A group of physicians who authored a "Perspective" piece for the New England Journal of Medicine propose all hospitals big and small can combat maternal mortality by employing tactics that include expanding their focus on the preventable causes of birth-related complications and death, implementing "multidisciplinary" staff meetings to assess each patient's risk factors, do simulations of emergency situations to train staff and improve readiness and use the Maternal Health Compact, an formalized agreement between lower-resource hospitals to referral hospitals when the patient requires a higher level of care.
The piece was written by Dr. Susan Mann, from Beth Israel Deaconess Medical Center and Harvard Medical School; Dr. Lisa M. Hollier, from Baylor College of Medicine in Houston,Texas. Hollier is also a member of the American College of Obstetricians and Gynecologists. Authors also included Dr. Kimberlee McKay, of Avera Health and Sanford School of Medicine, University of South Dakota; and Dr. Haywood Brown, of the Morsani College of Medicine, University of South Florida, Tampa.
WHY IT MATTERS
According to the authors, women in the U.S. are more likely to die in childbirth than women from any other high-income country, and black women die three to four times more than white women. The four actionable areas described by the authors can be applied and modified for virtually any hospital.
The Centers for Disease Control and Prevention defines a pregnancy-related death as "the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy," the authors wrote. The CDC identified the three most common and potentially preventable complications are postpartum hemorrhage, severe hypertension, and venous thromboembolism.
WHAT ELSE YOU SHOULD KNOW
Step one, expanding a hospital's focus on the issue of preventable maternal mortality involves implementing the "bundles of best practices" for improving maternity care safety created by the Alliance for Innovation on Maternal Health or AIM. The protocols help clinicians better manage the care of high-risk patients.
The bundles include best practices for readiness, recognition, response and reporting and can be customized for any unit and made available to to all staff. They should also be posted and regularly reviewed, the authors wrote. The staff should also be required to demonstrate their understanding and readiness to deal with emergencies. This includes 24/7 access to anti-hypertensive drugs even when the pharmacy is closed.
Second, the practice of holding "multidisciplinary" staff meetings to review each patient's risk factors should be held no matter the size of the obstetrics unit. With smaller units that have fewer staff, it is crucial to have a shared "mental model" of patients' risks and how their needs can be met. These meetings should also be held amongst surgeons, anesthetists, nurses and scrub technicians regarding patients that are facing elective or nonurgent c-sections to clarify understanding of the patient, the procedure, and additional resources that might be needed in the face of unforeseen complications.
"These identified safety concerns should be communicated to the patient, and she and her family should be given the opportunity to express their concerns. Shared decision making by the patient and the obstetrical team allows for the opportunity to address any potential institutional biases that affect disparities in maternal morbidity and mortality," the authors wrote.
Third, staff can simulate emergencies and use the exercises to illustrate the the importance of timing and logistics such as how long it takes to get a hold of blood products from the local blood bank, where to find a hemorrhage cart of medications that are not frequently used but might be needed, all the way up to low-probability but high-danger medical events. It allows allows staff to evaluate the current protocols for efficacy and make needed modifications.
Finally, hospitals can and should employ the Maternal Health Compact. This is a formal agreement made between lower-resource hospitals that might have to transfer patients in need of more complicated care and the referral hospitals. These relationships allow the lower-resource hospital to contact and consult with clinicians in the referral hospital in the event of an emergency they can't fully handle, providing support even if it is only needed while transport is orchestrated.
ON THE RECORD
"Creating a culture of safety in all birthing facilities while promoting and providing a supportive patient-centered environment for mothers is a critical task that requires strong administrative and clinical leadership, adequate resources for training, and a quality-improvement feedback system in which the entire health care team is held accountable for system changes. If we're to achieve such a culture, hospital leadership will need to create a vision for change by establishing relationships with referring and receiving hospitals, including by deploying telehealth resources...If leaders hold their staff and themselves accountable, they can curb the trend of increasing rates of preventable maternal deaths," the authors wrote.
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