making the judgments. So we know for sure that the rates are high and higher than they should be. We know for sure that there is very significant racial disparities, particularly among Black and Native American populations. But I wouldn't... Count on the exact number. Maternal morbidity is much easier to measure. But it's also somewhat controversial because when you get down to the hospital level, you find all kinds of, well, maybe she was. The codes that are used for individual cases aren't so over-called particular cases. But it's an approximation that's reasonable. And we're working to refine that. And I think that's going to be useful. But again, these aren't measures that are very good for the postpartum period. And we don't have good. Measures in the postpartum. Up to a year. And that's one of the handicaps that we have. Is a lack of data in that time period.
Christie - 00:40:01:
So you see that as being some of the next work that needs to happen?
Elliott - 00:40:06:
I wish I had answers for that. It's a very difficult one. You know, it's a lot of women lose their coverage at six weeks postpartum. Some states have have expanded it to a year, and I think that's an important step. You know, a lot of states that have the highest maternal mortality rates aren't doing that. And so that's a disappointment. The, uh... But still, you have to have folks willing to see the patients in that time period? Clinicians to see the patients. You have to have a system of care. You can't just say, oh, we have Medicaid coverage and that's it. You have to have a system of care.
Christie - 00:40:52:
So access. As I hear you talk about it, it's not a hopeful topic because we're talking about a hard topic and a big topic. I want to circle back to the beginning of our conversation when we actually talked about how we got started in AIM. And that was also not hopeful and didn't feel, I'm guessing at the time, like it could be addressed. It seems so much clearer in hindsight, at least for me coming into it partway through the process. So I appreciate and I'm hoping we can apply our lessons learned for those pieces. I want to ask you something. I've been ending podcast sessions with folks by asking about the one thing. And I think you probably have more than one because I've worked with you for a little while and have huge respect for the depth and breadth of knowledge you carry and appreciate, as well as the history you've shared with us today. But if there was one thing you wanted to leave our listeners with about the work that's happening in maternal health and in the spaces more broadly. What would that be?
Elliott - 00:41:51:
I think I've been very excited. By the ability to to get lots of people to work together on the topic. Lots of different organizations, lots of different... Specialties, nurses, midwives, physicians, and that's what it's going to take. And we were able to do that for, uh. Really addressing hospital maternal mortality. In a So I think that is going to be the ticket. To take into the next step is to really be able to get everybody involved working together. You know, that's how you address hard topics. These have been hard topics.
Christie - 00:42:32:
So just like we've worked so successfully with our midwifery colleagues and nursing colleagues and nurse practitioners, physician associates and so many other folks that contribute to the care, we're going to look into the communities and into the places where we find our patients to do that. Well, I so appreciate you taking the time to talk to me today and for sharing your sort of historical and or current knowledge and appreciate the time you spent.
Elliott - 00:43:00:
Thank you, Christie. This was a pleasure to work with you.
Christie - 00:43:07:
Thank you for tuning in to AIM For Safer Birth. If you like the show, be sure to follow wherever you get your podcasts so you don't miss an episode. To get involved in work related to maternal mortality, be sure to check out the Alliance for Innovation on Maternal Health at saferbirth.org. Together, we can work towards safer births and healthier outcomes for all families. I'm Christie Allen, and I'll talk with you next time on AIM For Safer Birth.