Applying the generic errors modeling system to obstetric hemorrhage quality improvement efforts

Obstetric hemorrhage is an emergency situation in which clinicians can make errors that cause women to suffer preventable maternal morbidity and mortality. Scrutinizing commonly occurring obstetric hemorrhage-related practice errors by applying the generic errors modeling system, a research-based framework, to quality improvement efforts facilitates the identification of error specific reduction strategies. The common types of errors are skill-based, rule-based, and knowledge-based active and latent errors.     

孕产妇危重事件发生率及防控策略研究进展

过去孕产妇死亡率是衡量一个国家或地区妇女健康状况和社会经济发展的重要指标之一。2019年美国疾病控制中心收集全国孕产妇死亡信息得出结论:如果采取行动,多达一半的孕产妇死亡是可预防的。随着2000年联合国“千年发展目标”的提出以及各国对孕产妇健康的重视,孕产妇死亡已经成为极低概率事件,而孕产妇危重事件发生率(severe maternal morbidity,SMM)已成为比孕产妇死亡率更常见和有用的产科护理指标。在美国,约50名经历SMM孕产妇中发生1例死亡。虽然孕产妇死亡率历来是孕产妇结局的关键指标,SMM的流行情况却可以为围生期健康提供更全面的信息,也是监测孕产妇结局的一种方法。同时,SMM通常是孕产妇死亡的先兆,作为导致孕产妇死亡的动态过程和前期指标,SMM对强化孕产妇管理、降低孕产妇死亡率有重要意义。许多国家开始将SMM作为评价产科质量的重要指标之一。防控SMM,除了常规策略外,避免医疗相关的延迟,使用孕产妇早期预警触发工具(MEWT)有重要临床价值。     

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks (“near misses,” adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, “near miss,” and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).     

Obstetric Hemorrhage Current Management and Usefulness of Protocols,Checklist, Drills

Obstetrical hemorrhage continues to be an important contributor to maternal morbidity and mortality in the USA. Although preventable, it is still the 5th leading cause of maternal death, often due to factors associated with a delay in recognition by providers and/or delay in treatment. We cannot overlook the fact that for every maternal death due to hemorrhage, there are at least 100 women who suffer severe morbidity. It is known that implementing hemorrhage-specific protocols can improve outcomes related to this condition. This review will update readers in early detection and preparation, diagnosis, and treatment of obstetric hemorrhage while highlighting the different institution-specific protocols, cognitive aids, and drills.     

A global view of severe maternal morbidity: moving beyond maternal mortality

Background

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

Severe maternal morbidity in high-income countries

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.

Severe maternal morbidity in low and middle income countries

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

Effects of SMM on delivery outcomes and infants

Severe maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

Conclusion

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

     

Advancing Safe Motherhood Through Human Rights

Governmental neglect of preventable causes of maternal death and pregnancy-related ill-health is not only an affront to women’s dignity, but is an aspect of a larger pattern of systemic unlawful discrimination against women. This article explains how preventable rates of maternal mortality and morbidity are a tragic symptom of a larger social injustice of violation of women’s human rights. The work ahead is to express not simply the fact but the injustice of preventable maternal mortality, and to impress Parliaments, courts of laws and, for example, various news media, that these avoidable tragedies require governmental accountability. The article reviews how specific human rights found in national constitutions and regional and international human rights conventions have been and could be used to foster the conditions necessary for safe motherhood. Governments as such, individual members of governments at UN conferences and supporters of governmental policies can be held to legal account, and compelled to devote resources at their command to address the preventable causes of maternal mortality. Momentum for advancing safe motherhood exists in the political commitments made by governments at UN conferences in Cairo and Beijing. The challenge is to reinforce these commitments through recognition of legally enforceable duties.     

The impact of obesity on maternal morbidity and feto-infant outcomes among macrosomic infants

Objective.?To estimate the contribution of obesity to maternal complications, neonatal morbidity and mortality among macrosomic births.

Design.?A population-based retrospective cohort design using State of Missouri maternally linked birth cohort files.

Methods.?Using pre-gravid body mass index (BMI), we categorized mothers of 116,976 singleton macrosomic live births as non-obese (BMI?<?30) or obese (BMI?≥?30). We used logistic regression models to generate adjusted odd ratios for pregnancy and neonatal complications. We also estimated the proportion of potentially preventable excess maternal and neonatal complications that could be eliminated among obese women with infant macrosomia at various levels of pre-pregnancy obesity reduction.

Result.?Obese mothers with macrosomic infants were at elevated risk for chronic hypertension (odds ratio (OR)?=?6.78 [95% confidence interval (CI): 5.82–7.88]), insulin-dependent diabetes mellitus, (OR?=?2.60 [CI: 2.34–2.88]) other types of diabetes mellitus (OR?=?2.83 [CI: 2.65–3.02]) and preeclampsia (OR?=?2.49 [CI: 2.33–2.67]). Macrosomic infants of obese mothers were at greater risk for hyaline membrane disease (OR?=?2.14 [CI: 1.73–2.66]), extended assisted ventilation (OR?=?1.71 [CI: 1.44–2.04]), birth injury (OR?=?1.58 [CI: 1.37–1.84]) and meconium aspiration syndrome (OR?=?1.42 [CI: 1.09–1.87]). The proportion of preventable excess maternal morbidity was 60%, 45%, 30% and 15%, assuming an effective pre-conception intervention that could reduce obesity down to 0%, 25%, 50% and 75% of its current level, respectively. The corresponding proportion of preventable excess neonatal complications would be 40%, 30%, 20% and 10%, respectively.

Conclusion.?Among obese mothers with macrosomic births, a substantial proportion of maternal and neonatal morbidity could be averted through effective pre-conception interventions.     

Maternal anemia during pregnancy and subsequent risk for cardiovascular disease

Objective: To investigate the association between anemia during pregnancy and subsequent future maternal cardiovascular morbidity and mortality.

Methods: A retrospective cohort study was conducted, comparing women with and without anemia during pregnancy. Deliveries occurred during 1988–1998 and had followed for more than a decade. Incidence of long-term cardiovascular morbidity was compared between the two groups.

Results: During the study period, 47?657 deliveries met the inclusion criteria; of these 12?362 (25.9%) occurred in women with anemia at least once during their pregnancies. Anemia of pregnancy was noted as a risk factor for long-term complex cardiovascular events (OR?=?1.6, 95% CI 1–2.8, p?=?0.04). Using a Cox multivariable regression model, controlling for ethnicity and maternal age, anemia was found to be an independent risk factor for long-term maternal cardiovascular hospitalization (OR for total hospitalizations?=?1.2, 95% CI 1.1–1.4, p?Conclusions: Anemia of pregnancy is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.     

Mechanical ventilation in an obstetric population: characteristics and delivery rates

OBJECTIVE: The purpose of this study was to describe the characteristics and outcomes of obstetric patients who require mechanical ventilation. STUDY DESIGN: A review was conducted of obstetric patients who required mechanical ventilation and who received care at our institutions between 1990 and 1998. Data that were collected included maternal demographics, medical condition that necessitated ventilation, delivery status, duration of ventilation, onset of parturition while receiving ventilation, mode of delivery, and maternal and early neonatal morbidity or death. RESULTS: Fifty-one women were identified; 43 women(84%) received care in the labor and delivery setting. The most common admission diagnoses were preeclampsia/eclampsia (44%), labor/preterm labor (14%), and pneumonia (12%). Forty-three women (86%) were undelivered on admission (mean gestational age, 31.6 weeks). Delivery occurred in 37 women (86%) during their admission; 24 women (65%) underwent cesarean delivery. Eleven women began labor while receiving ventilation; 6 were delivered vaginally. The maternal mortality rate was 14% (7/51 women), and the perinatal mortality rate was 11% (4/37 fetuses). CONCLUSION: A large number of obstetric patients who receive mechanical ventilation will require delivery because of their condition. Centers that care for such women should form a treatment strategy to coordinate obstetric and medical care for this unique population     

Maternal deaths in an urban perinatal network, 1992-1998

OBJECTIVE: The object of this study was to use an in-depth peer-review process to determine the maternal mortality ratio at a single urban perinatal center and to identify factors associated with fatal outcomes to elucidate opportunities for preventive measures to reduce the maternal mortality ratio. STUDY DESIGN: Between 1992 and 1998 all maternal deaths occurring within our perinatal network were identified. A peer-review committee was established to review all available data for each death to determine the underlying cause of death, whether it was related to pregnancy, and whether the death was potentially preventable. RESULTS: There were 131,500 births and 42 maternal deaths, for a maternal mortality ratio of 31.9 maternal deaths per 100,000 live births. The adjusted pregnancy-related maternal mortality ratio was 22.8 maternal deaths per 100,000 live births, with 37% of those deaths (11/30) deemed potentially preventable and a provider factor cited in >80% of these. Pulmonary embolus and cardiac disease together accounted for 40% of the pregnancy-related deaths. CONCLUSION: Local maternal mortality ratios identified through a peer-review process indicate that the magnitude of the problem is much greater than is recognized through national death certificate data. The high proportion of potentially preventable maternal deaths indicates the need for improvement in both patient and provider education if we are to reduce the maternal mortality ratio to 3.3 maternal deaths per 100,000 live births, the stated national health goal of Healthy People 2000.     

Delivery-related complications and early postpartum morbidity in Dhaka, Bangladesh.

OBJECTIVE: To describe delivery-related complications and postpartum morbidity of women living in slum areas of Dhaka, Bangladesh. METHOD: From November 1993 to May 1995, 1506 women were interviewed regarding delivery-related complications and postpartum morbidities. Operational definitions were applied to maternal reports to categorize serious delivery-related complications and postpartum morbidity. Corroborating information was identified from medical records for facility-based deliveries and physical examinations by female physicians 14 to 22 days postpartum. RESULT: Thirty-six percent of women described serious delivery-related complications and 75% of women reported postpartum morbidity. There were two maternal deaths among 1471 live births. When maternal reports were related to corroborating information, the proportion of women's reports of serious complications and morbidity appears reasonably accurate for some conditions. CONCLUSION: A large proportion of urban slum women in Dhaka experience serious delivery-related complications and/or postpartum morbidity. Information on delivery practices that contribute to morbidity and factors that influence appropriate care seeking is needed.     

Quantifying severe maternal morbidity: a Scottish population study

Objective   To quantify the incidence of severe maternal morbidity in Scotland and determine the feasibility of doing so.
Design   Prospective observational study.
Setting   All 22 consultant led maternity units in Scotland, between 1 October 2001 and 30 September 2002.
Population   Women during pregnancy and the puerperium.
Methods   Definitions for 13 categories of severe maternal morbidity were developed from published work. Recruitment of maternity units, and training of staff, took place at a national meeting. Each month, every unit reported cases meeting the agreed definitions, the category of incident and date. Data were collated centrally and analysed to determine the frequency of incidents. The number of maternal deaths occurring in Scotland over the same period was obtained from the Confidential Enquiry into Maternal Deaths.
Main outcome measures   Number and rate of defined events being reported. A subjective view of the feasibility of collecting national data routinely.
Results   Severe morbidity was reported in 196 women, out of 51,165 deliveries in Scotland (rate 3.8 per 1000 deliveries). Thirty percent of cases fell into more than one defined category. Major obstetric haemorrhage accounted for 50% of events. Only a third of identified patients were admitted to intensive care units. Four relevant maternal deaths occurred.
Conclusions   Categories of severe maternal morbidity can be defined and may provide a useful measure of the quality of maternity services, particularly in developed countries where maternal mortality is very rare. It appears feasible to set up a national reporting system for maternal morbidity, as well as mortality.     

The paradox of obstetric "near misses": converting maternal mortality into morbidity

OBJECTIVE: To systematically review evidence of obstetric near-misses and their consequences. DATA SOURCES: PUBMED, OVID, and references of retrieved articles were used. METHODS OF STUDY SELECTION: Only 13 original articles describe the occurrence of obstetric/maternal near-miss morbidity to date. All were included in this review, in addition to other articles related to the epidemiology and consequences of severe acute maternal morbidity. TABULATION, INTEGRATION, AND RESULTS: Serious forms of maternal morbidity occur in about 1% of women in the United States compared to 3.01 to 9.05% in some developing settings. Worldwide, the leading causes of near-miss morbidity are hemorrhage and pregnancy-related hypertension or eclampsia/pre-eclampsia. These complications can have lasting effects, and their sequelae may result in maternal illness, injury and disability. Based on severity, we have provided three phenotypes of obstetric near-misses: Class I (near-miss with healthy infant); Class II (near-miss with feto-infant morbidity); Class III (near-miss with fetal/infant death). CONCLUSION: Obstetric near-misses should be considered as potentially chronic illnesses that warrant follow-up care because the theoretical cycle of near-miss (as postulated in this paper) can only be interrupted by the resolution of residual issues or the mother's death. Some may consider near-miss events to be obstetric successes because ultimately the mother's life was spared, but the consequences of these complications can be overwhelming and enduring.     

Preventability of pregnancy-related deaths: results of a state-wide review

OBJECTIVE: Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced. METHODS: The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented. RESULTS: Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women. CONCLUSION: Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.     

Mode of delivery for breech presentation in grandmultiparous women.

OBJECTIVES: To compare maternal and neonatal outcomes of planned vaginal delivery vs. elective cesarean delivery for breech presentation at term. METHODS: Retrospective study of term breech deliveries from January 1997 through December 2000. A group of 128 women for whom vaginal delivery was planned was compared with a group of 122 women who had an elective cesarean delivery with regard to neonatal mortality and morbidity (birth trauma, birth asphyxia, hyperbilirubinemia, and duration of stay in the neonatal intensive care unit) and maternal morbidity (infections, hemorrhage, hysterectomy, deep venous thrombosis, and pulmonary embolism). RESULTS: There was no difference in neonatal mortality and morbidity between the two groups (13.0% vs. 9.4%). There were fewer maternal complications in the planned vaginal group than in the elective cesarean group (5.5% vs. 18%; P<0.01). In the planned vaginal delivery group 70% of multiparas and 85% of grandmultiparas were delivered vaginally compared with 50% of nulliparas. CONCLUSIONS: In breech presentations at term vaginal delivery can be achieved in 85% of grandmultiparas without significant neonatal morbidity. Elective cesarean section is associated with increased maternal morbidity compared with planned vaginal delivery.     

Evaluation of pregnant women with scarred uterus in a low resource setting

AIM: Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided. METHODS: An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted. RESULTS: A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively). CONCLUSIONS: Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple.     

A thirty-year review of maternal mortality in Oklahoma, 1950 through 1979

Oklahoma's Maternal Mortality Committee has been active since 1941. During the 30-year period 1950 through 1979, the committee reviewed in detail 75.9% of the pregnancy-related deaths that occurred in Oklahoma. The maternal mortality ratio in 1950 was 95.1/100,000 live births, and for 1979 it was 8.1/100,000 live births, a decrease of 91.5%. The risk of death from childbearing remained greater for black women than for American Indian or white women throughout the three decades. For American Indian women, the risk of death associated with pregnancy has decreased and is almost equal to the risk for white women. The Maternal Mortality Committee estimated that two thirds of Oklahoma's maternal deaths were preventable. The proportion of deaths judged preventable did not vary substantially during the study period. We conclude that maternal mortality in Oklahoma can be reduced to fewer than three deaths per 100,000 live births. Intensive monitoring and investigation of deaths and their causes by local maternal mortality committees continues to be an important mechanism for obtaining information to assist health workers in the prevention of deaths.