AIM Hypertension Bundle Implementation in Delivery Hospitals

The Alliance for Innovation in Maternal Health (AIM) is a national data-driven maternal safety and quality improvement initiative based on proven implementation approaches to improving maternal safety and outcomes in the U.S. AIM has created multiple evidence-based patient safety “bundles” that integrate system-based improvement initiatives to reduce adverse maternal outcomes. The first bundle that ODH is supporting through federal funding is the "Severe Hypertension in Pregnancy" Bundle. Although states do not have to be an AIM member to access the bundles, ODH partnered with the Ohio Hospital Association to applied to become an AIM State in the summer of 2020 and was accepted as part of the October 2020 Cohort. Being an AIM state allows Ohio to have access to evidence-based patient safety bundles and tools that can be disseminated to all birthing hospitals throughout the state. Additionally, participating AIM states are given entry to AIM’s national data center that will provide further timely surveillance to help address the factors related to maternal morbidity and mortality. It will allow for statewide analyses, state-to-state and hospital-to-hospital analyses and comparison. These comparisons can assist in driving continuous improvements in maternal care among individual hospitals and in statewide efforts.

The press release that announced Ohio acceptance as an Alliance for Innovation on Maternal Health (AIM) state can be found here.

Hypertension was selected as the first bundle for implementation because although preeclampsia and eclampsia are the 4th leading cause of pregnancy-related deaths in Ohio, over 80% of these deaths were determined to be preventable by PAMR. In order to reduce the number of preventable maternal deaths caused by hypertension, ODH has funded 2 projects:

1. In April 2019, ODH initiated a contract with the Ohio State University Wexner Medical Center to pilot the AIM Hypertension bundle within a main tertiary care facility and 2 affiliated rural hospitals. The overall expectation of the contract is to see improvement across all 3 hospitals in identification of and timely treatment of hypertension among prenatal and postpartum women. The pilot project will go through September 2021.
2. In April 2020, ODH awarded The Ohio State University College of Medicine, Ohio Colleges of Medicine Government Resource Center a grant to establish an AIM Hypertension Quality Improvement Project (QIP) to implement the AIM Hypertension bundle across all Ohio delivery hospitals over a 5-year period. The goal of this QIP is to decrease maternal mortality and preventable maternal deaths associated with severe hypertension in pregnancy among women who are Medicaid eligible or enrolled, uninsured, black, and/or have a mental health diagnosis. Over the course of the QIP, participating maternity care hospitals will use quality improvement science to address maternal mortality associated with hypertension in pregnancy. Participating sites will develop rapid cycle Plan-Do-Study-Act cycles to test interventions around early QI opportunities including:

• Early recognition of hypertension/preeclampsia
• Effective blood pressure measurement
• Point of Care for initiating anti-hypertensive medications early and aggressively
• Coordination of Care
• Postpartum Follow-Up and Patient Education

The AIM Hypertension QIP will go through September 2024. For questions, please contact Hallie.Kerr@odh.ohio.gov. 

Urgent Maternal Warning Signs Implementation in Public Health Settings

There is a known drop-off in service intensity after delivery, which can lead to missed diagnoses and/or symptoms resulting in maternal death that could have been prevented. In Ohio from 2008-2016, 46% of pregnancy-related deaths occurred within 42 days of delivery and an additional 19% occurred 43 to 365 days after delivery. Thus, postpartum deaths comprise 65% of all Ohio’s pregnancy-related deaths. The most common causes of postpartum deaths include infection, preeclampsia and eclampsia, cardiovascular and coronary conditions, and hemorrhage, respectively, of which over half are preventable. This Ohio data mirrors national data. Because many women do not receive consistent messages or adequate guidance on identifying the warning signs of postpartum complications, or instructions about when and where to obtain necessary medical attention, Urgent Maternal Warning Signs education can facilitate providing this critical information to help new mothers recognize warning signs of postpartum complications that could occur after discharge and to seek immediate medical attention if necessary. 

In April 2020, ODH awarded The Ohio State University College of Medicine, Ohio Colleges of Medicine Government Resource Center a grant to establish the Urgent Maternal Warning Signs Quality Improvement Project (QIP). The goal of this quality improvement activity is to implement Urgent Maternal Warning Signs education in public health settings (e.g., WIC, ODH evidence-based home visiting) throughout Ohio. The education will be based on the American College of Obstetricians and Gynecologists (ACOG) Council for Patient Safety education. The long-term goal is to decrease preventable maternal deaths related to the specific warning signs included in the Urgent Maternal Warning Signs education. Examples of such warning signs include:

• Headache that won't go away
• Dizziness or fainting
• Chest pain or fast-beating heart
• Obstructed breathing or shortness of breath
• Vaginal bleeding or fluid leaking during pregnancy
• Increased use of feminine hygiene products
• Swelling, redness or pain in legs, hands or face
• Fever or severe nausea
• Thoughts about hurting yourself or your baby

The QIP will particularly focus on women who are Medicaid eligible or enrolled, uninsured, Black, and/or have a mental health diagnosis.

Participating sites will use QI science to implement a change package and patient resources within Ohio public health settings with mothers during pregnancy in their immediate postpartum period. Sites will also develop rapid cycle Plan-Do-Study-Act cycles to test interventions around engaging and empowering new mothers to make appropriate health decisions for themselves. Sites will be asked to complete the following activities:

• Form a core QI team to implement the change package and patient resources and attend monthly calls to share best practices and learn from your peers
• Collect and enter data electronically or via fax on a monthly basis
• Engage in select site-specific QI coaching opportunities
• Commit to testing and adapting interventions related to maternal postpartum care

The Urgent Maternal Warning Signs QIP will go through September 2024. For questions, please contact Hallie.Kerr@odh.ohio.gov.

Healthy Mom, Healthy Family; An IMPLICIT Interconception Care Quality Improvement Project

After delivery, many women do not seek preventive care for themselves. Approaches to interconception care (ICC) through routine office visits may not reach women who are at highest risk for adverse birth outcomes such as low income, younger, or minority women. Without engaging with providers regularly after delivery, many women revert back to high-risk behaviors such as smoking. However, new mothers regularly attend their child’s well visits with the pediatrician. To address this missed opportunity to engage with provider(s) during the interconception period, the Healthy Mom, Heathy Family Project uses Interventions to Minimize Preterm and Low Birth Weight through Continuous Improvement Techniques (IMPLICIT) interconception care (ICC) model targets all women when they accompany their children to pediatric well-child visits, enhancing access to a health care provider especially for women who may not otherwise seek care. The IMPLICIT ICC model addresses barriers to maternal health care by pediatricians screening mothers in 4 intervention areas during well child visits at 0-24 months to provide brief counseling and referrals:

• Tobacco Cessation
• Family Planning
• Depression
• Use of Multivitamins with Folic Acid

These areas were chosen to (a) retain the concept of a brief screening and intervention strategy and (b) represent areas with strong evidence for improving maternal health and future birth outcomes. In a recent process evaluation of the IMPLICIT Interconception Care Model, mothers accompanied their babies to >90% of well child visits and at almost 70% of visits mothers were screened for these 4 areas. Over 60% of women screened positive for at least 1 risk factor, and rates of documented interventions to address the positively screened risk factors ranged from 60% - >90%).

ODH is extending existing, ongoing work in this area with The Ohio State University College of Medicine, Ohio Colleges of Medicine Government Resource Center and the Ohio Chapter of the American Academy of Pediatrics and in collaboration with the March of Dimes to implement the IMPLICIT ICC model through three waves with at least 12 to 15 pediatric practices, respectively. Recruitment of sites will focus on practices that serve a high proportion of patients living in Appalachian counties, who are black, and who are Medicaid-insured.

IMPLICIT Network will go through September 2024. For questions, please contact Hallie.Kerr@odh.ohio.gov.

Obstetric Emergency Training for Emergency Medicine Providers

Emergency medicine staff and responders are often the experts women turn to when they are experiencing acute distress during and after pregnancy.

Data from the ODH Pregnancy-Associated Mortality Review program revealed that:

• 23% of pregnancy-related deaths in Ohio from 2010-2016 occurred in an emergency department or in an outpatient setting.
• 41.2% of pregnancy-related deaths in Ohio from 2008-2016 involved a maternal transport.
• A needs assessment of Ohio's delivery hospitals found that only 30% of obstetric emergency simulations involve emergency department staff.

These simulation trainings will provide educational opportunities to emergency medicine physicians, physician assistants, nurse practitioners, nurses, and first responders to increase their knowledge and preparedness for obstetric emergencies-both in emergency departments and during maternal transports. Training content includes but is not limited to identification, treatment, and management of:

• Hemorrhage
• Hypertension
• Cardiac conditions with pregnant and postpartum patients

The Obstetric Emergency Trainings for Emergency Medicine Providers will go through September 2024. To inquire about trainings, please contact Rashelle.Ghanem@odh.ohio.gov.

Managing Implicit Bias and Maternal Health

Differences in the incidence and prevalence of health conditions and health status between groups are commonly referred to as health disparities. Unconscious beliefs can impact the work we conduct and contribute to these health disparities. Educating healthcare and public health professionals about implicit bias can support us in taking action to ensure equitable development and implementation of policies and programs that impact the women, children, and families we serve.

The PAMR program has contracted with Scale Strategic Solutions to provide live, virtual trainings focused around “Managing Implicit Bias and Maternal Health” through June 2022. To register for any available trainings, visit our Webinars and Trainings Page. 

Disparities in Maternal Health Community Grant Program

Maternal death disproportionately affects non-Hispanic black women both in the U.S. and in Ohio. Non-Hispanic black women are more than 2.5 times as likely to die from a pregnancy-related death than non-Hispanic white women in Ohio. The pregnancy-related mortality ratio for non-Hispanic black women in Ohio was 29.5 deaths per 100,000 live births compared to 11.5 deaths per 100,000 live births for non-Hispanic white women from 2008 to 2016.

In order to work toward eliminating disparities in maternal health among black women, initiatives, programming, and projects must view this public health program through an intersectional and socioecological lens. The Ohio Department of Health is currently funding three subgrantees between October 2021 to September 2022 to facilitate innovative initiatives to produce direct, measurable improvements in maternal health outcomes. Please see the Table 1 below to view the current subrecipients funded through this grant program. Table 2 includes the four subrecipients funded from October 2020 to September 2021. For questions about this grant program, please contact Rashelle.Ghanem@odh.ohio.gov.

Table 1. Current Subrecipients of the Disparities in Maternal Health Community Grant Program – October 2021-September 2022

Table 2. Past Subrecipients of the Disparities in Maternal Health Community Grant Program – October 2020-September 2021