A team-based approach to improve maternal outcomes in a middle-income country.
Cardiovascular disease is a leading cause of maternal death and severe morbidity. The maternal demographics and risk factors have changed over time. At the time of pregnancy, women are older and have more chronic medical conditions. The maternal mortality ratio (MMR), defined as the number of maternal deaths during a given time period per 100 000 live births during the same time period, was 51.4 per 100 000 live births for Colombia in 2017, counting to 487 deaths during this year. A 5.6 percent of pregnancies was complicated by cardiovascular diseases and 11 percent of women died at the same time.
Our Cardio-obstetrics Center is hosted in ‘Hospital San Vicente Fundación’, a non-for profit healthcare organization, and has as purpose to improve maternal and fetal outcomes in a middle-income country, while costs are lowered, or at least, without increasing them. This is a unique and pioneering care model in Colombia and Latin-America launched four years ago. This is centered on women with pre-existing and acquired cardiovascular disease, from they are contemplating pregnancy to care throughout pregnancy, delivery and their post-partum period.
As a cardio-obstetrics team requires a group of dedicated individuals committed to caring for this population of women, we have adopted an interdisciplinary team-based approach including obstetrics, cardiology, maternal-fetal medicine, anesthesiology, nursing and social worker, aligning with the IPU concept.
Each woman with a cardiovascular disease who is contemplating pregnancy or are pregnant is risk assessed and involved in a shared-decision making process in an out-patient pathway. If a complication arises, each patient is assessed and followed by cardio-obstetrics team in an in-patient pathway. The interdisciplinary meetings involve discussion of labor and delivery plans and definitive management of cardiac disease, with focus on patient’s progress with the pregnancy and a plan for safe delivery, and post-delivery follow-up which can be extended up to six months, according to the risk.
Throughout the whole cycle of care, each patient participates in an individual care plan co-designed with a nurse who acts as a case manager.
We have been measuring value through condition-specific patient-reported outcomes (PROMs) such as dyspnea experienced with daily living activities, and the outcomes endorsed by The ESC Registry Of Pregnancy and Cardiac disease (ROPAC), as well as subjective patient ‘satisfaction’ surveys. At a process level, we have recently raised process maps using Lean methodology in order to build cost in a comprehensive and accountable way.
From 2016 to 2018, 168 pregnant women with cardiovascular diseases have been assessed by the team. 5.4 percent have presented primary cardiac events (pulmonary edema, arrhythmia, cerebrovascular accident, cardiac arrest and sudden death) versus 13.8 percent in pregnant women not followed by the cardio-obstetrics team. To date, the center has involved 296 patients.
In our journey to enhance patient value, we have recently started measuring Health-related Quality of Life using a digital therapeutic platform, in a collaboration with ‘Biva’, a local entrepreneurship and partner.
As the Cardio-obstetrics Center has been developing, training opportunities for fellows and research are grown too.