Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative
15 December 2015
16 April 2016
30 May 2016 (online)
Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage.
Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 (n = 64 before training initiative) and 2010 (n = 71 after training initiative) were identified by a two-factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related.
Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p < 0.01) and delay or inappropriate treatment (76.5 vs. 39.5%, p < 0.01). System factors also differed (32.4 vs. 7.9%, p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p < 0.01) between 2006 and 2010.
Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.
An abstract from this study was presented in poster format at the Central Association for Obstetricians and Gynecologists in Charleston, South Carolina, October 21–24, 2015.
- 1 Saucedo M, Deneux-Tharaux C, Bouvier-Colle MH ; French National Experts Committee on Maternal Mortality. Ten years of confidential inquiries into maternal deaths in France, 1998-2007. Obstet Gynecol 2013; 122 (4) 752-760
- 2 Grobman WA, Bailit JL, Rice MM , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol 2014; 123 (4) 804-810
- 3 Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol 1996; 88 (2) 161-167
- 4 Berg CJ, Harper MA, Atkinson SM , et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005; 106 (6) 1228-1234
- 5 Hoyert DL, Danel I, Tully P. Maternal mortality, United States and Canada, 1982-1997. Birth 2000; 27 (1) 4-11
- 6 Nannini A, Weiss J, Goldstein R, Fogerty S. Pregnancy-associated mortality at the end of the twentieth century: Massachusetts, 1990-1999. J Am Med Womens Assoc 2002; 57 (3) 140-143
- 7 California Maternal Quality Care Collaborative. Improving Healthcare Response to Obstetric Hemorrhage: Version 2.0, A California Quality Improvement Toolkit. Palo Alto; CMQCC; 2015. Available at: www.cmqccorg/ob_hemorrhage . Accessed June 15, 2015
- 8 American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol 2006; 108 (4) 1039-1047
- 9 Geller SE, Rosenberg D, Cox S, Brown M, Simonson L, Kilpatrick S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol 2004; 57 (7) 716-720
- 10 Geller SE, Rosenberg D, Cox SM , et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004; 191 (3) 939-944
- 11 Della Torre M, Kilpatrick SJ, Hibbard JU , et al. Assessing preventability for obstetric hemorrhage. Am J Perinatol 2011; 28 (10) 753-760
- 12 Kilpatrick SJ, Prentice P, Jones RL, Geller S. Reducing maternal deaths through state maternal mortality review. J Womens Health (Larchmt) 2012; 21 (9) 905-909
- 13 Wong CA, Scott S, Jones RL, Walzer J, Geller S. The state of Illinois obstetric hemorrhage project: pre-project and post-training examination scores. J Matern Fetal Neonatal Med 2015; 29 (5) 845-849
- 14 Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, DʼAlton M. Facility-based identification of women with severe maternal morbidity: it is time to start. Obstet Gynecol 2014; 123 (5) 978-981
- 15 Geller SE, Adams MG, Kominiarek MA , et al. Reliability of a preventability model in maternal death and morbidity. Am J Obstet Gynecol 2007; 196 (1) 57.e1-57.e6
- 16 Geller SE, Cox SM, Kilpatrick SJ. A descriptive model of preventability in maternal morbidity and mortality. J Perinatol 2006; 26 (2) 79-84
- 17 Lal AK, Geller S, Scott S, Hibbard J. Assessment of hospital readiness for obstetric hemorrhage. Evid Based Womens Health J 2015; 5: 80-85
- 18 Einerson BD, Miller ES, Grobman WA. Does a postpartum hemorrhage patient safety program result in sustained changes in management and outcomes?. Am J Obstet Gynecol 2015; 212 (2) 140-4.e1
- 19 Al-Kadri HM, Dahlawi H, Al Airan M , et al. Effect of education and clinical assessment on the accuracy of post partum blood loss estimation. BMC Pregnancy Childbirth 2014; 14: 110
- 20 Shields LE, Smalarz K, Reffigee L, Mugg S, Burdumy TJ, Propst M. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011; 205 (4) 368.e1-368.e8
- 21 Kilpatrick SJ, Berg C, Bernstein P , et al. Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol 2014; 124 (2 Pt 1) 361-366
- 22 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (1) 5-12
- 23 Geller SE, Koch AR, Martin NJ, Rosenberg D, Bigger HR ; Illinois Department of Public Health Maternal Mortality Review Committee Working Group. Assessing preventability of maternal mortality in Illinois: 2002-2012. Am J Obstet Gynecol 2014; 211 (6) 698.e1-698.e11
- 24 Chaillet N, Dubé E, Dugas M , et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol 2006; 108 (5) 1234-1245