Four Steps to Reduce Maternal Mortality

Marlene Busko

October 31, 2018

All hospitals can take four steps to reduce maternal mortality: implement best practices for managing the care of high-risk pregnant women; review each obstetric patient's risk factors at multidisciplinary staff meetings; conduct simulated obstetric emergencies; and formalize relationships between lower- and higher-resource hospitals.

The current and immediate past presidents of the American College of Obstetrics and Gynecologists (ACOG) and two other experts urge US hospitals that provide obstetric care to take these actions now to reduce maternal mortality.

Others call on healthcare providers to advocate for policy changes to improve postpartum care.   

These "call to action" statements were published online October 31 as two perspective articles in the New England Journal of Medicine.

Four Key Hospital Actions, Added Training for Rural Docs

The rising rate of maternal mortality in the United States "is a tragedy," according to Susan Mann, MD, Harvard Medical School, Boston, Massachusetts; Lisa M. Hollier, MD, ACOG president; Kimberlee McKay, MD, University of South Dakota, Sioux Falls; and Haywood Brown, MD, ACOG immediate past president, University of South Florida, Tampa.

"Women in the United States are more likely to die from childbirth- or pregnancy-related causes than women in any other high-income country," they note, "and black women die at a rate three to four times that of white women."

According to the Centers for Disease Control and Prevention (CDC), pregnancy-related death is "the death of a woman during pregnancy or within 1 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."

Mann and colleagues say hospitals of all sizes can implement the four steps.

First, hospitals should implement best practices to manage high-risk pregnant women. This includes women with the most common preventable pregnancy complications identified by the CDC — postpartum hemorrhage, severe hypertension, and venous thromboembolism.

All birthing centers should implement the "bundles" of best practices to improve pregnancy safety that were developed by the Alliance for Innovation on Maternal Health (AIM), an ACOG-led collaboration with 30 other organizations.

The AIM program best practices are based on "readiness, recognition, response, and report."

For example, hospitals should have a protocol to ensure that severe hypertension is treated within 60 minutes. Hospitals without a pharmacist available at all times should create an emergency lockbox for antihypertensive medications for pregnant and postpartum patients.

Second, hospitals need to hold multidisciplinary staff meetings — or huddles — to review each obstetrical patient's risk factors, including hemorrhage risk levels.

Third, hospitals need to conduct obstetric emergency simulations in their labor and delivery units. This training is similar to the training pilots receive to be prepared for rare events.

Fourth, lower- and higher-resource hospitals need to formalize relationships to allow for transfer of high-risk patients and/or immediate consultation in an unexpected emergency.

If hospital administrators and clinician leaders "hold their staff and themselves accountable," the authors summarize, "they can curb the trend of increasing rates of preventable maternal deaths."

In addition to these hospital actions, the authors call for ACOG and the American Academy of Family Physicians to jointly develop an extra year of training for family medicine physicians who want to practice obstetrics in rural areas.

"It Is Time to Advocate for Policy Changes" for Postpartum Care

"More than half of pregnancy-related deaths occur during the year after delivery, and many women have postpartum complications such as pain and bleeding, high blood pressure, lactation difficulties, and pelvic-floor dysfunction," Mara E. Murray Horwitz, MD, Harvard Medical School, and colleagues note in the second perspective article.

Insurance reimbursement policies and parental leave policies are the main barriers to this care, the authors write, and they call on healthcare practitioners to play a role in changing these policies.  

The Healthcare Effectiveness Data and Information Set (HEDIS) performance measure for reimbursement requires one checkup within 3 to 8 weeks after delivery, so most women are scheduled for a single postpartum visit at 4 to 6 weeks.

However, ACOG recommends 12-week, "fourth trimester" care and a comprehensive well-woman visit within 12 weeks postpartum for all women.

Currently, many women have abrupt changes in insurance coverage as they move through the postpartum period.  

Moreover, only half of US workers qualify for unpaid parental leave under the national Family and Medical Leave Act of up to 12 weeks in companies of 50 or more employees.

ACOG endorses at least 6 weeks of parental leave at full pay with full benefits for all women.

"Healthcare professionals are essential agents for leading efforts to improve maternity care reimbursement and parental leave policies," the authors urge.

"As ACOG notes, 'providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants.' We believe it is time to advocate for policy changes that support timely, ongoing, and equitable postpartum care in the United States." 

Disclosures provided by the authors are available on the journal website.

N Engl J Med. Published online October 31, 2018. Article 1, Article 2

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