Severe Maternal Morbidity Review Research Articles

Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths.

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly..

Severe Maternal Morbidity Review and Preventability Assessment in a Large Academic Center.

With the goal of identifying factors contributing to severe maternal morbidity (SMM) at our institution, we established a formal SMM review process. We performed a retrospective cohort study including all SMM cases as defined by American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine consensus criteria that were managed at Yale-New Haven Hospital over a 4-year period. Overall, 156 cases were reviewed. The SMM rate was 0.49% (95% CI 0.40-0.58). The leading causes of SMM were hemorrhage (44.9%) and nonintrauterine infection (14.1%). Two thirds of the cases were deemed to be preventable. Preventability was mostly associated with health care professional-level (79.4%) and system-level (58.8%) factors that could coexist. Detailed case review allowed for identification of preventable causes of SMM, revealed gaps in care, and allowed for implementation of practice changes targeting health care professional-level and system-level factors.

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

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. To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. 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. Hospitalization during pregnancy or within 42 days post partum. 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. 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. 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.

A Systematic Review of Severe Maternal Morbidity in High-Income Countries.

With declining maternal mortality rates in high-income countries (HICs), severe maternal morbidity (SMM) is becoming an important quality measure of maternal care. However, there is no international consensus on the definition and types of SMM. This study aims to critically analyze published literature on SMM in HICs. The objectives are to compare definitions and criteria used to identify SMMand identify the main causes and risk factors contributing to SMM in HICs. PubMed, Cumulative IndextoNursing and Allied Health Literature(CINAHL), and Scopus databases were searched for articles published between 2010 and 2022, results were filtered, and 10 studieswere critically appraised. Six of the articles discussed SMM identification criteria and proposed definition modifications. Longer hospital stays and admission to the intensive care unit (ICU) were suggested as additional criteria. Disease-based criteria were shown to be superior to organ dysfunction criteria. Seven articles detailed common types of SMM as severe hemorrhage, hypertensive disorders, and preeclampsia/eclampsia. Six articles described SMM risk factors, of which advanced maternal age and cesarean delivery were the most common. This literature review identified disease-based criteria and Canadian study criteria as promising measures of SMM. It also identified several causes and risk factors of SMM common between HICs. These findings can help physicians identify women at risk of SMM. The study is however limited to eight HICs and 10 studies. Further research should aim to investigate how these criteria compare with previous sources of criteria and discern the association of weight and race risk factors with SMM.

Reviewing the past to inform the future: an 8-year review of severe maternal morbidity

Maternal morbidity is becoming a key indicator used to compare health systems in the developed world and also to inform clinical practice. This study aimed to evaluate a single center experience of severe maternal morbidity over an 8-year period. We conducted a retrospective review of all cases of severe maternal morbidity from 2012 to 2019 at a tertiary level maternity hospital in the Republic of Ireland with approximately 9000 births per year. We examined maternal demographics, pregnancy characteristics, and care requirements. Descriptive statistics were used throughout. There were 81,504 maternity cases and 67,894 births during the study period. A total of 504 women had a severe maternal morbidity, giving a rate of 6.1 per 1000 maternity cases overall, peaking in 2017 at 8.8 per 1000. When individual severe maternal morbidity events were evaluated, the rate increased from 6 per 1000 to 9 per 1000 over the 8-year period. There were no differences in maternal age, nationality, or body mass index during the years analyzed. Interestingly, 8.9% (n=45) were multiple gestations, and nearly one-fifth (19.4%; n=98) required escalation of care to a general hospital; of these, 14.0% (n=74) required cardiac or intensive care management. The majority of morbidities manifested in the third trimester (58.7%; n=296) or postnatally (42.8%, n=216). The most common severe maternal morbidities were hypertensive disorders of pregnancy, followed by postpartum hemorrhage and sepsis (45.0%, 44.2%, and 12.7%, respectively). We provide a longitudinal overview of severe maternal morbidity in a large maternity hospital that replicates other international findings. This information can be used for healthcare comparisons and for resource planning and allocation.

Statewide Severe Maternal Morbidity Review in Illinois.

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

Implementation of an Interdisciplinary Severe Maternal Morbidity Review Committee to Improve Identification Through a Hospital-Specific Protocol

Implementation of an Interdisciplinary Severe Maternal Morbidity Review Committee to Improve Identification Through a Hospital-Specific Protocol

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

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. 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. 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). 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. · 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..

Preeclampsia Causing Severe Maternal Morbidity—A National Retrospective Review of Preventability and Opportunities for Improved Care

(Aust N Z J Obstet Gynaecol. 2019;59:825–830) Preeclampsia complicates 3% to 8% of all pregnancies and is a major cause of mortality and morbidity for both mother and baby. Pregnancy-related severe maternal morbidity (SMM) is often preventable. As a result, there have been worldwide efforts to identify preventable factors of SMM with the goal of improving patient outcomes. A national preventability review of SMM in New Zealand between 2013 and 2015 found 23.3% of SMM cases admitted to intensive care units (ICUs) or high-dependency units (HDUs) involved preeclampsia. This study aimed to analyze the cohort of women from that study who had severe preeclampsia to identify factors associated with preventability and develop strategies to improve care.

Comparing Internal and External Severe Maternal Morbidity (SMM) Review in Illinois [06L

INTRODUCTION: A majority of states have implemented maternal mortality review committees, but Illinois is the only state to also implement facility-level, multidisciplinary review of SMM at all obstetric hospitals as recommended by the Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists. METHODS: Facility-level multidisciplinary SMM review was implemented in all perinatal networks in 2017 using a modified 2-factor scoring system recommended by CDC/ACOG (ICU admission and >4 units of packed red blood cells). A standing external, multidisciplinary SMM review committee was also established to review a subset of reviewed cases to improve the hospital review process and to compare external committee decisions to the internal review. RESULTS: The external committee found 34% of SMMs were potentially preventable compared to 16% across internal review. In external review, the most common factors contributing to SMM was medical decision making, however internal review found pre-existing conditions and pregnancy complications as leading preventable factors. The external committee found more provider (63% vs 16%) and system (41% vs 16%) opportunities to alter SMM than the internal committees (patient factors). CONCLUSION: This study is the first to present findings on statewide implementation of SMM review both within hospital and by external committee and compare parallel facility-level and state-level review. External review shows more preventability and more provider and system opportunities to prevent SMM compared to internal review. External review by a multidisciplinary committee provided more opportunities to identify strategies to alter outcomes, however both offer opportunities for quality improvement and population-based findings.

Preventability Review of Severe Maternal Morbidity

(Acta Obstet Gynecol Scand. 2019;98:515–522) Severe maternal morbidity (SMM) has been increasingly used to gauge the quality of maternal care. Worldwide, rates of SMM are increasing and are higher in women in ethnic minorities. Standardized SMM reviews have been recommended by the World Health Organization and other bodies to determine the preventability of SMM and to identify opportunities to improve SMM rates. This study aimed to establish the national incidence of SMM in intensive care units (ICUs) or high dependency units (HDUd) in New Zealand, and additionally, to establish ethnicity-specific rates of SMM.

Preventability Review of Severe Maternal Morbidity

(Abstracted from Acta Obstet Gynecol Scand 2019;98(4):515–522) Severe maternal morbidity (SMM) is defined as life-threatening complications in pregnancy, or within 42 days of the termination of the pregnancy. The rate of SMM is rising globally, and minorities have higher rates; in high-resource countries, the reported prevalence is reported as 3.8 to 13.8 per 1000 deliveries.

Implementation of a Multidisciplinary Review of Severe Maternal Morbidity

Implementation of a Multidisciplinary Review of Severe Maternal Morbidity

Results From an Multidisciplinary Severe Maternal Morbidity Review at a Tertiary Academic Medical Center [23P

Results From an Multidisciplinary Severe Maternal Morbidity Review at a Tertiary Academic Medical Center [23P

Pre‐eclampsia causing severe maternal morbidity – A national retrospective review of preventability and opportunities for improved care

Pre-eclampsia and related sequelae are a leading cause of severe maternal and neonatal morbidity and mortality. A significant proportion of these poor outcomes may be preventable with improvements along the continuum of maternal and neonatal care. The aim of this study was to review cases of pre-eclampsia resulting in severe maternal morbidity, describing the maternal and neonatal outcomes and the potential preventability of severe maternal morbidity (SMM). This was a retrospective cohort study of cases of SMM associated with severe pre-eclampsia - a subset of a national SMM review study. Inclusion criteria for this subset were women who were pregnant or within 42days of delivery with severe pre-eclampsia as the main reason for admission to an intensive care unit or high dependency unit in New Zealand between 1 August 2013 and 31 January 2015 inclusive. A multidisciplinary expert panel reviewed cases for preventability using a validated preventability tool. Of the 89 severe morbidities that were reviewed, 10 had eclampsia (11%) and there were four neonatal mortalities (4.3%). Multidisciplinary committees assessed the severe morbidity as potentially preventable in 31% (28) of cases with the majority due to delays in diagnosis and suboptimal treatment. We found a high level of preventable morbidity in cases of severe pre-eclampsia with a concerning number of preventable eclampsia. Implementation of evidence-based guidelines reinforced with education would assist clinicians to improve risk recognition, timely diagnosis and treatment and decrease potentially preventable severe morbidity associated with pre-eclampsia.

Preventability review of severe maternal morbidity.

Severe maternal morbidity (SMM) is rising globally. Assessing SMM is an important quality measure. This study aimed to examine SMM in a national cohort in New Zealand. This is a national retrospective review of pregnant or postpartum women admitted to an Intensive Care Unit or High Dependency Unit during pregnancy or recent postpartum. Outcomes were rates of SMM and assessment of potential preventability. Preventability was defined as any action on the part of the provider, system or patient that may have contributed to progression to more severe morbidity, and was assessed by a multidisciplinary review team. Severe maternal morbidity was 6.2 per 1000 deliveries (95% confidence interval 5.7-6.8) with higher rates for Pacific, Indian and other Asian racial groups. Major blood loss (39.4%), preeclampsia-associated conditions (23.3%) and severe sepsis (14.1%) were the most common causes of SMM. Potential preventability was highest with sepsis cases (56%) followed by preeclampsia and major blood loss (34.3% and 30.9%). Of these cases, only 36.4% were managed appropriately as determined by multidisciplinary review. Provider factors such as inappropriate diagnosis, delay or failure to recognize high risk were the most common factors associated with potential preventability of SMM. Pacific Island women had over twice the rate of preventable morbidity (relative risk2.48, 95% confidence interval 1.28-4.79). Multidisciplinary external anonymized review of SMM showed that over a third of cases were potentially preventable, being due to substandard provider care with increased preventability rates for racial/ethnic minority women. Monitoring country rates of SMM and implementing case reviews to assess potential preventability are appropriate quality improvement measures and external review of anonymized cases may reduce racial profiling to inform unbiased appropriate interventions and resource allocation to help prevent these severe events.

Multidisciplinary Severe Maternal Morbidity Reviews Can Teach the Clinical Learning Environment Review Focus Areas of Patient Safety and Quality

PURPOSE: To describe a resident focused multidisciplinary severe maternal morbidity (SMM) review program. BACKGROUND: The Joint Commission defined SMM as peri-partum blood transfusion of 4 units or admission to ICU and recommends multidisciplinary reviews to determine opportunities for improvement in care METHODS: An ongoing process detects cases of SMM with root-cause-analysis performed if case qualifies as a sentinel event. Data is extract and presented quarterly to, a multidisciplinary committee to determine contributory factors, opportunities to alter outcome, best practices and recommendations. RESULTS: Forty-five SMM cases were reviewed from 1/15 to 6/17 by residents 67%, fellows 9%, nurses 7%, and MFM faculty 17%. Opportunities to alter care were determined to be strong in 9% and possible in 62%. System/provider could alter outcome in 53% while the patient could have altered outcome in 33% of cases. Outcomes could have been altered by contraception/sterilization in 13%, patient compliance 11%, early prenatal care 20%, referral/consultations 9%, improved documentation 7%, early recognition 33%, team communication 4% and management 31%. Good practices recognized included multidisciplinary teamwork/communication 60%, evidence-based response 36%, timely recognition 24%, documentation 20%, quality obstetric care 22%, timely referral 13%, expertise care 9%, and patient-centered-care 7%. Strong opportunity to alter outcome was present with hypertensive crisis (P=.026). Significant opportunities to alter outcomes were: preterm SMM cases by contraception/sterilization (P=.036); patient compliance in Medicaid insured (P=.01) and younger women (P=.04). Transfusions were recognized for the good practice of timely recognition (P=.045). DISCUSSION: Residents' involvement in SMM reviews can determine care improvement opportunities and provide training on safety and quality.

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience.

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. 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. 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). 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.

Understanding Severe Maternal Morbidity: Hospital-based Review.

Cases of severe maternal morbidity (SMM) share similarities to maternal deaths, including increasing in frequency and having similar rates of preventability. This article will review steps to organizing and implementing standard reviews of all cases of SMM. These steps include create multidisciplinary SMM review committee; identify potential SMM cases and confirm true SMM; identify the morbidity; abstract and summarize data; present case to review committee for discussion; determine events leading to morbidity; determine opportunities to improve outcome; assess provider, system and patient factors in cases with opportunities to improve outcome; make recommendations; and effect change and evaluate improvement.

A Review of Severe Acute Maternal Morbidity (SAMM) through “Three Delays Model”

A Review of Severe Acute Maternal Morbidity (SAMM) through “Three Delays Model”