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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 55th and 65th 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:


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:

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:


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:


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:


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:


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






USA Today. Deadly Deliveries. USA Today 2020



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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



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







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