Maternal Safety

"There is no statistic that can quantify what it's like to tell an 18-month-old that his mother is never coming home." Charles Johnson

Pregnancy and birth are normal physiologic processes that often require support rather than medical intervention. There are nearly 4 million annual births in the United States, the vast majority of births occur in hospitals, and nearly one-third are by cesarean delivery. Since most US births occur in hospitals, childbirth is subject to typical patient safety threats such as medication errors. Yet, in addition to typical threats to patient safety, pregnancy, childbirth, and the postpartum year present a complex set of safety challenges involving potential underuse, overuse, misdiagnosis, omission, and emotional harm.

The unique adaptations of pregnancy involve dramatic physiologic changes across all body systems. Many of these changes result in signs and symptoms that can make it more challenging to distinguish normal "discomforts of pregnancy" (or postpartum) from changes that would be concerning in a nonpregnant adult. During pregnancy and birth, patients' signs, symptoms, and health concerns are often minimized or discounted by clinicians. Patients experience discrimination in health care encounters on the basis of race/ethnicity, marital, and socioeconomic status, and may not receive adequate information about their care. These factors can lead to misdiagnosis or outright failure to recognize signs and symptoms of serious illness.

In addition, vital signs, physiologic indices, and laboratory values are altered such that findings that are "normal" for an adult can be grossly abnormal in pregnancy, labor, or postpartum, which can similarly lead to failure to recognize clinical deterioration or serious illness. Moreover, labor and birth themselves are highly dynamic and situations can change rapidly. Thus, patients are at risk for underuse or omission if they do not receive the right care for their condition, or do not receive the right care quickly enough in an emergency. Finally, more than half of rural US counties do not have hospital-based obstetric services, adding to the threat.

Patients may also be at risk via overuse of interventions. For example, cesarean delivery rates vary widely, with the liability and policy environments contributing to a substantial increase in use of cesarean delivery. While the optimal cesarean delivery rate is unknown, the increase in cesarean delivery rates has not improved maternal or neonatal outcomes and contributes to maternal morbidity. Finally, patients report a variety of situations that make them feel unsafeduring labor and birth, and they can experience birth as traumatic whether or not they have serious complications.

The Centers for Disease Control and Prevention (CDC) currently estimates that there are approximately 700 pregnancy-related deaths each year in the US. The national pregnancy-related mortality ratio has increased from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births for the years 2011–2015 (range 15.9–18.0); 31% of these deaths occurred prenatally, 36% during birth or within 1 week of birth, and 33% between 1 week and 1 year after birth. There are substantial racial/ethnic and socioeconomic disparities in pregnancy-related mortality, illustrated in Table 1. Furthermore, severe maternal morbidity (e.g., hysterectomy, massive transfusion, unplanned ICU admission) is 50 times more common than maternal mortality, has been increasing, and is subject to similar health disparities.

Based on close analysis of deaths in 13 states, the CDC estimates that approximately 3-in-5maternal deaths each year—about 420 deaths—were likely preventable. This is consistent with multiple studies showing more than 50% of maternal deaths evaluated had at least some possible preventability, and that multiple opportunities for improvement and prevention of morbidity and mortality exist at the policy, system, facility, clinician, and patient levels (Table 2). For example, in a study of the relationship between hospital birth volume and progression of severe maternal morbidity to maternal death (failure to rescue), investigators found that—after adjusting for patient characteristics and comorbidities—the hospital where the birth took place was the most important contributor to failure to rescue.

Table 1. Pregnancy-Related Deaths, by Sociodemographic Characteristics—Pregnancy Mortality Surveillance System, United States, 2011–2015.

Characteristic	No. of Pregnancy-related deaths	Pregnancy-related mortality ratio*
Total	3,410	17.2
Race/Ethnicity† (N = 3,400)
White	1,385	13
Black	1,252	42.8
Native American/Alaska Native	62	32.5
Asian/Pacific Islander	182	14.2
Hispanic	519	11.4
Age group (yrs) (N = 3,409)
<20	158	11.3
20–24	543	12.1
25–29	751	13.2
30–34	799	15.3
35–39	706	28.7
≥40	452	76.5
Highest level of education (N = 2,938)
Less than high school	572	19.8
High school graduate	1,090	24.2
Some college	775	14.8
College graduate or higher	501	9.4
Marital status (N = 3,371)
Married	1,543	13.1
Not married	1,828	22.8
Year
2011	702	17.8
2012	627	15.9
2013	679	17.3
2014	718	18
2015	684	17.2
* Number of pregnancy-related deaths per 100,000 live births.
† Women identified as white, black, Native American/Alaska Natives, or Asian/
Pacific Islanders were not Hispanic. Hispanic women could be of any race.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.

Table 2. Maternal Mortality Review Committee–Identified Contributing Factors and Strategies to Prevent Future Pregnancy-Related Deaths—Maternal Mortality Review Committees, 13 States, 2013–2017.

Level	Contributing factor	Strategies to address contributing factor
Community	Access to clinical care	Expand office hours, increase number of providers who accept Medicaid, increase availability and use of group prenatal care programs
	Unstable housing	Prioritize pregnant and postpartum women for temporary housing programs
	Lack of, or inadequate, transportation options	Strengthen or build systems to link persons to affordable transportation, or provide vouchers for transport to medical appointments
		Improve availability of transportation services covered by Medicaid
	Obesity and associated chronic disease complications	Improve access to healthy foods and enhance efforts to educate and promote healthy eating habits and weight management strategies
Health Facility	Limited experience with obstetric emergencies	Implement obstetric emergency simulation training for emergency department and obstetric staff members
		Ensure emergency department staff members ask about recent pregnancy history and consult with obstetrician on call if patient is pregnant or has recently been pregnant
	Lack of appropriate personnel or services	Provide telemedicine for facilities with no obstetric provider on-site
		Ensure Medicaid managed care organizations' contracts include sufficient access to specialists for patients at high risk
	Lack of guiding protocols or tools to help ensure quality care provision	Ensure sepsis, hemorrhage, and massive transfusion protocols are in place and followed by staff members
		Implement applicable patient safety bundles
		Implement systems to foster communication among multiple providers to ensure proper case coordination
		Implement protocols for using patient navigators
Patient/Family	Lack of knowledge of warning signs or need to seek care	Improve counseling and use of patient education materials on warning signs and when to seek care, such as AWHONN Save Your Life discharge instructions
		Implement a public education campaign to increase awareness of signs and symptoms of common complications
	Nonadherence to medical regimens or advice	Standardize patient education to ensure providers relay consistent messages and implement techniques for
		ensuring patient understanding, such as patient "teaching back" to the provider
		Make education materials available in the clinic and online
		Strengthen and expand access to patient navigators, case managers, and peer support
		Ensure access to interpreter services when needed
		Offer home health or social work follow-up services
Provider	Missed or delayed diagnosis	Repeat blood pressure measurement in a timely (and possibly manual) manner when initial blood pressure result is unexpected
		Offer provider education on cardiac conditions in pregnant and postpartum women
		Perform thorough evaluation of patients reporting pain and shortness of breath
	Inappropriate or delayed treatment	Only perform cesarean deliveries when medically indicated
		Implement a maternal early warning system
	Lack of continuity of care	Improve care transition communication among obstetrician–gynecologists and other primary and specialty care physicians
System	Inadequate receipt of care	Develop policies to ensure pregnant women are transported to a hospital with an appropriate level of maternal care
		Enlist state perinatal quality collaboratives to identify quality improvement procedures and periodic drills/simulation training for birth facilities, including obstetric emergency drills
		Design education initiatives for emergency department staff members on the care of pregnant and postpartum women
	Case coordination or management	Extend expanded Medicaid coverage eligibility for pregnant women to include 1 year of postpartum care
		Create quality improvement entity to manage outpatient care gaps and improve care coordination
		Implement a postpartum care transition bundle for better integration of services for women at high risk
		Develop procedures for all hospitals to improve documentation of abnormal test results, plan for follow-up care, and management of conditions
		Develop universal health record system that allows for sharing of medical records among hospitals
	Guiding policies, procedures, or standards not in place	Develop protocol for timely referrals and consults
		Ensure all hospitals within a health care system follow the same protocols and policies
Abbreviation: AWHONN = Association of Women's Health, Obstetric and Neonatal Nurses. Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.

In 1999, Knox and colleagues laid the foundation for what is now a nationwide maternal safety movement with their early application of high reliability theory (see High Reliability Primer) to the inpatient birth setting (see maternal safety Annual Perspective). Over the past decade, a number of safety bundles specific to maternity care have been developed and disseminated through perinatal improvement collaboratives. This approach ultimately became a national one, through the Council on Patient Safety in Women's Health Care and the Alliance for Innovation on Maternal Health (AIM). Two important facets of high reliability are standardization and effective teamwork, including "mindful interdependence." These concepts are integrated into the national and regionally developed maternal safety bundles, which are designed around the "4Rs" to enhance readiness for, recognition of, response to, and reporting (learning from) safety threats and maternal complications. The safety bundles, resources, implementation guides, and related education modules are freely available online (Table 3).

Table 3. Maternal Safety Bundles.

Council for Patient Safety in Women's Health

Current Context

With the volume of births that occur in hospitals and the high degree of preventability of hemorrhage- and hypertensive-related deaths, emergency response at birth and in the immediate postpartum period have been the focus of the majority of maternal safety initiatives to date. However, this has begun to shift through strong community-based advocacy; increased attention from policy makers and media; and stronger recognition of the distribution of deathsacross the continuum of antenatal to the full postpartum year, and the role of inequity and structural racism in producing persistent maternal health disparities.

As of May 2019, the Council on Patient Safety in Women's Health Care has posted 11 maternal safety bundles and 4 safety tools, along with implementation guidance and an ongoing series of safety action webinars. The Agency for Healthcare Research and Quality (AHRQ) has an integrated perinatal safety toolkit that includes an implementation guide, and AIM provides support for bundle implementation in participating states. AHRQ is currently implementing and evaluating the integration of vital teamwork and communication strategies from this toolkit with two maternal safety bundles. The California Maternal Quality Care Collaborative, an early developer of maternal safety bundles and implementation strategies, recently launched a Birth Equity Collaborative to address the role of racism in birth disparities. The Health Resources and Services Administration funds multiple initiatives to improve maternal health outcomes and is initiating an AIM Community Care Initiative to address maternal safety outside of the hospital. There are also multiple state and national legislative initiatives aimed at addressing the crisis in maternal health.