ACOG, SMFM Update Guidance on Severe Maternal Morbidity

Troy Brown, RN

August 29, 2016

A joint consensus on severe maternal morbidity has been issued by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). The document instructs healthcare providers to screen and review cases that meet at least one of two criteria: transfusion of at least four units of blood or intensive care unit admission of a pregnant or postpartum woman.

The document is the fifth in a series of joint ACOG and SMFM obstetric care consensus documents and is published in the September issue of Obstetrics and Gynecology.

"The intent of this document is to provide a standard, evidence-based approach to help obstetric providers and their facilities more easily recognize cases of severe maternal morbidity which deserve more detailed review," Sarah J. Kilpatrick, MD, PhD, chair of the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center, Los Angeles, California, and a lead author of the document, explained in a news release. "These criteria and the examples listed in the document are not categorical definitions and should not be misconstrued as quality measures. Rather, we understand that as women's health care physicians we need to be at the forefront of developing a reference to identify severe maternal morbidity and that's what this document is intended to do."

ACOG and SMFM developed the document in collaboration with Dr Kilpatrick; Jeffrey L. Ecker, MD, chief, Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston; and the Centers for Disease Control and Prevention's representative member, William M. Callaghan, MD.

Maternal morbidity and maternal mortality are on the rise in the United States, and both are largely preventable, the authors write.

Maternal morbidity "can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death," the authors explain. "Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries."


  • As in maternal mortality cases, severe maternal morbidity cases warrant quality review (grade 1C recommendation).

  • Healthcare facilities need to have a screening process for detecting cases of severe maternal morbidity for review (1C). ACOG and SMFM recommend the use of two screening criteria for identifying severe maternal morbidity: transfusion of at least four units of blood, and intensive care unit admission of a pregnant or postpartum woman (1B).

  • Healthcare institutions may incorporate additional screening criteria to select cases for detailed review (1C).

  • Healthcare facilities should review all cases that meet one or more of the screening criteria to ascertain whether the case is actually a case of severe maternal morbidity; to characterize the relevant events, diagnoses, and outcomes; and to determine whether or not an identified morbidity might have been avoided and might therefore "present opportunities for system change and improved future performance" (1C).

  • Not all cases that meet the review criteria will qualify as a case of severe morbidity; cases that are a result of a woman's underlying health status or that of her pregnancy are considered unavoidable. The authors caution that, "simply screening positive for one of the two recommended screening criteria does not constitute a sentinel event, and the rates of occurrence of either criterion (ICU admission and transfusion of 4 or more units of blood) should not be used as a quality metric" (1C).

The joint consensus document also provides a detailed table with examples of diagnoses and complications that do and do not constitute severe maternal morbidity.

"Quality improvement is something all obstetrician-gynecologists should be actively involved in — regardless of hospital size, location, or low- or high-risk pregnancy status. There is almost always something to learn about our systems following these types of complex cases. We owe it to our future patients to continuously improve the care we provide and this document will help these efforts," Sean Blackwell, MD, chair of the publications committee for the SMFM, concluded in the news release. Dr Blackwell is the director of the Larry C. Gilstrap, MD, Center for Perinatal and Women's Health, vice chair for clinical research in the department of Obstetrics and Gynecology, and assistant dean for Healthcare Quality in Perinatal Medicine and Women's Health at UTHealth Medical School, Houston, Texas.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;128:670-671. Abstract

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