By Melinda Young
Women in the United States have a higher rate of childbirth-related morbidity and mortality than women in most other wealthy nations. Often, these complications can be prevented.
- One solution involves The Joint Commission’s Proposed Standards for Perinatal Safety, which provides evidence-based solutions to addressing pregnancy complications.
- A comprehensive, multidisciplinary approach can help solve the problem.
- Maternal health education should be provided to hospital staff, including nurses and physicians.
About 700 women die each year of childbirth complications in the United States, and most of these deaths could have been prevented. The death rate is double the United Kingdom’s rate and higher than nearly 40 other developed nations. (For more information, visit: http://bit.ly/2QiNVpA and: http://bit.ly/2JxleVk.)
Health officials point to a variety of contributing factors, including healthcare professionals overlooking early danger signs. Researchers, obstetric experts, and professional organizations are working to fix this problem.
For example, The Joint Commission (TJC) published its new Proposed Standards for Perinatal Safety in April to provide evidence-based procedures that hospitals can use to identify and treat maternal hemorrhage and pre-eclampsia. (The standards can be found online at: http://bit.ly/2Hv7CaA.)
“Hemorrhage and severe hypertension — pre-eclampsia — are leading causes of preventable maternal death or harm,” says Jennifer Hurlburt, MSN, RN, APN/CNS, associate director of TJC’s department of standards and survey methods in Oakbrook Terrace, IL.
TJC’s requirements to address these complications could make a significant difference in maternal morbidity and mortality, she adds. (See Q&A about The Joint Commission’s perinatal safety standards in this issue.)
Public health officials first observed a bump in maternal deaths when states changed their reporting structure to include information about whether a death was pregnancy-related, says Michael R. Foley, MD, chair of the department of obstetrics and gynecology at the University of Arizona College of Medicine - Phoenix. Foley also is chair of obstetrics and gynecology at Banner-University Medical Center in Phoenix.
Compared to other industrialized nations, the U.S. rate of maternal mortality within a year of giving birth is very high, Foley adds.
This problem is comprehensive and requires a multidisciplinary approach to understand it, which is why a group of obstetric experts — including Foley — and organizations wrote a recent paper about a collaborative effort to address maternal morbidity and mortality in the United States.1
“We recognized a number of things we could do to reduce mortality for the future,” Foley says.
Also, the Alliance for Innovation on Maternal Health (AIM) has partnered with professional societies and industries to improve maternal health and reduce morbidity and mortality, he says.
“They’re bringing in bundles, a representation of existing guidelines that provide a template for what’s needed and how to educate, prevent, and prepare,” Foley adds. “It’s a cookbook of guidelines that all hospitals should be moving toward and endorsing, and it’s not expensive.”
It does require hospitals to collect and share data, but they benefit from a report card to see how they are performing.
Nurses, including RN case managers, are very important to these collaborative efforts, Foley notes.
“Nurses are frontline people and the most important,” he says. “All of these Alliance bundles include nursing assistance, teamwork, multidisciplinary care. It’s about the entire team.”
One evidence-based bundle has nurses administer medication for a hypertensive crisis if they are unable to contact the doctor to reduce risk to the patient, Foley explains.
“In this one example, we make it an emergency order so the nurse could administer this medication to save lives,” Foley says. “If the nurse has 30 minutes to get the order from the doctor and the order doesn’t arrive on time, she can do it.”
One of the issues related to inpatient cases of pregnant women identified as critically ill is that there has been no plan in hospitals on how to manage these cases, says Suzanne McMurtry Baird, DNP, RN, co-owner and nursing director of Clinical Concepts in Obstetrics in Brentwood, TN.
When it comes to neonatal care, there are established processes for handling challenging cases. If a baby meets certain criteria, he or she is transferred to another neonatal center that is able to handle a higher level of care.
But there has not been a regionalized program for transporting pregnant women who are critically ill to a higher level of care, Baird explains.
This deficit is being addressed. Now, hospitals will be rated according to the level of maternal care that they can provide for obstetric patients. The level will be designated by the state’s department of health, she says.
“Lots of work will go on within states to do that and determine how each hospital will level out,” Baird adds. “The main objective is getting obstetrics patients to the right level of care so they can be managed by a team that has training in high-risk, critical obstetrics.”
For example, a hospital might have a level 4 neonatal unit and a level 4 maternal care unit, meaning the hospital can handle the highest-risk births.
“Hospitals are going to be leveled and will have some idea of where to transport patients when they become high-risk or critically ill,” Baird says. “A huge piece for case management is to get the patient to the right level of care to meet the woman’s needs — and it’s not just about neonatal needs anymore.”
All hospitals can do a better job of diagnosing serious illness among pregnant women and new mothers — and the place for hospitals to start is in educating staff, Baird says.
“One of the biggest mistakes hospitals make is thinking they just need to educate their nurses,” she says. “In other words, they will send nurses to a conference and when they come back, they say, ‘We’ll be fine.’”
But everyone needs to be educated on maternal health, Baird adds. (See story on how hospitals can improve diagnosis and case management of pregnant women and new mothers in this issue.)
One area of maternal mortality that may be overlooked involves trauma, such as automobile collisions and domestic partner violence, says Christy Pearce, MD, MS, director of maternal fetal medicine at Centura Health and Southern Colorado Maternal Fetal Medicine in Colorado Springs.
Healthcare providers and public health officials are putting systems in place to reduce maternal morbidity and mortality with hemorrhage, and states are adopting these guidelines. But less attention is paid to maternal deaths connected to trauma, as these are less common, Pearce says. (See story on maternal morbidity and trauma in this issue.)
Public discourse about maternal deaths also overlooks a systemic problem related to shortages of obstetricians, Pearce notes.
“Why don’t we have enough people taking care of pregnant women?” Pearce says. “So many centers don’t do OB/GYN care because it loses money for that hospital.”
Unless doctors are trained to provide obstetrics care, they cannot provide such care optimally.
“It’s a hard specialty because people want a perfect outcome, and that’s not how life works. And it’s a high-litigation specialty, which goes into the risk-benefit analysis of whether an obstetrician continues to deliver babies,” Pearce adds.
This shortage of obstetricians and fetal medicine specialists places women at risk.
“We did notice that in areas where there were a lot of maternal fetal medicine specialists, within those geographical locations the maternal mortality rate was lower.” Foley says.
This suggests that healthcare providers need additional training and education.
“We convened a huge group of people with expertise in this area from across the country, and we identified a couple of areas we could launch into,” Foley explains.
First, training programs should be developed for maternal-fetal medicine specialists. Educational sessions could focus on the maternal side of the equation, increasing physicians’ comfort levels, he says.
“The American Board of Obstetrics and Gynecology was interested and acted nicely in changing the training model for a fellowship to include mandatory intensive care training,” he says.
The plan was to get hospital providers confident in taking care of people who are critically ill and to spend more time on labor and delivery, Foley adds.
The second step was to create an international training program in critical care and obstetrics that would provide experiential learning. In Phoenix, Foley was involved in developing the simulation program. The program used pregnant mannequins that were realistic enough to blink eyes and bleed.
“We worked with a national team, many experts from across the country, to create the facility,” he says. “Also, there are 22 online lectures, including testing simulation, and we followed it up with an online simulation course at Phoenix.”
Close to 2,000 OB/GYN doctors have rotated through the program over the past five years. They learn new skills, such as airway management and handling cardiac arrest when new mothers are bleeding, he says.
“They go through an actual simulation,” Foley explains. “Many hospitals bring in their teams and we train them, giving them materials to take back to their hospitals where they can use them.”
- D’Alton ME, Friedman AM, Bernstein PS, et al. Putting the “M” back in maternal-fetal medicine: a 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States. Am J Obstet Gynecol. 2019;Epub ahead of print.