Specific Steps to Reduce Maternal Mortality & Morbidity
The coalescence of the awareness of increasing maternal mortality and severe morbidity, acceptance that a high percentage of maternal morbidity and mortality is likely preventable, recognition that other countries were decreasing their maternal mortality, patient safety principals and that meaningful assessment of care must be multidisciplinary and focused on system as well as provider factors, resulted in a national call to seriously address maternal care and outcomes. Two recent pivotal papers made the call to action: "Put the M (maternal) back into MFM (maternal fetal medicine)".[27,28] These calls to action stimulated multiple multidisciplinary, inclusive activities which resulted in the efforts listed below intended to improve maternal care and reduce severe maternal morbidity and mortality.
Communication and collaboration between all stake holders involved in perinatal health.
Multiple national organizations were represented at meetings held in 2012–2013 to build consensus around improving maternal care and outcomes. These meetings resulted in alignment to reduce maternal morbidity and mortality and The National Partnership for Maternal Safety and the Council on Patient Safety in Women's Healthcare were created to bring together organizations interested in maternal outcomes.[28,29] The breadth of participants in the Council of Patient Safety in Women's Healthcare is impressive and currently includes American College of Obstetrics and Gynecology (ACOG), Society for Maternal Fetal Medicine, American College of Nurse Midwives, Association of Women's Health, Obstetric, and Neonatal Nurses, Society of Obstetric Anesthesia and Perinatology, National Association of Nurse Practitioners in Women's Health and Academy of Family Physicians. The full listing is on their website for the Council on Patient Safety in Women's Healthcare.[30] The website contains educational items, bundles, forms for severe maternal morbidity review and other updates are ongoing national efforts to reduce maternal morbidity.
Creation of national guidelines or bundles addressing key maternal care areas.
Although ACOG for years has provided practice bulletins, committee opinions on obstetric care and health, these have not consistently been multidisciplinary nor specific guidelines. Maternal care is complex and often multiple disciplines are involved not only in high-risk care but also in low-risk care. Thus, the broad inclusion of multidisciplinary providers is crucial to developing consensus around the development of patient safety bundles.[28] The initial bundles in various stages of production focused on areas associated with maternal death and morbidity include obstetric hemorrhage, severe hypertension and venous thromboembolism prevention in pregnancy. Each bundle was or is being developed with a multidisciplinary team representing multiple organizations. The bundle concept is to facilitate the ability of providers to reliably provide the best care was derived from the Institute for Healthcare Improvement[31] and each bundle is written to allow individual site modification if desired. Currently, the hemorrhage bundle is available to be downloaded from this website.[30] As more bundles are created they will be made available to the public at this website. The belief that implementation of national bundles will improve maternal outcomes is supported by data that sentinel events were decreased after the implementation of an obstetric safety program that included obstetric team training, specific protocols and efforts at clear communication and chain of command.[32]
Call to review and analyze all cases of severe maternal morbidity.
Following the model of reviewing all maternal deaths, each facility that provides obstetric care should review all their cases of severe maternal morbidity to determine if there are areas for improvement in care. It was recommended that all pregnant or recently postpartum women who received four or more units of blood or who were admitted to an ICU should be reviewed. As noted above these characteristics will identify most women with severe morbidity.[33] The purpose of reviewing cases of severe maternal morbidity is to determine if there were opportunities for improvement in care that could potentially reduce morbidity. Key steps to begin the process to review these cases include creating a confidential multidisciplinary maternal morbidity review committee that focuses on whether there are opportunities to improve outcome.[34] The primary data should be abstracted from the chart focused on the specific morbidity such as eclampsia, severe postpartum hemorrhage or disseminated intravascular coagulation, and then details of the care around the morbidity presented to the committee for discussion and assessment. Abstraction and assessment forms including instructions as to their use are available for anyone to download on this website.[30] The committee should focus on systems and if opportunities for improvement in care are identified mechanisms in-place to facilitate change. The culture of the committee should be nonjudgmental. Finally, data should be trended and analyzed eventually.
Research.
It is critical that as new efforts are developed to understand maternal morbidity that research efforts are ongoing. These efforts include prospective trials such as those undertaken by the NICHD-funded MFMU network that currently includes 14 hospitals which create and participate in clinical trials about obstetric care and outcomes.[35] In addition, as more reviews of severe maternal morbidity are undertaken it will be critical to determine if heightened review and if data analyzed from such reviews can be shown to reduce maternal morbidity.
Contraception.
Unplanned pregnancies may represent a significant proportion of pregnancies that ultimately have severe maternal morbidity. Therefore, easy access to desired contraception and family planning services must be maintained.
Educational enhancements for American Board of Obstetrics and Gynecology Maternal–Fetal Medicine Fellowship training.
Maternal–Fetal Medicine Fellowship training requirements were changed to increase the proportion of time spent focused on maternal care and disease including increased requirement for critical care experience.
Women's Health. 2015;11(2):193-199. © 2015 Future Medicine Ltd.
