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

Effectiveness of Oral Iron Therapy in Anemic Inpatient Pregnant Women: A Single Center Retrospective Cohort Study

Background and aim Oral iron therapy is effective in treating iron deficiency anemia in outpatient pregnant women but has not been studied in inpatient pregnant women. We aimed to evaluate the effect of oral iron therapy versus no therapy during hospitalization on maternal and neonatal outcomes in women with anemia who are hospitalized for pregnancy-related morbidities (i.e., preterm premature rupture of membranes, preterm labor, pre-eclampsia, abnormal placentation, or fetal monitoring). Methods A retrospective, single-center study was conducted in hospitalized pregnant women (2018 to 2020) with inpatient stays of more than three days. The primary outcome was a change in hemoglobin level from admission to delivery in women treated with oral iron compared with those left untreated. Secondary outcomes included the total amount of iron administered before delivery, the time interval from admission to delivery, and neonatal effects. Results Two hundred sixty-three women were admitted, 79 women had anemia, and 29 (36.7%) received at least one dose of oral iron. Baseline patient characteristics were similar between groups. The median (interquartile range) dose of iron in the oral iron group was 1185.0 (477.0, 1874.0) mg. Neither absolute hemoglobin before delivery (control group: 10.0±1.2 g/dL; iron group: 10.1±1.1 g/dL; p=0.774) nor change in hemoglobin from admission to delivery (control group: -0.1±1.1 g/dL vs. iron group: 0.4±1.1 g/dL; p=0.232) differed between groups. Women in the control group had shorter length of stay (LOS) median (IQR) than women in the iron group (control group: 7.1 (5.0, 13.7) days; iron group: 11.4 (7.4, 25.9) days; p=0.03). There were no differences in maternal mode of delivery, though each group had high rates of cesarean delivery (control group: 53.7%; iron group: 72.4%; p=0.181). There were no differences in estimated blood loss at delivery (control group: 559±401; iron group: 662.1±337.4;p=0.264) in either group. Neonatal birthweight (control group: 1.9±0.7 kg; iron group: 1.9±0.7 kg; p=0.901), birth hemoglobin (control group: 16.3±2.2 g/dL; iron group: 16±2.2 g/dL; p=0.569), neonatal intensive care unit (NICU) admission (control group: 93.3%; iron group: 84.8%;p=0.272 ), or neonatal death (control group: 8.9%; iron group: 3%; p=0.394) were not different between groups. Conclusions Oral iron administered to anemic inpatient pregnant women was not associated with higher hemoglobin concentrations before delivery. Lack of standardized iron regimens and short hospital stays may contribute to the inefficacy of oral iron for this inpatient pregnant population. The small sample size and retrospective nature of this study are limiting factors in drawing conclusive evidence from this study.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts

OBJECTIVE

The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative.

METHODS

Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle.

RESULTS

Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle.

CONCLUSION

Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Busy day effect on adverse obstetric outcomes using a nationwide ecosystem approach: Cross-sectional register study of 601 247 hospital deliveries

OBJECTIVE

To study the busy day effect on selected neonatal adverse outcomes in different sized delivery hospitals and in the entire nationwide obstetric ecosystem.

DESIGN

A cross-sectional register study.

SETTING

The lowest and highest 10% of the daily delivery volume distribution were defined as quiet and busy days, respectively. The days between (80%) were defined as optimal delivery volume days. The differences in the incidence of selected adverse neonatal outcome measures were analysed between busy versus optimal days and quiet versus optimal days at the hospital category and for the entire obstetric ecosystem level.

POPULATION

A total of 601 247 singleton hospital deliveries between 2006 and 2016, occurred in non-tertiary (C1-C4, stratified by size) and tertiary level (C5) delivery hospitals.

METHODS

Analyses were performed by the methods of the regression analyses with crude and adjusted odds ratios including 99% CI.

MAIN OUTCOME MEASURES

Birth asphyxia.

RESULTS

At the ecosystem level, adjusted odds ratio for birth asphyxia was 0.81 (99% CI 0.76-0.87) on busy versus optimal days. Breakdown to hospital categories show that adjusted odds ratios for asphyxia on busy versus optimal days in non-tertiary hospitals (C3, C4) were 0.25 (99% CI 0.16-0.41) and 0.17 (99% CI 0.13-0.22), respectively, and in tertiary hospitals was 1.20 (99% CI 1.10-1.32).

CONCLUSIONS

Busy day effect as a stress test caused no extra cases of neonatal adverse outcomes at the ecosystem level. However, in non-tertiary hospitals busy days were associated with a lower and in tertiary hospitals a higher incidence of neonatal adverse outcomes.

Challenges and Opportunities for Clinician Implicit Bias Training: Insights from Perinatal Care Stakeholders

Introduction

In an attempt to address health inequities, many U.S. states have considered or enacted legislation requiring antibias or implicit bias training (IBT) for health care providers. California's "Dignity in Pregnancy and Childbirth Act" requires that hospitals and alternative birthing centers provide IBT to perinatal clinicians with the goal of improving clinical outcomes for Black women and birthing people. However, there is as yet insufficient evidence to identify what IBT approaches, if any, achieve this goal. Engaging the experiences and insights of IBT stakeholders is a foundational step in informing nascent IBT policy, curricula, and implementation.

Methods

We conducted a multimethod community-based participatory research study with key stakeholders of California's IBT policy to identify key challenges and recommendations for effective clinician IBT. We used focus groups, in-depth interviews, combined inductive/deductive thematic analysis, and multiple techniques to promote rigor and validity. Participants were San Francisco Bay Area-based individuals who identified as Black or African American women with a recent hospital birth (n=20), and hospital-based perinatal clinicians (n=20).

Results

We identified numerous actionable challenges and recommendations regarding aspects of (1) state law; (2) IBT content and format; (3) health care facility IBT implementation; (4) health care facility environment; and (5) provider commitment and behaviors. Patient and clinician insights overlapped substantially. Many respondents felt IBT would improve outcomes only in combination with other antiracism interventions.

Health Equity Implications

These stakeholder insights offer policy-makers, health system leaders, and curriculum developers crucial guidance for the future development and implementation of clinician antibias interventions.

Descriptions of Maternal Mortality From Nurses Who Practice in Perinatal Settings

OBJECTIVE

To explore nurses' descriptions of maternal mortality when caring for women in the perinatal period in Indiana.

DESIGN

A qualitative descriptive approach was used to produce nurses' descriptions of maternal mortality.

SETTING/PARTICIPANTS

Convenience sample of 16 nurses recruited from the Indiana Section of the Association of Women's Health, Obstetric and Neonatal Nurses.

MEASUREMENTS

Semistructured phone interviews were conducted, and participants were asked to explain their experiences related to maternal mortality. This information, which was summarized using content analysis, provided data related to nurses' descriptions of maternal mortality when caring for women in the perinatal period.

RESULTS

Analysis revealed three main themes that explain nurses' descriptions of maternal mortality: When It Comes to Maternal Mortality: Out of Sight Is Out of Mind, Nurses Express Detachment From Their Role in Preventing Maternal Mortality, and Experience With Maternal Mortality or a Near-Miss Event Is a Turning Point for Nurses.

CONCLUSION

Nurses who have limited experience with maternal mortality and who approach the issue in a detached manner may miss opportunities to provide health education to women in the perinatal period. Nurses need education on substance use disorders in the perinatal period, guidance on how to support women in the postpartum period, and support for coping with death and dying in the perinatal period.

A Critical Review on the Complex Interplay between Social Determinants of Health and Maternal and Infant Mortality

Background: U.S. maternal and infant mortality rates constitute an important public health problem, because these rates surpass those in developed countries and are characterized by stark disparities for racial/ethnic minorities, rural residents, and individuals with less privileged socioeconomic status due to social determinants of health (SDoH). Methods: A critical review of the maternal and infant mortality literature was performed to determine multilevel SDoH factors leading to mortality disparities with a life course lens. Results: Black mothers and infants fared the worst in terms of mortality rates, likely due to the accumulation of SDoH experienced as a result of structural racism across the life course. Upstream SDoH are important contributors to disparities in maternal and infant mortality. More research is needed on the effectiveness of continuous quality improvement initiatives for the maternal–infant dyad, and expanding programs such as paid maternity leave, quality, stable and affordable housing, and social safety-nets (Medicaid, CHIP, WIC), in reducing maternal and infant mortality. Finally, it is important to address research gaps in individual, interpersonal, community, and societal factors, because they affect maternal and infant mortality and related disparities. Conclusion: Key SDoH at multiple levels affect maternal and infant health. These SDoH shape and perpetuate disparities across the lifespan and are implicated in maternal and infant mortality disparities.

Pregnancy-Associated Deaths Due to Drugs, Suicide, and Homicide in the United States, 2010-2019

OBJECTIVE

To estimate the prevalence of pregnancy-associated deaths due to drugs, suicide, and homicide nationwide from 2010 to 2019.

METHODS

Using U.S. death certificate records from 2010 to 2019 for 33 states plus the District of Columbia, we identified pregnancy-associated deaths using the pregnancy checkbox and International Classification of Diseases, Tenth Revision codes, calculated pregnancy-associated death ratios, and categorized deaths by cause, timing relative to pregnancy, race or ethnicity, and age.

RESULTS

Of 11,782 pregnancy-associated deaths identified between 2010 and 2019, 11.4% were due to drugs, 5.4% were due to suicide, and 5.4% were due to homicide, whereas 59.3% were due to obstetric causes and the remaining 18.5% were due to other causes. Drug-related deaths, suicide, and homicide accounted for 22.2% of pregnancy-associated deaths. All three causes of death increased over the study period, with drug-related pregnancy-associated deaths increasing 190%. Homicide during pregnancy and drug-related deaths, suicides, and homicide in the late postpartum period (43-365 days) accounted for a larger proportion of all deaths in these time periods than the contribution of these causes to all deaths among females of reproductive age. Pregnant and postpartum people identified as non-Hispanic American Indian or Alaska Native were at highest risk of drug-related and suicide death, and people identified as non-Hispanic Black were at highest risk of homicide.

CONCLUSION

Deaths due to drug use, suicide, and homicide constitute more than one fifth of all deaths during pregnancy and the first year postpartum. Drug-related deaths and homicides have increased over the past decade. Substantial racial and ethnic inequities in these deaths exist.

Association of Epilepsy and Severe Maternal Morbidity

OBJECTIVE

To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy.

METHODS

We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models.

RESULTS

Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion.

CONCLUSION

Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

Historical and Recent Changes in Maternal Mortality Due to Hypertensive Disorders in the United States, 1979 to 2018

[Figure: see text].

Maternal Heart Failure

Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.

Geographic barriers to prenatal care access and their consequences

BACKGROUND

Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes.

OBJECTIVE

This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services.

STUDY DESIGN

This was a retrospective cohort study of pregnant women delivering at ≥24 weeks' gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks' gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features.

RESULTS

Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95-3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic.

CONCLUSION

Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality

The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.

Evaluation of Implementation and Unit Impact of a Hypertensive Disorder of Pregnancy Guideline: A Model-Based Approach

BACKGROUND

Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. To address this, a large Midwestern hospital initiated a practice guideline. Practice guidelines should improve outcomes, but implementation of these remains challenging. At the time of initiation of the guideline, no implementation or evaluation plan was conceived.

OBJECTIVE

Evaluate the implementation and unit impact of a guideline for the management of hypertensive disorders of pregnancy in a large academic health system in the Midwest.

METHODS

Six objectives, guided by the constructs of the Ottawa Model of Research Utilization, were operationalized to evaluate the implementation and unit impact of the guideline.

RESULTS

The guideline implemented was consistent with national recommendations. Intervention education was inconsistent across provider types. A survey of staff revealed insight into a unit in the midst of practice change. A chart review revealed below-target management of patients with severe range blood pressures. Not following the guideline was associated with hospital readmission.

CONCLUSIONS

Guideline implementation can be efficiently and holistically evaluated with a model-based framework, even in projects that were not initiated with such an approach.

IMPLICATIONS FOR NURSING PRACTICE

Nurses provide expertise in model-based approaches that result in comprehensive evaluations of quality improvement processes.

Association of Maternal Comorbidity With Severe Maternal Morbidity: A Cohort Study of California Mothers Delivering Between 1997 and 2014

BACKGROUND

Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further.

OBJECTIVE

To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM.

DESIGN

Population-based cohort study using linked delivery hospitalization discharge data and vital records.

SETTING

California, 1997 to 2014.

PATIENTS

All 9 179 472 mothers delivering in California during 1997 to 2014.

MEASUREMENTS

SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index.

RESULTS

Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM.

LIMITATIONS

Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years.

CONCLUSION

Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Time of Birth and the Risk of Severe Unexpected Complications in Term Singleton Neonates

OBJECTIVE

To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births.

METHODS

We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models.

RESULTS

Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions.

CONCLUSION

After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions

The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.

Maternal complications and risk factors for mortality

Background: Maternal mortality could be prevented through early detection, including the period preceding pregnancy. Women of childbearing age are faced with extreme uncertainties, hence the purpose of this study was to analyse maternal complications and the possible high-risk factors connected to maternal mortality. Design and methods: A case-control study was used to study the causes of maternal mortalities amongst pregnant, delivering, and postpartum mothers between 2017 and 2018. A total sample size of 48 samples was selected through simple random sampling. Results: The result of logistic regression analysis showed nutritional status, prominence of anemia, history of illness, age, antenatal care ANC examination, method of delivery, late referral, occupational status, as well as postpartum complications, as the most influencing risk factors. This very high significance for maternal mortality was based on the chi-square value of 109.431 (p equal to 0.000), and R square (0.897). Conclusions: In conclusion, the potential risk factors of maternal mortality include nutritional status, state of anemia, history of illness, age, ANC examination, delivery method, late referral, occupational status, and pregnancy complications, which is specifically the most dominant factor.

Obstetrical safety indicators for preventing hospital harms in low risk births: a scoping review protocol

INTRODUCTION

Optimising the safety of obstetric patient care is a primary concern for many hospitals. Performance indicators measuring aspects of patient care processes can lead to improvements in health systems and the prevention of harm to the patient. We present our protocol for a scoping review to identify indicators for obstetric safety in low risk births. We aim to identify indicators addressing preventable hospital harms, to summarise the data and synthesise results.

METHODS AND ANALYSIS

We will use methods described by Arksey and O'Malley and further expanded by Levac et al. We will search electronic databases such as Medline, Embase, CINAHL and the Cochrane Library, and websites from professional bodies and other organisations, using an iterative search strategy.Two reviewers will independently screen titles and abstracts of search results to determine eligibility for inclusion. If eligibility is not clear, the reviewers will screen the full text version. If reviewers' decisions regarding eligibility differ, a third reviewer will review the record. Two reviewers will independently extract data from records that meet our inclusion criteria using a standardised data collection form. We will narratively describe quantitative data, such as the frequency with which indicators are identified, and conduct a thematic analysis of the qualitative data. We will compile a comprehensive list of patient safety indicators and organise them according to concepts that best suit the data such as the Donabedian model or the Hospital Harm Framework. We will discuss the implications for future research, clinical practice and policy-making. We will report the conduct of the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews checklist.

ETHICS AND DISSEMINATION

The sources of information included in this scoping review will be available to the public. Therefore, ethics approval is not warranted. We will disseminate results in a peer-reviewed publication, conference/event presentation(s) and stakeholder communications.

Death audits and reviews for reducing maternal, perinatal and child mortality

BACKGROUND

The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost-effective way of auditing and reviewing deaths: community-based audit (verbal and social autopsy), facility-based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry).

OBJECTIVES

To assess the impact and cost-effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality.

SEARCH METHODS

We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles.

SELECTION CRITERIA

Cluster-randomised trials, cluster non-randomised trials, controlled before-and-after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta-analysis using a random-effects model but included studies were not homogeneous enough to make pooling their results meaningful.

MAIN RESULTS

We included two cluster-randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline. The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate-certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported. The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 - 2.57, moderate-certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported. We did not find any studies that evaluated child death audit and review or community-based death reviews or costs.

AUTHORS' CONCLUSIONS

A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low-income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high-income setting where mortality was already very low. The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost-effective ways of implementing maternal, perinatal and paediatric death reviews in low- and middle-income countries.

Implementation of the Safe Reduction of Primary Cesarean Births Safety Bundle During the First Year of a Statewide Collaborative in Maryland

OBJECTIVE

To describe the status of implementation of the Alliance for Innovation in Maternal Health's primary cesarean birth patient safety bundle in Maryland after 1 year (2016-2017), and assess whether hospital characteristics and implementation strategies employed are associated with bundle implementation.

METHODS

The Alliance for Innovation in Maternal Health's bundle to decrease primary cesarean births includes 26 evidence-based practices that hospitals can adopt based on specific needs. One year after the start of a statewide implementation collaborative at 31 of 32 birthing hospitals in Maryland, we sent a computer-based survey to hospital collaborative leaders to assess progress. Respondents reported on hospital characteristics, adoption of bundle practices, and use of 15 selected implementation strategies. We conducted descriptive and bivariate analyses of their responses.

RESULTS

Among 26 hospitals with complete reporting, 23 fully implemented at least one bundle practice (range 1-7) during the collaborative's first year. Of 26 bundle practices, on average, hospitals had fully implemented a third (mean 8.6; SD 5.5; range 0-17) before the collaborative, and 3 new practices (SD 2.4; range 0-8) during the collaborative. Hospitals' use of six implementation strategies, all highly dependent on strong clinician involvement, was significantly associated with their fully implementing more practices during the collaborative's first year.

CONCLUSION

Our assessment has promising results, with a majority of hospitals having implemented new cesarean birth bundle practices during the collaborative's first year. However, there are lessons from the wide variability in the number and type of practices adopted. Clinicians should be aware of this variability and become more involved in the implementation of cesarean birth bundle practices. We identified six strategies associated with full implementation of more bundle practices for which clinicians' support and commitment to practice changes are critical. Clinicians' understanding of available and effective implementation strategies can better assist with the implementation of this and other Alliance for Innovation in Maternal Health patient safety bundles.

Designing Quality Improvement Collaboratives for Dissemination: Lessons from a Multiple Case Study of the Implementation of Obstetric Emergency Safety Bundles

BACKGROUND

Quality improvement collaboratives (QICs) can help to disseminate evidence-based practices, but there is limited guidance from the perspectives of QIC organizers and participants of best practices to support practice change. To address this gap, this study aimed to identify key structures and processes of QICs that support dissemination and implementation of quality improvement projects.

METHODS

Semistructured one-on-one and group interviews were conducted from December 2017 to May 2018 with project administrators (n = 28) at three QICs that had been funded to develop and disseminate obstetric emergency safety bundles in more than 300 hospitals across five states. For further study, the project leads (n = 25) at six hospitals nominated by each QIC were interviewed. A multiple case study design was used to evaluate the dissemination strategies of each of the three QICs. For the QIC interviews, questions asked about dissemination approach, and for the hospital interviews, questions asked about implementation facilitators and barriers. All interviews were transcribed, coded, and analyzed using both deductive and inductive methods.

RESULTS

A key element supporting the dissemination strategy of each QIC was leveraging existing partnerships and relationships and promoting a shared vision with participating hospitals. A robust data infrastructure to support the project was identified as a critical element to support dissemination, yet was a challenge for the QICs.

CONCLUSION

These findings highlight specific elements of a dissemination approach that QICs can deploy to support their dissemination efforts. In particular, building data infrastructure may be a useful strategy to support ongoing quality improvement projects.

Addressing Maternal Mortality And Morbidity In California Through Public-Private Partnerships

In 2006, noting a rise in maternal deaths and complications, the California Department of Public Health launched efforts to investigate maternal deaths. In that year, the California Maternal Quality Care Collaborative was formed as a public-private partnership to lead maternal quality improvement activities. Key steps undertaken over the next decade included linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects. While US maternal mortality has worsened in the 2010s, by 2013 California's rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births. The state's rate had become comparable to the average rate in Western Europe (7.2 per 100,000). In this article we describe the key steps undertaken by the California Department of Public Health and the California Maternal Quality Care Collaborative that supported change at large scale. Special challenges for implementation are also discussed.

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.