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Patient Safety Tip of the Week

December 8, 2020

Maternal Mortality: Looking in All the Wrong Places?

Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” highlighted the dire status of maternal mortality in the US. The US “rank” in maternal mortality varies between 55^th and 65^th depending upon which source you go to for statistics. But clearly, compared to 10 “peer” industrialized OECD countries, the US ranks dead last, with a maternal mortality rate at least double the next highest country (Tikkanen 2020). The U.S. maternal mortality rate was 17.4 deaths per 100,000 births in 2018 (CDC 2020). The persistently high maternal mortality rates in the US have garnered the attention of many US media entities (USA Today, Bloomberg, Vox, US News & World Report).

Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” also highlighted the disparities in maternal mortality in the US. The maternal mortality rate for 2018 was 17.4 deaths per 100,000 live births, and the rate for non-Hispanic black women (37.1) was 2.5 to 3.1 times the rates for non-Hispanic white (14.7) and Hispanic (11.8) women (Hoyert 2020).

The Annals of Internal Medicine recently devoted a whole supplement to maternal mortality. But it was an article for the Commonwealth Fund that caught our attention (Tikkanen 2020). It focused attention on the timing of the maternal deaths as reported by Petersen et al. (Petersen 2019) and this somewhat surprised us. About a third of U.S. pregnancy-related deaths occur during pregnancy. Seventeen percent of deaths occur on the day of delivery. But 52 percent occur after delivery:

• 19% occur between one and six days postpartum
• 21% occur between one and six weeks postpartum
• 12% take place during the remaining portion of the year

Petersen et al. (Petersen 2019) also looked at causes of maternal death. They noted that approximately sixty percent of pregnancy-related deaths from state MMRC’s (maternal mortality review committees) were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. Causes of death did vary by timing of death related to the pregnancy. Most deaths caused by amniotic fluid embolism occurred on the day of delivery or within 6 days postpartum. Approximately 60% of deaths caused by hypertensive disorders of pregnancy occurred 0–6 days postpartum, whereas those caused by cerebrovascular accidents occurred most frequently 1-42 days postpartum. Deaths caused by cardiomyopathy most commonly occurred 43-365 days postpartum; deaths caused by other cardiovascular conditions occurred most commonly during pregnancy and within 42 days postpartum. Multiple factors contributed to pregnancy-related deaths and they categorized contributing factors and prevention strategies at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.

Between 2003 and 2016, inpatient maternal mortality fell by 20%. There was a similar (24%) decline in maternal deaths in outpatient facilities and emergency departments. But, there was a significant increase in mortality in other settings, particularly within the descendant’s home with a doubling in maternal mortality rate over this time period (Burgess 2020). These numbers and trends are especially bothersome since so many maternal deaths are potentially preventable. The authors suggest that future progress in lowering maternal mortality in the US will require successfully addressing social, cultural, and financial issues beyond the direct control of the medical community.

We do many presentations on the fact that the high cost of healthcare in the US does not result in better health outcomes compared to other countries. We often highlight the high infant mortality and maternal mortality rates in the US as examples. But we also point out that statistics on infant and maternal mortality are somewhat misleading, since social and economic issues are as important as the strictly medical ones. Other countries spend significantly more on social issues that we do in the US.

Tikkanen and colleagues point out the US has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports. Ob/Gyn’s are overrepresented in the US maternity care workforce relative to midwives, but there is an overall shortage of maternity care providers (both Ob/Gyn’s and midwives) relative to births. In most other countries, midwives outnumber Ob/Gyn’s by severalfold, and primary care plays a central role in the health system. They also note that, although a large share of its maternal deaths occur post-birth, the US is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. Tikkanen et al. note that home visits give providers an opportunity to address mental health concerns and allow them to assess social determinants of health, including needs for food, housing, financial security, and protection from domestic violence. They also note that the US is the only high-income country that does not guarantee paid leave to mothers after childbirth.

Tikkanen et al. point out a number of features of the Affordable Care Act (ACA) that have been beneficial to maternal care (expanded access to insurance coverage, expanded Medicaid, covered preventive services, better reimbursement rates for some providers, etc). But they also point out that the COVID-19 pandemic is likely to exacerbate the disparities, given that the pandemic has disproportionately impacted minorities economically.

Most quality improvement and patient safety efforts have focused on prenatal care and inpatient care. But the statistics noted above would suggest, as emphasized by Tikkanen et al., that we need to be focusing much more on what happens after the mothers and infants leave the hospital.

Petersen et al. in a separate paper (Petersen 2019b) addressed factors contributing to racial/ethnic disparities in pregnancy-related mortality, identified at multiple levels, including community, health facility, patient/family, provider, and system. Differences in access to care, quality of care, and prevalence of chronic diseases are among the leading factors. Chronic diseases associated with increased risk for pregnancy-related mortality, particularly hypertension, are more prevalent and less well controlled in black women. They note that ensuring access to quality care, including specialist providers, during preconception, pregnancy, and the postpartum period is crucial for all women to identify and manage those chronic medical conditions. Systemic factors, such as gaps in health care coverage and preventive care, lack of coordinated health care, and social services, and community factors, like securing transportation for medical visits and inadequate housing, are also contributors to pregnancy-related deaths.

But they also note that quality of care likely has a role in pregnancy-related deaths and associated racial disparities. They note a previous study (Tucker 2007) found a similar prevalence of 5 specific complications among black and white women, but a significantly higher case-fatality rate among black women. They also note that some studies have suggested that black women are more likely than are white women to receive obstetric care in hospitals that provide lower quality of care.

ACOG recognized the role of cardiovascular disease as a leading cause of maternal mortality in a 2019 Practice Bulletin (ACOG 2019). In a discussion of that ACOG Practice Bulletin, it was pointed out that a key barrier to adequate care is that 40% of women do not return for post-partum visits (Nackerdien 2019).

Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” discussed many of the social issues related to maternal mortality and disparities in care. But there we also mentioned the plight of women living in rural areas. Over 100 rural hospitals have closed since 2010 and about a quarter of rural hospitals are at risk of closing today. Rural hospitals have great difficulty recruiting doctors, nurses, and other healthcare professionals. As these hospitals hemorrhage financially, many cannot afford to staff labor & delivery units 24x7 when there are few actual deliveries, so this service is often dropped and women are forced to seek their obstetrical care elsewhere. That often leads to discontinuity between their obstetrical care and their overall medical care.

Though inpatient maternal mortality rates have been improving, Joint Commission this past summer introduced 13 new elements of performance (EP’s) related to maternal safety (TJC 2019), though Joint Commission has suspended regular hospital surveys during the current COVID-19 pandemic. The new EP’s focus on maternal harm related to hypertension/eclampsia and to maternal hemorrhage. They also stress the importance of multidisciplinary teams and use of drills and simulations.

Standard PC.06.01.01: Reduce the likelihood of harm related to maternal hemorrhage

EP 1: Complete an assessment using an evidence-based tool for determining maternal hemorrhage risk on admission to labor and delivery and on admission to postpartum.

EP 2: Develop written evidence-based procedures for stage-based management of pregnant and postpartum patients who experience maternal hemorrhage that includes the following:

• The use of an evidence-based tool that includes an algorithm for identification and treatment of hemorrhage
• The use of an evidence-based set of emergency response medication(s) that are immediately available on the obstetric unit
• Required response team members and their roles in the event of severe hemorrhage
• How the response team and procedures are activated
• Blood bank plan and response for emergency release of blood products and how to initiate the organization’s massive transfusion procedures
• Guidance on when to consult additional experts and consider transfer to a higher level of care
• Guidance on how to communicate with patients and families during and after the event
• Criteria for when a team debrief is required immediately after a case of severe hemorrhage

Note: The written procedures should be developed by a multidisciplinary team that includes representation from obstetrics, anesthesiology, nursing, laboratory, and blood bank

EP 3: Each obstetric unit has a standardized, secured, dedicated hemorrhage supply kit that must be stocked per the organization’s defined process and, at a minimum, contains the following:

• Emergency hemorrhage supplies as determined by the organization
• The organization’s approved procedures for severe hemorrhage response

EP 4: Provide role-specific education to all staff and providers who treat pregnant and postpartum patients about the organization’s hemorrhage procedure. At a minimum, education occurs at orientation, whenever changes to the processes or procedures occur, or every two years.

EP 5: Conduct drills at least annually to determine system issues as part of on-going quality improvement efforts. Drills include representation from each discipline identified in the organization’s hemorrhage response procedure and include a team debrief after the drill.

EP 6: Review hemorrhage cases that meet criteria established by the organization to evaluate the effectiveness of the care, treatment, and services provided by the hemorrhage response team during the event.

EP 7: Provide education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:

• Signs and symptoms of postpartum hemorrhage during hospitalization that alert the patient to seek immediate care
• Signs and symptoms of postpartum hemorrhage that alert the patient to seek immediate care

Standard PC.06.01.03: Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia

EP 1: Develop written evidence-based procedures for measuring and remeasuring blood pressure. These procedures include criteria that identify patients with severely elevated blood pressure.

EP 2: Develop written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia that includes the following:

• The use of an evidence-based set of emergency response medications that are stocked and immediately available on the obstetric unit
• The use of seizure prophylaxis
• Guidance on when to consult additional experts and consider transfer to a higher level of care
• Guidance on when to use continuous fetal monitoring
• Guidance on when to consider emergent delivery•
• Criteria for when a team debrief is required

Again, the written procedures should be developed by a multidisciplinary team

EP 3: Provide role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/ preeclampsia procedure. At a minimum, education occurs at orientation, whenever changes to the procedure occur, or every two years. (Note that this requirement for education applies to to staff and providers in emergency departments regardless of the hospital’s ability to provide labor and delivery services.)

EP 4: Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.

EP 5: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.

EP 6: Provide printed education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:

• Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care
• Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care
• When to schedule a post-discharge follow-up appointment

Note that the EP’s for both maternal hemorrhage and hypertension/eclampsia include performance of multidisciplinary drills. Most organizations that provide labor and delivery services do simulation exercises (see our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”).

And, of course, we are always big fans of drills and exercises that help prepare teams for emergencies. Fortunately, Ob/Gyn has been a pioneer in simulation programs that use team-based interdisciplinary training for events like post-partum hemorrhage and other obstetrical emergencies. Many academic medical centers put on such simulation programs for interested parties to attend. We are familiar with the one put on by the University of Rochester Medical Center. These simulations can be quite comprehensive. There’s even one module in which there is simulation of the expectant father fainting in the delivery room!

We also hope you’ll go back to our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”. There we not only discussed programs using maternal safety bundles and simulations, but also discussed maternal safety issues such as RSI’s (retained surgical items), surgical fires, obstructive sleep apnea, epidural catheter mistaken infusions, unintentional hypothermia, the weekend effect, medication mix ups, and other issues. In that column we also discussed the Patient Safety Bundles developed by the National Partnership for Maternal Safety (NPMS) and Council on Patient Safety in Women’s Healthcare and supported by ACOG and the Anesthesia Patient Safety Foundation (Banayan 2020).

One way to address the inpatient portion of obstetrical care has been introduction of obstetrical hospitalist programs. Internal medicine hospitalist and Ob/Gyn laborist programs have been around for a couple decades. OB hospitalist programs have been envisioned as a potential way to address issues such as physician burnout, unpredictable work schedules, fragmentation of care, lack of standardization, and patient safety. Decesare and colleagues (Decesare 2020) recently reported that implementation of an OB hospitalist program significantly reduced patient safety events.

So, we have, in fact, been doing a better job at reducing maternal mortality in hospitalized patients. But the real message in today’s column is that much maternal mortality occurs after the pregnancy has ended and is potentially preventable. We clearly need better focus on those system features that could address factors contributing to those deaths.

Some of our previous columns on maternal and ob/gyn issues:

February 5, 2008 “Reducing Errors in Obstetrical Care”

February 2010 “Joint Commission Sentinel Event Alert on Maternal Deaths”

April 2010 “RCA: Epidural Solution Infused Intravenously”

July 20, 2010 “More on the Weekend Effect/After-Hours Effect”

August 2010 “Surgical Case Listing Accuracy”

September 7, 2010 “Patient Safety in Ob/Gyn Settings”

January 2011 “Surgical Fires Not Just in High Risk Cases”

February 8, 2011 “Inducing Too Early”

April 2011 “Ob/Gyn Patient Safety Programs”

April 24, 2012 “Fire Hazard of Skin Preps Oxygen”

July 2012 “WHO Safe Childbirth Checklist”

December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”

September 2013 “Full-Time Laborists Reduce C-Section Rates”

October 2013 “Challenging the 39-Week Campaign”

November 2013 “The Weekend Effect: Not One Simple Answer”

January 2014 “It MEOWS But Doesn’t Purr”

May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”

August 19, 2014 “Some More Lessons Learned on Retained Surgical Items”

November 3, 2015 “Medication Errors in the OR - Part 2”

February 7, 2017 “Maternal Safety Bundles”

January 23, 2018 “Unintentional Hypothermia Back in Focus”

January 8, 2019 “Maternal Mortality in the Spotlight”

References:

USA Today. Deadly Deliveries. USA Today 2020

https://www.usatoday.com/series/deadlydeliveries/

Flam F. American Mothers Are Dying Because of the U.S. Health Care System. The U.S. has an inexcusably high maternal mortality rate. Bloomberg 2020; February 9, 2020

https://www.bloomberg.com/opinion/articles/2020-02-09/broken-u-s-health-care-system-causes-high-maternal-death-rate

Belluz J. We finally have a new US maternal mortality estimate. It’s still terrible.

Among 10 similarly wealthy countries, “the US would rank 10th.” Vox 2020; Jan 30, 2020

https://www.vox.com/2020/1/30/21113782/pregnancy-deaths-us-maternal-mortality-rate

Galvin G. The U.S. Has a Maternal Mortality Rate Again. Here’s Why That Matters. US News & World Report 2020; January 30, 2020

https://www.usnews.com/news/healthiest-communities/articles/2020-01-30/why-the-new-us-maternal-mortality-rate-is-important

Tikkanen R, Gunja MZ, FitzGerald M, Zephyrin L. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund 2020; November 18, 2020

https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries

Petersen EE, Davis NL, Goodwin D, et al. Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR 2019; 68(18): 423-429 Published May 10, 2019

https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm

Hoyert DL, Miniño AM. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, National Vital Statistics Report 2020; 69(2): 1-18

https://pubmed.ncbi.nlm.nih.gov/32510319/

CDC (Centers for Disease Control and Prevention). National Center for Health Statistics. Maternal Mortality. CDC 2020; Page last reviewed: November 9, 2020

https://www.cdc.gov/nchs/maternal-mortality/index.htm

Burgess A, Clark S, Dongarwar D, SalihuH. Hospital maternal mortality rates are falling,overall maternal mortality still rises: Implications forforward movement. Amer J Obstet Gyn 2020; 222(1): Supplement S5

https://www.ajog.org/article/S0002-9378(19)31391-2/fulltext#sec2

Annals of Internal Medicine. Maternal Health in the United States: Findings From the Health Resources and Services Administration and Partners. Annals of Internal Medicine 2020’ 173(11): Supplement

https://www.acpjournals.org/toc/aim/173/11_Supplement

Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019; 68: 762-765

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6730892/

Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007; 97: 247-251

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781382/

ACOG (American College of Obstetricians and Gynecologists). ACOG Practice Bulletin No. 212 Summary: Pregnancy and Heart Disease. Obstetrics & Gynecology 2019; 133(5): 1067-1072

https://journals.lww.com/greenjournal/Abstract/2019/05000/ACOG_Practice_Bulletin_No__212_Summary__Pregnancy.36.aspx

Nackerdien Z. ACOG Plan Addresses Cardiovascular Disease as Top Killer of Pregnant Women in U.S. MedPage Today 2019; May 12, 2019

https://www.medpagetoday.org/obgyn/pregnancy/79780?_ga=2.79344284.987778444.1557776604-34830772.1511907054

TJC (The Joint Commission). R³ Report. Provision of Care, Treatment, and Services standards for maternal safety. The Joint Commission R³ Report 2019; Issue 24: August 21, 2019

https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_24_maternal_safety_hap_9_6_19_final1.pdf

URMC (University of Rochester Medical Center). Center for Obstetrics and Gynecology Simulation (COGS).

https://www.urmc.rochester.edu/ob-gyn/education/simulation.aspx

Decesare JZ, Bush SY, Morton AN. Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit. Journal of Patient Safety 2020; 16(3): e179-e181

https://journals.lww.com/journalpatientsafety/Fulltext/2020/09000/Impact_of_an_Obstetrical_Hospitalist_Program_on.24.aspx

Council on Patient Safety in Women’s Healthcare. Patient Safety Bundles. 2020

https://safehealthcareforeverywoman.org/

Banayan JM, Scavone BM. National Partnership for Maternal Safety—Maternal Safety Bundles. APSF Newsletter 2020; 35(3): 96-97 October 2020

https://www.apsf.org/article/national-partnership-for-maternal-safety-maternal-safety-bundles-2/

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