Preventability of severe acute maternal morbidity

Maternal Sepsis

Sepsis is the second leading cause of pregnancy-related mortality in the United States. Early recognition, treatment, and escalation of care for the obstetric patient affected by sepsis mitigate the risk of mortality and improve patient outcomes. In this article, we provide an overview of maternal sepsis and address topics of maternal pathophysiology, early warning signs, diagnostic criteria, early goal-directed therapy, and contemporary critical care practices. We also present an overview of common etiologies of maternal sepsis and suggested treatment approaches.

Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population

BACKGROUND

Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models.

OBJECTIVE

To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population.

STUDY DESIGN

This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen.

RESULTS

The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01-41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40-22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4-1.6).

CONCLUSION

Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

Validation of a measure of hospital maternal level of care for the United States

BACKGROUND

Lack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers.

METHODS

This was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method.

RESULTS

The sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%-58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% - 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%).

CONCLUSIONS

This method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

Pre-pregnancy Weight and Racial-Ethnic Disparities in Pregnancy-Associated Conditions in the State of Georgia: A Population-Based Study

INTRODUCTION

We investigate racial-ethnic disparities in pre-pregnancy obesity and pregnancy weight gain, which are known to increase the risk of pregnancy-associated conditions.

METHODS

We used 4-year (2017-2020) combined Georgia Pregnancy Risk Assessment Monitoring System data (N = 3208) to investigate racial-ethnic disparities in the incidence of gestational hypertension (GHT), gestational diabetes mellitus (GDM), and postpartum depression (PPD) and their associated risk with pre-pregnancy overweight/obesity after controlling for demographic and other confounders using regression modeling. The geographic distributions of hypertension and PPD rates at the county level were compared to the patterns of racial-ethnic populations and hospitals.

RESULTS

The PPD rates were higher among Asian (17.6), Hispanic (14.4), and Black (14.3); GDM was highest among Asian (16.0) mothers; and GHT was the highest among Black (11.7) followed by White mothers (9.0). Pre-pregnancy overweight and obese conditions increased the odds of hypertension in Black (2 ½ times) and White (> 3 ½ times) mothers. Premature birth increased the odds of hypertension (2-3 times) in all mothers. Pre-pregnancy weight also increased the odds of GDM (3-7 times) in these racial groups. Premature birth increases the odds twice as likely for PPD in Hispanic and White mothers. The convergence of high PPD and hypertension rates with high proportions of racial and ethnic minorities, and lack of hospital presence, indicates areas where healthcare interventions are required.

CONCLUSIONS

These findings underscore the importance of promoting a healthy pre-pregnancy weight to reduce the burden of maternal morbidity and pregnancy outcomes in general. More comprehensive prenatal monitoring using technological interventions for self-care has a great promise of being effective in maintaining a healthy pregnancy.

Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis

BACKGROUND

Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs.

METHODS

We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed.

RESULT

Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00.

CONCLUSION

The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity.

TRIAL REGISTRATION

CRD42023409229.

Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015

OBJECTIVE

 This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment.

STUDY DESIGN

 Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics.

RESULTS

 Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history.

CONCLUSION

 Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System.

KEY POINTS

· Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..

A biomarker for bacteremia in pregnant women with acute pyelonephritis: soluble suppressor of tumorigenicity 2 or sST2

Objective: Sepsis is a leading cause of maternal death, and its diagnosis during the golden hour is critical to improve survival. Acute pyelonephritis in pregnancy is a risk factor for obstetrical and medical complications, and it is a major cause of sepsis, as bacteremia complicates 15-20% of pyelonephritis episodes in pregnancy. The diagnosis of bacteremia currently relies on blood cultures, whereas a rapid test could allow timely management and improved outcomes. Soluble suppression of tumorigenicity 2 (sST2) was previously proposed as a biomarker for sepsis in non-pregnant adults and children. This study was designed to determine whether maternal plasma concentrations of sST2 in pregnant patients with pyelonephritis can help to identify those at risk for bacteremia.Study design: This cross-sectional study included women with normal pregnancy (n = 131) and pregnant women with acute pyelonephritis (n = 36). Acute pyelonephritis was diagnosed based on a combination of clinical findings and a positive urine culture. Patients were further classified according to the results of blood cultures into those with and without bacteremia. Plasma concentrations of sST2 were determined by a sensitive immunoassay. Non-parametric statistics were used for analysis.Results: The maternal plasma sST2 concentration increased with gestational age in normal pregnancies. Pregnant patients with acute pyelonephritis had a higher median (interquartile range) plasma sST2 concentration than those with a normal pregnancy [85 (47-239) ng/mL vs. 31 (14-52) ng/mL, p < .001]. Among patients with pyelonephritis, those with a positive blood culture had a median plasma concentration of sST2 higher than that of patients with a negative blood culture [258 (IQR: 75-305) ng/mL vs. 83 (IQR: 46-153) ng/mL; p = .03]. An elevated plasma concentration of sST2 ≥ 215 ng/mL had a sensitivity of 73% and a specificity of 95% (area under the receiver operating characteristic curve, 0.74; p = .003) with a positive likelihood ratio of 13.8 and a negative likelihood ratio of 0.3 for the identification of patients who had a positive blood culture.Conclusion: sST2 is a candidate biomarker to identify bacteremia in pregnant women with pyelonephritis. Rapid identification of these patients may optimize patient care.

Severe maternal morbidity by race and ethnicity before vs. during the COVID-19 pandemic

PURPOSE

To examine the change in racial disparity in severe maternal morbidity (SMM) during the COVID-19 pandemic and the associations between SARS-CoV-2 infection and SMM.

METHODS

This retrospective cohort study used linked databases of all livebirths delivered between 2018 and 2021 in South Carolina (n = 162,576). Exposures were 1) pre-pandemic and pandemic periods (before vs. March 2020 onwards); 2) SARS-CoV-2 infection, severity, and timing of first infection. Log-binomial regression models were used.

RESULTS

SMM rate was higher among pandemic childbirths than pre-pandemic period (p = 0.06). The risk of SMM among Hispanics was doubled from pre-pandemic to pandemic periods (adjusted relative risk (aRR)= 2.50, 95% CI: 1.27, 4.94). During pre-pandemic, compared to White women, Black women (aRR=1.37, 95% CI: 1.14-1.64), while Hispanics had lower risk of SMM (aRR=0.42, 95% CI: 0.24-0.73). During the pandemic, the Black-White difference in the risk of SMM persisted (aRR=1.24, 95% CI: 1.00-1.54) and Hispanic-White difference in SMM risk became insignificant (aRR=0.85, 95% CI: 0.54-1.34). SARS-CoV-2 infection, its severity, and the late diagnosis were associated with 1.78-5.06 times higher risk of SMM.

CONCLUSIONS

During pandemic, Black-White racial disparity in SMM persisted but the relative pre-pandemic advantage in SMM among Hispanic women over White women disappeared during the pandemic.

Association between gestational age at delivery and indicator-specific severe maternal morbidity

OBJECTIVE

Individuals who deliver preterm are disproportionately affected by severe maternal morbidity. Limited data suggest that indicator-specific maternal morbidity varies by gestational age at delivery. We sought to evaluate the relationship between gestational age at delivery and the incidence of severe maternal morbidity and indicator-specific severe maternal morbidity.

METHODS

We used a hospital administrative delivery database to identify all singleton deliveries between 16 and 42 weeks gestation from 2002 to 2018. We defined severe maternal morbidity as the presence of any International Classification of Disease diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, intensive care unit admission, and/or prolonged postpartum hospital length of stay. Indicator-specific severe maternal morbidity was based on the diagnosis and procedure codes and was characterized across gestational age epochs. We categorized gestational age into three epochs to capture extremely preterm birth (less than 28 weeks gestation), preterm birth (28-36 weeks gestation) and term birth (37 weeks gestation and above). Multivariable binomial regression was used to assess the association between categories of gestational age at delivery and severe maternal morbidity adjusting for confounders including age, race, body mass index (BMI), insurance status, and preexisting hypertension or diabetes.

RESULTS

Severe maternal morbidity occurred in 2.5% of all deliveries. The unadjusted incidence of severe maternal morbidity by gestational age epoch was 12% at less than 28 weeks gestation, 8.4% at 28 to 36 weeks of gestation, and 1.7% at greater than or equal to 37 weeks gestation. After controlling for potential confounders the predicted probability of severe maternal morbidity was 16% (95% CI 14,17%) at 24 weeks compared to 2.2% (95% CI 2.1,2.3%) at 38 weeks. Sepsis, acute respiratory distress syndrome, mechanical ventilation, and shock were the most common diagnostic codes in deliveries less than 28 weeks gestation. Heart failure and cardiac arrhythmias were more common in patients with severe maternal morbidity delivering at term.

CONCLUSION

A high proportion of severe maternal morbidity occurred in preterm patients, with the highest rates occurring at less than 28 weeks gestation. Individuals with severe maternal morbidity who deliver preterm had distinct indicators of morbidity compared to those who deliver at term.

Development and evaluation of a wearable peripheral vascular compensation sensor in a swine model of hemorrhage

Postpartum hemorrhage (PPH) is the leading and most preventable cause of maternal mortality, particularly in low-resource settings. PPH is currently diagnosed through visual estimation of blood loss or monitoring of vital signs. Visual assessment routinely underestimates blood loss beyond the point of pharmaceutical intervention. Quantitative monitoring of hemorrhage-induced compensatory processes, such as the constriction of peripheral vessels, may provide an early alert for PPH. To this end, we developed a low-cost, wearable optical device that continuously monitors peripheral perfusion via laser speckle flow index (LSFI) to detect hemorrhage-induced peripheral vasoconstriction. The measured LSFI signal produced a linear response in phantom models and a strong correlation coefficient with blood loss averaged across subjects (>0.9) in a large animal model, with superior performance to vital sign metrics.

Maternal near miss at Kathmandu Medical College: An analysis of severe maternal morbidity at a Nepalese tertiary care facility

BACKGROUND

The World Health Organization (WHO) 'near miss' tool has been extensively used to audit maternal morbidity in low- and middle-income countries. Analysis of the cases of 'near miss' enables a better understanding of the associated factors, identifies deficiencies in the provision of maternity services and lays a foundation for better preventive measures in the future.

AIMS

To understand the epidemiology, aetiology and determine the aspects of preventability of maternal 'near miss' (MNM) at Kathmandu Medical College.

MATERIALS AND METHODS

A prospective audit of MNM and maternal deaths (MD) was undertaken at Kathmandu Medical College over a period of 12 months. The cases were identified using WHO 'near miss' criteria and areas of preventability in the provision of care determined using the modified Geller's criteria.

RESULTS

The total number of deliveries and live births in the study period were 2747 and 2698 respectively. A total of 34 'near misses' and two MDs were identified. The common direct aetiologies of MNM and MDs identified were obstetric haemorrhage followed by hypertensive disorders with one-third of cases being of indirect aetiology. Fifty-five percent of cases had some aspects of provider- or system-related preventability with the leading delays being lack of diagnosis and recognition of high-risk status among patients and lack of interdepartmental communication.

CONCLUSION

The WHO near miss rate at Kathmandu Medical College was 12.5/100 live births. Significant aspects of preventability, especially at the level of the provider, were noted among cases of MNM and MDs.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers

BACKGROUND

Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA.

METHODS

This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures.

RESULTS

Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research.

CONCLUSIONS

Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Development and evaluation of a wearable peripheral vascular compensation sensor in a swine model of hemorrhage

Postpartum hemorrhage (PPH) is both the leading and most preventable cause of maternal mortality. PPH is currently diagnosed through visual estimation of blood loss or vital sign analysis of shock index (ratio of heart rate to systolic blood pressure). Visual assessment underestimates blood loss, particularly in the setting of internal bleeding, and compensatory mechanisms stabilize hemodynamics until hemorrhage is massive, beyond the point of pharmaceutical intervention. Quantitative monitoring of hemorrhage-induced compensatory processes, such as the constriction of peripheral vessels to shunt blood to the central organs, may provide an early alert for PPH. To this end, we developed a low-cost, wearable optical device that continuously monitors peripheral perfusion via laser speckle flow index (LSFI) to detect hemorrhage-induced peripheral vasoconstriction. The device was first tested using flow phantoms across a range of physiologically relevant flow rates and demonstrated a linear response. Subsequent testing occurred in swine hemorrhage studies (n=6) by placing the device on the posterior side of the swine's front hock and withdrawing blood from the femoral vein at a constant rate. Resuscitation with intravenous crystalloids followed the induced hemorrhage. The mean LSFI vs. percent estimated blood volume loss had an average correlation coefficient of -0.95 during the hemorrhage phase and 0.79 during resuscitation, both of which were superior to the performance of the shock index. With continued development, this noninvasive, low-cost, and reusable device has global potential to provide an early alert of PPH when low-cost and accessible management strategies are most effective, helping to reduce maternal morbidity and mortality from this largely preventable problem.

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

Importance

In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities.

Objective

To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program.

Design, Setting, and Participants

This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records.

Exposures

Hospitalization during pregnancy or within 42 days post partum.

Main Outcomes and Measures

The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care.

Results

A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such.

Conclusions and Relevance

The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.

Comparing Postpartum Estimated and Quantified Blood Loss Among Racial Groups: An Observational Study

Objective: Racial and ethnic disparities in peripartum blood loss and postpartum hemorrhage (PPH) have not been adequately evaluated. We sought to compare postpartum blood loss and PPH in African American and Hispanic parturients compared to other groups.

Methods: This was a secondary analysis of an observational study at a tertiary academic center of a historical (August 2016 to January 2017) and interventional (August 2017 to January 2018) cohort of 7618 deliveries. Visual estimation of blood loss (EBL) was used in the historical group and quantitative blood loss (QBL) was implemented in the intervention group. Our primary endpoint was median blood loss in African Americans versus other racial groups between cohorts.

Results: A total of 7618 deliveries were evaluated; 755 (9.9%) were identified as African American with 1035 (13.6%) identifying as Hispanic. Blood loss was similar in racial groups using EBL (p=0.131), but not QBL that was 430 (227-771) in African Americans and 348 (200-612) in non-African Americans (p<0.001). PPH was greater among African Americans in both groups (10.3% vs. 6.9% in EBL cohort, p=0.023, and 16.9% vs. 11.6% in QBL cohort, p<0.001).

Conclusion: Racial and ethnic differences in peripartum blood loss were more apparent with QBL than EBL. It is unknown if these differences are caused by provider cognitive bias, socioeconomic differences, language barriers and/or other factors.

Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries

OBJECTIVE

To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries.

STUDY DESIGN

This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions.

RESULTS

Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79).

CONCLUSION

SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries.

KEY POINTS

· Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..

Routine Multidisciplinary Review of Severe Maternal Morbidity Is Associated with a Reduction in Preventable Cases of Severe Maternal Morbidity

OBJECTIVE

Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM.

STUDY DESIGN

A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process.

RESULTS

There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p = 0.005).

CONCLUSION

We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes.

KEY POINTS

· Benefit to routine review of SMM has not been demonstrated.. · Routine review of SMM is associated with 36% reduction in potentially preventable SMM.. · This is the first study to demonstrate the benefit of routine review of SMM..

Social determinants and inequitable maternal and perinatal outcomes in Aotearoa New Zealand

Objectives:

Aotearoa New Zealand has demonstrable maternal and perinatal health inequity. We examined the relationships between adverse outcomes in a total population sample of births and a range of social determinant variables representing barriers to equity.

Methods:

Using the Statistics New Zealand Integrated Data Infrastructure suite of linked administrative data sets, adverse maternal and perinatal outcomes (mortality and severe morbidity) were linked to socio-economic and health variables for 97% of births in New Zealand between 2003 and 2018 (~970,000 births). Variables included housing, economic, health, crime and family circumstances. Logistic regression examined the relationships between adverse outcomes and social determinants, adjusting for demographics (socio-economic deprivation, education, parity, age, rural/urban residence and ethnicity).

Results:

Māori (adjusted odds ratio = 1.21, 95% confidence interval = 1.18–1.23) and Asian women (adjusted odds ratio 1.39, 95% confidence interval = 1.36–1.43) had poorer maternal or perinatal outcomes compared to New Zealand European/European women. High use of emergency department (adjusted odds ratio = 2.68, 95% confidence interval = 2.53–2.84), disability (adjusted odds ratio = 1.98, 95% confidence interval = 1.83–2.14) and lack of engagement with maternity care (adjusted odds ratio = 1.89, 95% confidence interval = 1.84–1.95) had the strongest relationship with poor outcomes.

Conclusion:

Maternal health inequity was strongly associated with a range of socio-economic and health determinants. While some of these factors can be targeted for interventions, the study highlights larger structural and systemic issues that affect maternal and perinatal health.

A scoping review of maternal near miss assessment in Australia, New Zealand, South-East Asia and the South Pacific region: How, what, why and where to?

BACKGROUND

Severe maternal morbidity or maternal near miss (MNM) events can have significant consequences for individuals, their families and society and the study of these events may inform practices to reduce future adverse pregnancy outcomes.

AIMS

To review the scope of MNM studies undertaken in Australia, New Zealand, South-East Asia and the South Pacific region.

MATERIALS AND METHODS

A systematic search of four online databases (MEDLINE, EMBASE, SCOPUS and CINAHL) and the World Health Organization Library was conducted to identify all relevant studies published between 1 January 2011 and 31 December 2020. The studies were reviewed and included if they assessed MNM using a composite outcome or a predefined set of indicators.

RESULTS

The literature search yielded 143 articles of which 49 are included in this review. There were substantial differences in the monitoring approach to MNM in the Australasian region. Overall rates of MNM in the region ranged from two to 100/1000 births and the most common aetiologies identified were direct obstetric causes such as postpartum haemorrhage, pre-eclampsia and sepsis. Multidisciplinary review indicated a substantial number of MNM cases were preventable or amenable to improved management, mostly from a provider perspective.

CONCLUSIONS

Assessment of MNM is an important part of the evaluation of maternity care provision. Reaching a consensus on indicators and how best to collect information will allow a more discerning assessment of MNM including longer-term health outcomes, aspects of preventability and financial implications for health services.

Maternal morbidity and mortality: an iceberg phenomenon

OBJECTIVE

To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis.

DESIGN

Secondary analysis of national data on maternal morbidity and mortality.

SETTING

Republic of Ireland.

POPULATION OR SAMPLE

Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths.

METHODS

Incidence rates and case-fatality ratios were calculated.

MAIN OUTCOME MEASURES

Maternal death, SMM and hospitalisation.

RESULTS

At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis.

CONCLUSIONS

Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus.

TWEETABLE ABSTRACT

Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.

Examining the potential preventability of adverse fetal/neonatal outcomes associated with severe maternal morbidity

BACKGROUND

Severe maternal morbidity (SMM) occurs in 1-2% of pregnancies. Despite the knowledge that a SMM event can contribute to poor fetal/neonatal outcomes, little is known about the preventability of these adverse outcomes.

AIMS

To examine adverse fetal/neonatal outcomes associated with SMM to determine if these outcomes were potentially preventable.

MATERIALS AND METHODS

A New Zealand national retrospective cohort study examining cases of SMM with an adverse fetal/neonatal outcome. Maternity and initial neonatal care were explored by multidisciplinary panels utilising a preventability tool to assess whether the fetal/neonatal harm was potentially preventable. Adverse fetal/neonatal outcomes were defined as fetal or early neonatal death, Apgar score <7 at five minutes, admission to neonatal intensive care unit or special care baby unit and neonatal encephalopathy.

RESULTS

Of 85 cases reviewed, adverse fetal/neonatal outcome was deemed potentially preventable in 55.3% of cases (n = 47/85). Preventability was related to maternal antenatal/peripartum care (in utero) in 39% (n = 33/85), to initial neonatal care (ex utero) in 36% (n = 29/80), and to both maternal and neonatal care in 20% (16/80) of cases. Main contributors to potential preventability were factors related to healthcare providers, particularly lack of recognition of high risk, delayed or failure to diagnose, and delayed or inappropriate treatment.

CONCLUSIONS

Multidisciplinary panels found that over half of adverse fetal/neonatal harm associated with SMM was potentially preventable. The novel approach of examining both maternal and neonatal care identifies opportunities to improve fetal/neonatal outcomes associated with SMM at multiple points on the perinatal continuum of care.

Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis

Maternal sepsis is a leading cause of preventable maternal mortality that requires early recognition, expedient evaluation, and appropriate management.

Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a challenge as the normal physiologic changes of pregnancy may mask the signs and symptoms of sepsis. Bedside assessment tools may aid in the detection of maternal sepsis. Timely and targeted antibiotic therapy and fluid resuscitation are critical for survival in patients with suspected sepsis. Once diagnosed, a search for etiologies and early application of source control measures will further reduce harms. If the patient is in septic shock or not responding to initial treatment, multidisciplinary consultation and escalation of care is necessary. Health care professionals should be aware of the unique complications of sepsis in critically ill pregnant and postpartum patients, and measures to prevent poor outcomes in this population. Adverse pregnancy outcomes may occur in association with sepsis, and should be anticipated and prevented when possible, or managed appropriately when they occur. Using a standardized approach to the patient with suspected sepsis may reduce maternal morbidity and mortality.

Intertwined disparities: Applying the maternal-infant dyad lens to advance perinatal health equity

Differences in the quality of delivery hospital care contribute to persistent, intertwined racial and ethnic disparities in both maternal and infant health. Despite the shared causal pathways and overlapping burden of maternal and infant health disparities, little research on perinatal quality of care has addressed obstetric and neonatal care jointly to improve outcomes and reduce health inequities for the maternal-infant dyad. In this paper, we review the role of hospital quality in shaping perinatal health outcomes, and investigate how a framework that considers the mother-infant dyad can enhance our understanding of the full burden of obstetric and neonatal disparities on health and society. We conclude with a discussion of how integrating a maternal-infant dyad lens into research and clinical intervention to improve quality of care can move the needle on disparity reduction for both women and infants around the time of birth and throughout the life course.

Correlation between hemorrhage risk prediction score and severe maternal morbidity

BACKGROUND

Obstetrical hemorrhage is a leading cause of severe maternal morbidity, a key indicator of a nation's healthcare delivery system and often associated with a high rate of preventability. Limited data suggest that a patient's hemorrhage risk score may be associated with risk for maternal morbidity such as severe hemorrhage, intensive care unit admission, or transfusion. Little is known regarding the relationship between hemorrhage risk score and nontransfusion-related morbidity.

OBJECTIVE

We sought to evaluate the association between a patient's California Maternal Quality Care Collaborative admission hemorrhage risk score and severe maternal morbidity.

STUDY DESIGN

This was a retrospective cohort of delivery admissions from 2018 to 2019 in a single healthcare network. Admission risk scores were assigned to each patient using the California Maternal Quality Care Collaborative criteria. Rates of transfusion- and nontransfusion-associated severe maternal morbidity were compared across low-, medium-, and high-risk strata. We defined severe maternal morbidity as the presence of any International Classification of Diseases diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, need for intensive care unit admission, or prolonged postpartum hospital length of stay. A multivariable logistic regression was used to assess the association between hemorrhage risk score and severe maternal morbidity.

RESULTS

In the overall cohort, severe maternal morbidity occurred in 2.4% (n=517) of all deliveries. Excluding cases requiring transfusion, 0.6% (n=131) of cases still had a severe maternal morbidity event. The incidence of severe maternal morbidity was 1.6% (n=264) in patients categorized as low risk for hemorrhage compared with 2.5% (n=118) and 13.6% (n=135) in patients who were categorized as medium or high risk for hemorrhage, respectively (P<.001). Patients classified as high risk had a significant association with both severe maternal morbidity (adjusted odds ratio, 8.8; 95% confidence interval, 7.0-11) and nontransfusion-associated severe maternal morbidity (adjusted odds ratio, 3.6; 95% confidence interval, 2.2-5.9).

CONCLUSION

In addition to predicting the risk for obstetrical hemorrhage and transfusion, our findings indicate that the California Maternal Quality Care Collaborative admission hemorrhage risk tool predicts risk for transfusion- and nontransfusion-associated severe maternal morbidity. Our findings imply that despite awareness and the identification of patients at high risk for obstetrical hemorrhage on admission, significant hemorrhage-associated morbidity persisted. Our data indicate that the identification of risk alone may be insufficient to reduce morbidity and imply that further work is needed to investigate and implement new practices in response to a patient's score stratum.

Statewide Severe Maternal Morbidity Review in Illinois

OBJECTIVE

To address rising rates of severe maternal morbidity and persistent racial disparities, Illinois established severe maternal morbidity review in all obstetric hospitals. The purpose of this study is to describe the findings from the statewide severe maternal morbidity review in 2018.

METHODS

This is a retrospective analysis of a hospital-level severe maternal morbidity review that occurred in 2018 (n=408) compared with all 2018 Illinois live births (n=141,595), inclusive of any severe maternal morbidity cases resulting in a live birth before hospital discharge. Cases were chosen for review based on completeness of records, complexity of the case, or an assessment that cases presented opportunities for learning and quality improvement; ie, not all severe maternal morbidity cases were reviewed. We present descriptive characteristics that contributed to the severe maternal morbidity event, and health care professional, system, and patient opportunities to alter the severe maternal morbidity outcome.

RESULTS

A total of 408 severe maternal morbidity cases were reviewed. Women with severe maternal morbidity were more likely to be non-Hispanic Black, multiparous, aged 35 years or older, have public insurance, and receive inadequate prenatal care. The most common causes of severe maternal morbidity were hemorrhage (48%), and preeclampsia and eclampsia (20%). Overall, 42% of severe maternal morbidity cases had opportunities to improve care. Non-Hispanic Black women had a disproportionately high burden of severe maternal morbidity due to preeclampsia and eclampsia (31% vs 18.1%) and were more likely to need improvement in care compared with non-Hispanic White women (53% vs 39.0%). The most common opportunities to alter the severe maternal morbidity outcome were health care professional factors during the intrapartum (9%) and postpartum (10%) periods.

CONCLUSION

Standardized severe maternal morbidity review gives a fuller view of the state of maternal health and highlights opportunities to improve quality of care.

Do maternity services in New Zealand's public healthcare system deliver on equity? Findings from structural equation modelling of national maternal satisfaction survey data

BACKGROUND

Birthing outcomes in New Zealand are demonstrably inequitable based on governmental reports and research. However, the last Ministry of Health maternal satisfaction survey in 2014 indicated that 77% of women were satisfied or very satisfied with care. This study used data from the maternal satisfaction survey to examine aspects of inequity in reported satisfaction with care.

METHODS

Structural Equation Modelling (SEM) was used to infer latent variables of satisfaction with equity domains from responses to the satisfaction survey. Additional data (residential location and deprivation score), not used in the Ministry of Health primary analysis, were provided and included in this modelling.

RESULTS

SEM showed that satisfaction was not equitably distributed. Younger women, those from areas of high socio-economic deprivation, and remote rural women were most likely to be affected by dissatisfaction associated with physical access, cultural care, information provided, and/or barriers to equity associated with additional costs (all p<0.05). Financial burden of additional costs was also unevenly distributed.

CONCLUSION

While these findings are congruent with other research on the association between social determinants and maternal satisfaction, it is concerning that they remain sources of inequity in New Zealand twenty years after they were first identified as priorities to address. On the basis of this study, urgent attention needs to be paid to removing sources of inequity within the health system and maternity care in particular.

Trends and Risk Markers for Severe Maternal Morbidity and Other Obstetric Complications

Background: Studies of obstetric quality of care have almost exclusively focused on severe maternal morbidity (SMM) and have rarely examined more common complications. Methods: This 2016-2018 retrospective, population-based cohort study analyzed maternal delivery outcomes at 127 Illinois hospitals. International Classification of Disease (ICD)-10 Revision codes were used to describe the incidence of SMM and route-specific complications. Poisson regression models were used to estimate the association of maternal sociodemographic, clinical, and hospital characteristics with the likelihood of coded complications. Results: Among 421,426 deliveries, the SMM rate was 1.4% overall, 0.4% for vaginal, and 2.8% for cesarean delivery. Other complications were documented for 6.9% of women with vaginal and 10.0% of women with cesarean deliveries. While SMM rates were stable, vaginal delivery complications increased 5.9% from 2016 to 2018 and cesarean delivery complications increased 13.8%. Patient age, minority race and ethnicity, high poverty level, and preexisting and pregnancy-related clinical conditions were significantly associated with each complication outcome. Higher hospital delivery volume was associated with higher route-specific complications. Conclusion: SMM significantly underestimates the incidence of maternal complications. Complicated deliveries have much higher charges and length of stay, although ICD-10 coding intensity may influence incidence. New outcome measures based on more detailed clinical data and linked antepartum and postpartum care will be necessary to improve obstetric quality of care measurement.

Preventing Complications in Pregnant Women With Cardiac Disease

BACKGROUND

Pregnancy can lead to complications in women with heart disease, and these complications can be life threatening. Understanding serious complications and how they can be prevented is important.

OBJECTIVES

The primary objectives were to determine the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, whether they were preventable, and their impact on fetal and neonatal outcomes. Serious obstetric events were also examined.

METHODS

A prospectively assembled cohort of 1,315 pregnancies in women with heart disease was studied. SCEs included cardiac death or arrest, ventricular arrhythmias, congestive heart failure or arrhythmias requiring admission to an intensive care unit, myocardial infarction, stroke, aortic dissection, valve thrombosis, endocarditis, and urgent cardiac intervention. The Harvard Medical Study criteria were used to adjudicate preventability.

RESULTS

Overall, 3.6% of pregnancies (47 of 1,315) were complicated by SCEs. The most frequent SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent interventions. Most SCEs (66%) occurred in the antepartum period. Almost one-half of SCEs (49%) were preventable; the majority of preventable SCEs (74%) were secondary to provider management factors. Adverse fetal and neonatal events were more common in pregnancies with SCEs compared with those without cardiac events (62% vs. 29%; p < 0.001). Serious obstetric events were less common (1.7%) and were primarily due to pre-eclampsia with severe features.

CONCLUSIONS

Pregnant women with heart disease are at risk for serious cardiac complications, and approximately one-half of all SCEs are preventable. Strategies to prevent serious cardiac complications in this high-risk cohort of women need to be developed.

Association between nurse work environment and severe maternal morbidity in high-income countries: A systematic review and call to action

AIM

To identify evidence related to association between the nurse work environment and severe maternal morbidity in high-income countries.

DESIGN

Quantitative Systematic review.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PubMed/Medline, and Scopus were systematically searched for studies published in English from January 1990-December 2019. Studies were selected based on a priori eligibility criteria.

REVIEW METHODS

Two independent reviewers used a two-phase screening process. First, the reviewers assessed the eligibility of studies based on titles and abstracts; followed by assessing the full text of all remaining studies based on the eligibility criteria. An adapted version of the Joanna Briggs Institute data extraction tool was created to extract relevant information from studies reviewed during the second screening phase.

RESULTS

Of the 535 de-duplicated articles examined by two independent reviewers, there were no eligible empirical studies that assessed the association between nurse work environment and severe maternal morbidity.

CONCLUSION

There is a critical gap in knowledge regarding how characteristics of the nurse work environment may influence severe maternal morbidity in high-income countries. Future directions for nursing research include using available maternal health surveillance hospital-level data, conducting high-quality studies, and using evidence-based frameworks to guide future studies. Future directions for nursing practice include leveraging professional learning communities for nursing education and training and leveraging quality improvement initiatives.

IMPACT

As the first known systematic review of its kind, this 'empty review' provides evidence of a lacking body of literature on the association between nurse work environment, as a modifiable organizational characteristic and preventable severe maternal morbidity in high-income countries. This article provides a call to action in the form of five recommendations for future nursing research and practice, which could serve to elucidate research, practice, and policy opportunities to reduce preventable severe maternal morbidity in high-income countries.

Severe maternal morbidity among migrants with insecure residency status in Sweden 2000-2014: a population-based cohort study

BACKGROUND

Migrants with insecure residency status (i.e., undocumented migrants and asylum-seekers, who are denied or waiting for authorized residency) often experience social and psychosocial adversities and limited access to health care. Nonetheless, they have not been profiled on the risk of severe maternal morbidity (SMM), a sentinel measure of maternal health and maternity care.

METHODS

A cohort study on all births recorded in the Swedish Medical Birth Register from 2000-2014 (N = 1,570,472). Lacking a maternal personal identification number was used as an indicator for insecure residency status (1.3% of all births). We used Poisson regression models to estimate risk ratios of SMM in migrant women with insecure residency status compared to the Swedish-born or migrant women with long-term residency, adjusting for the calendar year of birth, maternal age, and parity.

RESULTS

Overall SMM rate among migrant women with insecure residency status was 21.5/1000 and 14.7/1000 among Swedish-born women. Compared to Swedish-born, migrants with insecure residency status had 50% higher risk of overall SMM (adjusted risk ratio (aRR)=1.54 [1.37-1.74]) and over 80% higher risk of SMM excluding transfusion-only cases (aRR=1.88 [1.37-2.57]). When compared to migrant women with long-term residency, migrant women with insecure residency also had a higher risk of SMM (overall SMM aRR=1.42 [1.26,1.61]; SMM excluding transfusion only cases aRR=1.43 [1.04,1.97]), suggesting that insecure residency conferred additional risks of SMM beyond migration.

CONCLUSION

Migrant women with insecure residency status had increased risk of severe maternal morbidity.

Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death

BACKGROUND

There is no international consensus on the definition and components of severe maternal morbidity (SMM).

OBJECTIVES

To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada.

METHODS

Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality.

RESULTS

There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4).

CONCLUSIONS

The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Characteristics and preventability of obstetric intensive care unit admissions in Far North Queensland

BACKGROUND

The rarity of maternal deaths in developed countries has increased interest in auditing cases of severe maternal morbidity or maternal 'near miss'. The assessment and preventability of cases of maternal 'near misses' are important in improving the provision of maternity care.

AIMS

To describe the epidemiology and determine aspects of preventability in care among women admitted to an obstetric intensive care unit (ICU) in Far North Queensland.

MATERIALS AND METHODS

A retrospective observational study of pregnant and postpartum patients admitted to the Cairns Hospital ICU between 1 January 2013 and 31 December 2017 was undertaken. Cases of severe maternal morbidity were identified using the World Health Organization (WHO) 'near miss' criteria and reviewed to determine reasons for admission to ICU and ascertain aspects of preventability in the care provided.

RESULTS

Sixty-nine out of 12 081 (0.6%) women admitted for obstetric care were transferred to the ICU with 31 cases fulfilling WHO 'near miss' criteria. The most common direct obstetric-related diagnosis for ICU admission was hypertensive disease of pregnancy and obstetric haemorrhage. Indirect obstetric causes contributed to approximately 40% of ICU admissions. Among the 31 cases of WHO 'near miss', ten cases were deemed preventable with the most common reason for preventability related to lack of recognition of high-risk clinical status.

CONCLUSION

Maternal 'near miss' and rates of obstetric admission to the ICU at Cairns Hospital are reassuringly low. Nevertheless, one-third of women with 'near miss' required improvements in the provision of care, emphasising the need for continued audit and improvement of clinical practice.

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity

BACKGROUND

While there is a global focus on severe maternal morbidity (SMM), less is known about the impact of SMM on fetal and neonatal outcomes.

AIMS

To examine fetal/neonatal outcomes associated with SMM.

MATERIALS AND METHODS

A national New Zealand (NZ) retrospective cohort study describing fetal/neonatal outcomes of all women with SMM admitted to a NZ Intensive Care Unit (ICU) or High Dependency Unit (HDU) in 2014. Adverse fetal/neonatal outcomes were defined as one or more of the following: fetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score less than seven at five minutes, admission to Neonatal Intensive Care Unit or Special Care Baby Unit.

RESULTS

There were 400 women with SMM admitted to NZ ICU/HDU units in 2014, and 395 (98.8%) had complete birth/pregnancy outcome information. Of these, 49.4% (195/395) were associated with an adverse fetal/neonatal outcome. Indigenous Māori women had a 30% higher rate of adverse fetal/neonatal outcome compared to NZ European women (63.7% and 48.9% respectively; relative risk = 1.30, 95% CI 1.04-1.64). Pre-eclampsia was associated with an adverse fetal/neonatal outcome in 67% (81/120). Perinatal-related mortality rate was 53.1 per 1000 total births compared to NZ perinatal mortality of 11.2 per 1000 total births for 2014.

CONCLUSION

SMM events are associated with high rates of adverse fetal/neonatal outcomes with a higher burden of adverse events for Māori. Further research is needed to explore opportunities in maternal and neonatal care pathways to improve fetal/neonatal outcomes and address inequities.

Severe acute maternal morbidity trends in Victoria, 2001-2017

BACKGROUND

The incidence of severe acute maternal morbidity (SAMM) is one method of measuring the complexity of maternal health and monitoring maternal outcomes. Monitoring trends may provide a quantitative method for assessing health care at local, regional, or jurisdictional levels and identify issues for further investigation.

AIMS

Identify temporal trends for SAMM event rates and maternal outcomes over 17 years in the state of Victoria, Australia.

MATERIALS AND METHODS

All maternal public health service admissions were extracted from an administrative dataset from July 2000 to June 2017. SAMM-related diagnoses were defined by matching as closely as possible with published definitions. Outcomes included annual SAMM event rates, hospital survival, and hospital length of stay (LOS). Temporal trends were analysed using mixed-effects generalised linear models.

RESULTS

There were 854 777 live births and 1.21 million pregnancy-related hospital admissions which included 34 008 SAMM events in 29 273 records and in 3.42% (95%CI = 3.39-3.46) of births. Most common were severe pre-eclampsia (0.87% of births), severe postpartum haemorrhage (0.59%), and sepsis (0.62%). SAMM-related admissions were associated with longer LOS and higher mortality risk (P < 0.001). Maternal mortality ratio remained unchanged at 8.6 fatalities per 100 000 births (P = 0.65).

CONCLUSION

Over 17 years, there was a significant increase in birth rate and SAMM-related events in Victoria. Administrative data may provide a pragmatic approach for monitoring SAMM-related events in maternal health services.

National Partnership for Maternal Safety Recommended Maternal Early Warning Criteria Are Associated With Maternal Morbidity

BACKGROUND

Many cases of maternal mortality and morbidity are preventable. A delayed response to clinical warning signs contributes to preventability. Therefore, the National Partnership for Maternal Safety devised maternal early warning criteria (MEWC), composed of abnormal vital signs that trigger bedside evaluation by a provider with the capacity to escalate care. The relationship of the MEWC to maternal morbidity has not been studied. We evaluated the correlation between the MEWC and maternal morbidity.

METHODS

We retrospectively reviewed the first 400 deliveries at the University of Chicago in 2016. We analyzed the electronic medical record to determine whether vital signs triggered the MEWC during the admission to labor and delivery and whether patients experienced morbidity during their delivery hospitalization. The association between MEWC and morbidity was tested using χ analysis. We calculated the sensitivity, specificity, and positive and negative predictive values of the MEWC.

RESULTS

Two hundred eighty-one (70%) of 400 patients triggered the MEWC at least once, and 198 (50%) of 400 patients had multiple or recurrent triggers. Ninety-nine (25%) of 400 patients experienced morbidity. The most common causes of morbidity were hemorrhage, suspected infection, and preeclampsia with severe features. The relative risk of maternal morbidity with at least a single trigger was 13.55 (95% confidence interval [CI], 4.38-41.91) and with recurrent or multiple triggers was 5.29 (95% CI, 3.22-8.71). The sensitivity of the MEWC in predicting morbidity was 0.97 (95% CI, 0.92-0.99) and the specificity was 0.39 (95% CI, 0.33-0.44) when patients with at least a single trigger were included. When including only patients with multiple or recurrent triggers, the sensitivity was 0.84 (95% CI, 0.75-0.90) and the specificity was 0.62 (95% CI, 0.56-0.67). The positive predictive value of the MEWC in our population was 0.34 (95% CI, 0.29-0.40), and the negative predictive value was 0.97 (95% CI, 0.93-0.99). When considering only patients with multiple or recurrent triggers, the positive predictive value was 0.42 (95% CI, 0.38-0.46) and the negative predictive value was 0.92 (95% CI, 0.88-0.95).

CONCLUSIONS

The MEWC are associated with maternal morbidity. As a screening tool, they appropriately prioritize sensitivity and have an excellent negative predictive value. The criteria demonstrate low specificity, which is slightly improved by considering only patients with recurrent or multiple triggers. Additional efforts to improve the specificity of MEWC, with a focus on identifying sustained or recurrent patterns of abnormal vital signs, may be necessary before their widespread implementation.

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience

CONTEXT

Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines.

IMPLEMENTATION

Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement.

EVALUATION

Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases).

DISCUSSION

Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

Barriers to equitable maternal health in Aotearoa New Zealand: an integrative review

Background

The purpose of this review was to examine the literature for themes of underlying social contributors to inequity in maternal health outcomes and experiences in the high resource setting of Aotearoa New Zealand. These ‘causes of the causes’ were explored and compared with the international context to identify similarities and New Zealand-specific differences.

Method

A structured integrative review methodology was employed to enable a complex cross disciplinary analysis of data from a variety of published sources. This method enabled incorporation of diverse research methodologies and theoretical approaches found in the literature to form a unified overall of the topic.

Results

Six integrated factors – Physical Access, Political Context, Maternity Care System, Acceptability, Colonialism, and Cultural factors – were identified as barriers to equitable maternal health in Aotearoa New Zealand. The structure of the maternal health system in New Zealand, which includes free maternity care and a woman centred continuity of care structure, should help to ameliorate inequity in maternal health and yet does not appear to. A complex set of underlying structural and systemic factors, such as institutionalised racism, serve to act as barriers to equitable maternity outcomes and experiences. Initiatives that appear to be working are adapted to the local context and involve self-determination in research, clinical outreach and community programmes.

Conclusions

The combination of six social determinants identified in this review that contribute to maternal health inequity is specific to New Zealand, although individually these factors can be identified elsewhere; this creates a unique set of challenges in addressing inequity. Due to the specific social determinants in Aotearoa New Zealand, localised solutions have potential to further maternal health equity.

Using Scorecard Feedback to Improve Quantitative Blood Loss Measurement at Birth

OBJECTIVE

To increase the percentage of cases in which quantitative blood loss (QBL) was documented by labor and delivery nurses for women giving birth.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

Labor and delivery unit of a community hospital in which a previous implementation of QBL measurement was not sustained.

PARTICIPANTS

Labor and delivery nurses were the focus of the intervention, but the entire multidisciplinary team became involved.

INTERVENTION/MEASUREMENTS

Based on literature supporting the use of scorecard feedback to stimulate performance improvement, weekly blinded individual scorecards showing the percentage of births attended by each labor and delivery nurse with QBL documented and a run chart showing the percentage of all births with QBL documented were posted on the unit and discussed during huddles for 12 weeks. Data on blood product administration were collected, and charts comparing QBL and estimated blood loss (EBL) volumes documented were shared with nurses and physicians.

RESULTS

Over 12 weeks, the percentage of births with QBL documented increased from 22.7% to 80.0%. Consistent with previous reports comparing QBL and EBL volumes at birth, there was a significant difference between the mean QBL volume (mean = 482.20 ml, standard deviation = 358.03) and the mean EBL volume (mean = 313.15 ml, standard deviation = 211.91; p < .001) for total births. The mean QBL volume was also greater than the mean EBL volume for vaginal and cesarean births, but those differences were not statistically significant. There was no increase in blood product administration associated with the increase in QBL documentation.

CONCLUSION

Discussing weekly scorecards and a run chart of QBL measurement was associated with an increase in documentation of QBL by labor and delivery nurses. Planning this project and discussing the results engaged the entire multidisciplinary team in more consistent measurement of QBL. The increased level of QBL documentation has been sustained for longer than 1 year.

Recent advances in the diagnosis and management of sepsis in pregnancy

Background: Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common causes of maternal death, such as haemorrhage and thromboembolism. Methods: This review addresses important topics, including the epidemiology, risk factors, prevention, diagnosis, care bundles and management of maternal sepsis, including antibiotic treatment, and critical care interventions such as extracorporeal membrane oxygenation. Preventative measures that have had an impact on maternal sepsis as well as future research directions are also covered in this review. Case studies of maternal sepsis which highlight key learning points relevant to all clinicians involved in the management of obstetric patients will also be presented. Results: Although, historically, maternal death from sepsis was considered to be a problem for low-income countries, severe obstetric morbidity and maternal death from sepsis are increasing in high-income countries. The global burden of maternal sepsis and the obstetric-related and patient-related risk factors and the likely sources are presented. Recent changes in definition and nomenclature are outlined, and challenges in diagnosis and identification are discussed. Conclusions: Following maternal sepsis, early diagnosis and early intervention are critical to save lives and prevent long-term adverse sequelae. Dogma surrounding critical care interventions in pregnancy is being challenged, and future research is warranted to maximise therapeutic options available for maternal septic shock.

Management of post-partum hemorrhage and the role of the obstetric anesthesiologist

PURPOSE OF REVIEW

The landscape of post-partum hemorrhage management is rapidly changing. Modifications to definitions, bundles, and care plans occur frequently with management strategies becoming more complex. It has become apparent that the management of these patients requires a multidisciplinary approach with the involvement of obstetricians, anesthesiologists, gynecologist/oncologists, nursing, and care associates. This review article is meant to be an evidence-based review of post-partum hemorrhage with practical recommendations and a look at future directions of the management of post-partum hemorrhage from the vantage point of the obstetric anesthesiologist in an effort to enhance the collaborative treatment of this at risk population.

Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization

BACKGROUND

Cardiovascular disease is the leading cause of pregnancy-related death in the United States. Identification of short-term indicators of cardiovascular morbidity has the potential to alter the course of this devastating disease among women. It has been established that hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease 10-30 years after delivery; however, little is known about the association of hypertensive disorders of pregnancy with cardiovascular morbidity during the delivery hospitalization.

OBJECTIVE

We aimed to identify the immediate risk of cardiovascular morbidity during the delivery hospitalization among women who experienced a hypertensive disorder of pregnancy.

MATERIALS AND METHODS

This retrospective cohort study of women, 15-55 years old with a singleton gestation between 2008 and 2012 in New York City, examined the risk of severe cardiovascular morbidity in women with hypertensive disorders of pregnancy compared with normotensive women during their delivery hospitalization. Women with a history of chronic hypertension, diabetes mellitus, or cardiovascular disease were excluded. Mortality and severe cardiovascular morbidity (myocardial infarction, cerebrovascular disease, acute heart failure, heart failure or arrest during labor or procedure, cardiomyopathy, cardiac arrest and ventricular fibrillation, or conversion of cardiac rhythm) during the delivery hospitalization were identified using birth certificates and discharge record coding. Using multivariable logistic regression, we assessed the association between hypertensive disorders of pregnancy and severe cardiovascular morbidity, adjusting for relevant sociodemographic and pregnancy-specific clinical risk factors.

RESULTS

A total of 569,900 women met inclusion criteria. Of those women, 39,624 (6.9%) had a hypertensive disorder of pregnancy: 11,301 (1.9%) gestational hypertension; 16,117 (2.8%) preeclampsia without severe features; and 12,206 (2.1%) preeclampsia with severe features, of whom 319 (0.06%) had eclampsia. Among women with a hypertensive disorder of pregnancy, 431 experienced severe cardiovascular morbidity (10.9 per 1000 deliveries; 95% confidence interval, 9.9-11.9). Among normotensive women, 1780 women experienced severe cardiovascular morbidity (3.4 per 1000 deliveries; 95% confidence interval, 3.2-3.5). Compared with normotensive women, there was a progressively increased risk of cardiovascular morbidity with gestational hypertension (adjusted odds ratio, 1.18; 95% confidence interval, 0.92-1.52), preeclampsia without severe features (adjusted odds ratio, 1.96; 95% confidence interval, 1.66-2.32), preeclampsia with severe features (adjusted odds ratio, 3.46; 95% confidence interval, 2.99-4.00), and eclampsia (adjusted odds ratio, 12.46; 95% confidence interval, 7.69-20.22). Of the 39,624 women with hypertensive disorders of pregnancy, there were 15 maternal deaths, 14 of which involved 1 or more cases of severe cardiovascular morbidity.

CONCLUSION

Hypertensive disorders of pregnancy, particularly preeclampsia with severe features and eclampsia, are significantly associated with cardiovascular morbidity during the delivery hospitalization. Increased vigilance, including diligent screening for cardiac pathology in patients with hypertensive disorders of pregnancy, may lead to decreased morbidity for mothers.

Hypertensive Diseases of Pregnancy Increase Risk of Readmission With Heart Failure: A National Readmissions Database Study

OBJECTIVE

To study the association between hypertensive diseases of pregnancy and immediate postpartum development of heart failure in a large national database.

PATIENTS AND METHODS

Using the 2013 to 2014 National Readmissions Database, which covered admissions from January 1 through September 30 in years 2013 and 2014, we examined 90-day readmission rates in parturients with a diagnosis of hypertensive disease of pregnancy who were discharged after delivery. The primary outcome was the association between the presence of hypertensive disease of pregnancy and readmission with heart failure within 90 days of delivery discharge. Secondary outcomes included readmission mortality, time between delivery discharge and readmission, length of stay, and costs of readmission.

RESULTS

Women with hypertensive disease of pregnancy were more likely to be readmitted with heart failure (1809 of 25,908 readmissions (7.0%) vs 2622 of 89,660 readmissions (2.9%); P<.001). This difference persisted after adjustment for potential cofounders (6.3% vs 3.1%; odds ratio, 2.15; 95% CI, 1.92-2.40; P<.001). Women with a diagnosis of heart failure at readmission were readmitted sooner (11 days vs 23 days; P<.001) and had a longer length of stay (4 days vs 3 days; P<.001) and higher costs of readmission ($10,361 vs $6977; P<.001) than did women without a diagnosis of heart failure.

CONCLUSION

Parturients with hypertensive disease of pregnancy were more likely to be readmitted with heart failure within 90 days of delivery. Most patients readmitted with heart failure were readmitted within 2 weeks of discharge after delivery. Patients readmitted with heart failure had substantial health care expenditures.

A Multidisciplinary Model for Reviewing Severe Maternal Morbidity Cases and Teaching Residents Patient Safety Principles

The Joint Commission recommends that severe maternal morbidity (SMM) cases involving peripartum ICU admissions and blood transfusion > 4 units undergo systematic reviews to determine opportunities for improvement in care. This article describes a retrospective study of an SMM multidisciplinary committee review using a published template.

METHODS

Residents attend a patient safety and quality improvement (PSQI) course at orientation, learn in serial PSQI educational sessions, and receive individual training on the SMM review. The multidisciplinary SMM review process determines contributory factors, identifies best practices, recognizes care improvement opportunities, and facilitates adoption of appropriate interventions. How the process educated residents on the Clinical Learning Environment Review (CLER) focus areas was explored.

RESULTS

From January 2015 to June 2017, 45 SMM cases were reviewed. Reviewers were primarily residents/fellows (64.4% of cases), nurses (11.1%), and maternal-fetal medicine faculty (24.4%). Transfusion > 4 units occurred in 44.4% of cases, and ICU admission in 68.9%. Causes of SMM included obstetric bleeding (57.8%), hypertensive crisis (42.2%), and cardiac disease (24.4%). Preterm delivery occurred in 60.0% of cases; 71.1% were postpartum, and 80.0% had cesarean deliveries. Contributory provider factors included diagnostic delays (55.6%) and treatment delays or errors (44.4%). Contributory patient factors included psychiatric/behavioral health (20.0%) and health care barriers (22.2%). Morbidity could have been prevented by provider factors in 53.3% of cases and by patient factors in 37.8%. Interventions initiated included recruiting a safety nurse, TeamSTEPPS® training, and adoption of hypertension and postpartum hemorrhage safety bundles.

CONCLUSION

SMM reviews can be successfully implemented and provide training on safety and quality.

Reducing Maternal Mortality and Severe Maternal Morbidity Through State-based Quality Improvement Initiatives

State Perinatal Quality Collaboratives (PQCs) represent a major advance for scaling up quality improvement efforts for reducing maternal mortality and severe maternal morbidity. The critical roles of partners, rapid-cycle low-burden data systems, and linkage to maternal mortality review committees are reviewed. The choice of measures is also explored. California's experience with its PQC, data center, quality improvement efforts, and promising results for reduction of maternal mortality and morbidity from hemorrhage are presented. Early data from other states is also shared.

Reducing Disparities in Severe Maternal Morbidity and Mortality

Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.