What is AIM?
AIM stands for the Alliance for Innovation on Maternal Health. In response to the disturbing rise in the U.S. maternal mortality rate, a national partnership of provider, public health, and advocacy organizations created AIM to support state teams and health systems in the implementation of patient safety bundles.
PNQIN applied for Massachusetts to become an AIM state in 2019.
What are Patient Safety Bundles?
Developed by multidisciplinary workgroups of experts in the field, patient safety bundles (or “bundles”) are standardized, evidence-informed toolkits to reduce variation in response to common issues arising in obstetric care.
AIM has developed 15 different bundles that focus on perinatal health and safety topics, including obstetric hemorrhage, preeclampsia, and opioid use among pregnant patients. All bundles provide several resources such as implementation guides, educational documents, and informative guidelines.
Ultimately, bundles help hospitals to implement policies and practices which address issues commonly associated with preventable maternal mortality and morbidity.
Which bundles has PNQIN implemented so far?
- Opioid Use Disorder in Pregnancy (June 2019 – May 2021)
- Obstetric Hemorrhage (June – November 2021)
- Severe Hypertension (January – June 2022)
- Maternal Equity (September 2022 – present)
- COMING SOON: Perinatal Mental Health Conditions (2024)
Learn about our bundles:
Equity-Focused Approach
Addressing equity is foundational to all PNQIN projects. Equity related to the Perinatal Opioid Project (POP) began with introduction of the AIM OUD bundle.
Initial efforts centered on awareness, with a panel presentation during the Massachusetts AIM Kick-Off conference in May 2019. Activities then broadened to include equity trainings specific to OUD (more details below) and multiple POP summit presentations focusing on inequalities in systems, care delivery, and outcomes.
Educational Webinars
PNQIN hosted a monthly, year-long webinar series for teams implementing the OUD Bundle. Each hour-long webinar included a 20-minute QI training module, discussion by participating teams about their work, and a 30-minute presentation by a guest presenter on topics key to OUD/SUD (Substance Use Disorder) care in pregnancy; many of these presentations were delivered by participating hospital and community health center teams.
Twenty-one hospital teams participated in the first webinar series from July 2019 to September 2020 (with a 4-month hiatus due to the COVID-19 pandemic) and ten additional teams in the second series from July 2020 to May 2021. Webinar recordings, slides, and accompanying resources are available in the Resource Library.
Speakers represented a range of disciplines and institutions, as well as family members, including:
- Dr. Nicole Smith (Brigham & Women’s Hospital, BWH)
- Latisha Goullaud (Lynn Community Health Center)
- Linda Burke, RNC-OB (Beth Israel Deaconess Plymouth Hospital)
- Lindsey Jeffs, RN (Sturdy Memorial Hospital)
- Dr. Katherine Callaghan (UMass Memorial Medical Center)
- Dr. Emily Reiff (BWH)
- Dr. Wendy Timpson (Beth Israel Deaconess Medical Center)
- Dr. Leena Mittal and Gina Gallagher (BWH)
- Dr. Kelley Saia (Boston Medical Center, BMC)
- Alexandra Heinz and Alissa Cruz (BMC)
- And members of the PNQIN Team: Bonnie Glass, MSN RN, and Dr. Ron Iverson, and Dr. Audra Meadows
Topics of guest presentations included: OUD Screening Options, Plans of Safe Care, Caring for Patients with OUD, Linkages to Care, Equity Considerations in OUD Care, Centering Patient Voice, Hospital Team Presentations, OUD SMM Data, SBIRT Training, Pain Relief During Pregnancy, Labor, Surgery, and Post-Op, and Early Head Start.
Resources
The QI topic presentations from the OUD in Pregnancy Webinar Series are part of a new collection that we call the PNQIN QI Starter Pack.
Our Resource Library also contains several years’ worth of literature, tools, and best practices for the respectful care of birthing people and families experiencing OUD/SUD.
Impact Statement
The Problem
Between 54%-93% of all deaths related to obstetric hemorrhage are preventable. Despite effective therapies, delay in diagnosis and management lead to poor outcomes and death.
While patients who experience hemorrhage have higher rates of severe maternal morbidity (SMM), racial disparities exist. In 2020, Black birthing people who experienced a hemorrhage in Massachusetts had around 1.5 times higher rate of SMM than White and Hispanic birthing people.
Although Black patients have an equal likelihood to have an obstetric hemorrhage, they are more likely to die if they hemorrhage.
The Intervention
From June through November 2021, PNQIN implemented the AIM Obstetric Hemorrhage bundle in 21 of the state’s 40 birthing facilities in response to the current public health crisis of maternal morbidity and mortality.
This work was a continuation of Massachusetts MHCI and MHCII (Maternal Hemorrhage Collaborative One and Maternal Hemorrhage Collaborative Two) statewide quality improvement efforts made to address hemorrhage between 2012 and 2017.
Changes to Care Structures and Processes
Among participating Massachusetts hospitals, the proportion of birthing people with measurement of blood loss from birth through recovery using quantitative blood loss (QBL)/cumulative blood loss (CBL) increased from 60% in June 2021 to 80% in June 2022.
Changes in Patient Outcomes
During the same period, Massachusetts experienced a decrease in statewide SMM among birthing people who experienced an obstetric hemorrhage (excluding blood transfusions) from 618.0 per 10,000 deliveries in July 2021 to 566.0 per 10,000 in June 2022.
Stratified by race/ethnicity, all groups experienced a decrease in SMM with the greatest change among Black non-Hispanic patients.
Although these decreases in SMM mirror an increase in QBL utilization across the state, Figures 1 and 2 show enough variation prior to bundle implementation that an overall downward trend because of our work is not yet clear.
We look forward to continuing our support of MA hospitals and monitoring change over time as more data becomes available.
Ongoing Work
PNQIN continues to collect structure and process measures for the AIM Obstetric Hemorrhage bundle, as more hospitals have begun engaging with our statewide collaborative and are motivated to report hemorrhage data.
Furthermore, as part of the Maternal Equity bundle that we launched in September 2022, one of the process measures reported by hospitals is stratified data by race/ethnicity for Black and white non-Hispanic birthing people on measurement of QBL and hemorrhage risk assessment.
Rationale
Hypertensive diseases of pregnancy (HPD) are a growing risk for maternal mortality. Hypertension-related deaths may be preventable conditions with improved healthcare systems. The American College of Obstetricians and Gynecologists and the AIM program created the Severe Hypertension Bundle to decrease cardiovascular and hypertension-related morbidity and mortality.
Keys to Success Include:
- A team and unit that is prepared and ready to manage severe hypertension.
- Timely recognition of patients with severe hypertension.
- Appropriate response in the peripartum period.
- A system that can provide reporting to track and continuously improve.
- Respectful, equitable, and supportive care of pregnant and postpartum people and their identified support network.
PNQIN Activities
We aim to eliminate preventable maternal morbidity related to severe hypertension in pregnancy including severe preeclampsia, eclampsia, or preeclampsia superimposed on pre-existing hypertension by:
- Engaging MA birthing hospitals in the Severe HTN Bundle;
- Providing education through collaborative learning;
- Providing quality improvement (QI) support and technical assistance to teams from the PNQIN HTN Advisory Workgroup and online resources; and
- Open sharing of real time data (structure, process, and outcome measures) to guide bundle implementation.
Success and Opportunity
Bundle implementation with 30 hospitals from January-June 2022 focused on QI learning and order sets, drills & simulation, standard blood pressure (BP) measurement, and staff education.
Despite 100% protocol adoption and increasing education, time to treat demonstrates room for improvement.
Ongoing Work
- Continue/increase monthly HTN data collection and address submission challenges.
- Hire a clinician to lead and support sustainment activities for the HTN bundle.
- 1:1 QI implementation coaching from the PNQIN team.
The Maternal Equity Bundle was created based on a comprehensive literature review and 25
interviews with stakeholders and experts in maternal health equity, respectful care, and
obstetric care quality.
Bundle measures were created based on the archived AIM Reduction of
Peripartum Racial & Ethnic Disparities Bundle, Birth Equity Initiatives in California and Illinois, and root codes and themes from stakeholder interviews.
Equity is a central mission for PNQIN; our initiative addresses ways to integrate equity measures into previous AIM Obstetric Hemorrhage and Severe Hypertension bundles.
The Massachusetts Child Psychiatry Access Program For Moms, a longtime partner of PNQIN, states that 1 in 7 women experience depression during pregnancy or in the postpartum period.
Racial/ethnic inequities in perinatal mental health conditions and access to and use of mental health services exist as well. A representative survey of over 2,000 women in California found that non-Latina Black women experienced both a higher rate of prenatal depressive symptoms and significantly lower use of postpartum counseling and medication than non-Latina white women (Declercq, Feinberg, & Belanoff, 2022).
PNQIN surveyed Massachusetts birthing hospitals in February/March 2023 about which AIM bundle they are interested in implementing next. Out of the 33 responding hospitals, 61% named the Perinatal Mental Health Conditions (PMHC) Bundle as their first choice. Here is why:
Data
- PMHC is the #1 cause of maternal mortality and deemed 100% preventable by CDC and maternal mortality review committees (MMRCs)
- Substance use co-morbidities
- Inequities in mental health outcomes, screening, and service access
Current community, state, national landscape
- Tragedy of the Clancy family in Duxbury, MA in January 2023
- National mental health crisis for the perinatal population
- Postpartum people are underserviced
- Not enough therapists and psychiatrists to manage patients properly (need support from Obstetrics, Midwifery, and Pediatrics)
- Mental health stigma leads to guilt and fear of child removal
- Least focused on in Massachusetts compared to other Bundle options
Lack of information and strategic action plan
- Providers want to learn how to recognize symptoms and connect patients to resources and services (and want more time to do so)
- Patients and families need more education
- Need evidence-based resources and interventions, esp. outside of major MA cities
- Some hospitals know best practices but cannot follow through on recommendations
- Desire for standardization of care, statewide learning and collaboration
- PNQIN should capitalize on rising public awareness around perinatal/postpartum mental health
In the words of a respondent, who is a Massachusetts care provider:
“There seems to be a mental health crisis overall, and as a mom, I know how hard is to get care for mental health during pregnancy and postpartum. There is also a lot of stigma and guilt and I think birthing people deserve better.”
Please check our website regularly for updates on timing of and participation in the AIM Perinatal Mental Health Conditions Bundle!
AIM Initiative Trainings
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
An essential component to caring for families affected by OUD/SUD in pregnancy is universal screening and treatment initiation for those who need to be served.
Implementing this process in an outpatient setting (whether in a private office or large clinic) can feel overwhelming. To help hospital teams approach these systematic improvements, PNQIN has facilitated 116 SBIRT meetings and trainings with MASBIRT (Massachusetts SBIRT) with over 1,000 participants at 20 organizations and hospitals throughout the Commonwealth.
PNQIN and MASBIRT recognize this as a mutually beneficial collaboration, and we continue to work together. To learn more about MASBIRT and request a training for your team, visit their website or email MASBIRT@bmc.org.
MOUD Waiver training
One barrier that many systems faced as they began caring for families affected by OUD/SUD in pregnancy was a lack of providers able to prescribe and manage Medications for OUD (MOUD). Providers must obtain a specific waiver to prescribe MOUD.
PNQIN worked with the Office Based Addiction Treatment program (OBAT) to arrange three MOUD waiver trainings across the state. All trainings (two in-person and one virtual) occurred in 2020 with a total of 50 providers trained. PNQIN’s ongoing relationship with OBAT helped spur the production, promotion, and distribution of the Boston Medical Center Project RESPECT Guidelines for Treating Opioid Use Disorder in Pregnant and Parenting Patients.
Our providers and teams continue to refer to OBAT and now each other as MOUD in pregnancy evolves. Learn more about OBAT’s Training and Technical Assistance program here.
PNQIN Stigma, Bias, and Trauma-Informed Care Training (SBTIC)
Stigma, bias, and trauma-informed care is the recommended model for interaction with people affected by OUD/SUD given the extremely high rate of trauma in this population.
As such, PNQIN collaborated with the Coordinated Approach to Resilience and Empowerment (C.A.R.E.) Clinic team at Brigham and Women’s Hospital to develop a SBTIC training module specifically for birthing people and newborns affected by OUD/SUD and NAS (Neonatal Abstinence Syndrome).
Dr. Annie Lewis-O’Connor and her staff were funded by the Robert Woods Johnson Foundation and consulted with PNQIN to train 15 hospital teams (with 185 participants) via Zoom between July and October 2020. The training was also recorded and has been viewed by over 375 providers and is available in our Resource Library.
SPEAK UP Implicit and Explicit Racial Bias Education
To address the racial inequities in screening and treatment of families with OUD/SUD, PNQIN contracted with the Institute for Perinatal Quality Improvement (PQI) to train hospital teams on obstetric racism. This collaboration is supported by funding from the MA Department of Public Health.
PQI’s SPEAK UP Against Racism Quality Improvement Initiative and Action Pathway supports individuals and teams to develop and implement strategic action plans to dismantle racism, provide respectful and high-quality care, and eliminate perinatal health inequities.
Massachusetts has held 10 SPEAK UP trainings to date, with 491 perinatal provider Champions representing 36 birthing facilities.