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Maternal Death from Obstetric Hemorrhage
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Maternal Death from Obstetric Hemorrhage Debra Bingham and Rene´e Jones
Correspondence Debra Bingham, DrPH, RN, Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), 2000 L Street, NW, Suite 740, Washington, DC 20036. [email protected]
ABSTRACT Obstetric hemorrhage remains the leading cause of maternal death in the United States, and 54% to 93% of these deaths may have been preventable. Leaders must honor the lives of women who die from obstetric hemorrhage by reviewing their deaths and sharing lessons learned. Shortening the current 3 to 7 year data gap will allow for timely initiation of quality improvement efforts. Designated leaders and researchers from the Association of Women’s Health, Obstetric, and Neonatal Nurses are ideally positioned to lead these quality initiatives.
JOGNN, 00, 1-8; 2012. DOI: 10.1111/j.1552-6909.2012.01372.x Accepted March 2012
Keywords maternal mortality maternal morbidity obstetric hemorrhage quality improvement state-wide maternal mortality reviews nurse leadership data limitations
Debra Bingham, DrPH, RN, is the Vice President of Research, Education, and Publications for the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Washington, DC. Rene´e Jones, MSN, WCNP-BC, is a nurse practitioner at the Women’s Link-Specialty Obstetrical Referral Center, Plano, TX.
bstetric hemorrhage has consistently remained the most common cause of maternal death (Berg, Callaghan, Syverson, & Henderson, 2010), and more than 50% of the hemorrhagerelated deaths have been shown to be preventable with researchers indicating preventability ranges between 54% to 93% (Berg et al., 2005; California Department of Public Health [CDPH], 2011; Della Torre et al., 2011). Thousands of women each year suffer from an obstetric hemorrhage but do not die. In 2006 approximately 2.9% of the women who gave birth, or 124,708 women, suffered a postpartum hemorrhage (Callaghan, Kuklina, & Berg, 2010). The number of women affected by a postpartum hemorrhage has been increasing, and there was a 92% increase in the number of obstetric-related blood transfusions in 2004 to 2005 compared to 1998 to 1999 (Kuklina et al., 2009). Callaghan et al. reported a 26% increase in rates of postpartum hemorrhage between 1994 (2.3%) and 2006 (2.9%).
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health leaders, and countless others to determine effective steps to eliminate preventable obstetric hemorrhage-related mortality and morbidity. There are two major purposes of this article. The first is to describe obstetric hemorrhage prevalence, etiology, and prevention. The second is to describe the necessity for enhanced data collection, case review, and data reporting methods to better support nurses’ ability to scrutinize the effect their practices have on the women under their care and to guide their quality improvement initiatives.
Prevalence and Etiology of Obstetric Hemorrhage Based on death certificate data, hemorrhage remained the leading cause of maternal death in the United States from 1998 to 2005 with 587 women dying from obstetric hemorrhage during those years (Berg et al., 2010). MacKay, Berg, Liu, Duran, and Hoyert (2011) also reported that the overall percent of hemorrhage deaths compared to other causes of death decreased. Reporting on the causes of death is an important first step in determining why women die; this leads to subanalyses to determine which deaths were most likely
The authors report no conflict of interest or relevant financial relationships.
Many of these studies were published in the past two years and represent the most current data available; however, these data were 4 to 7 years old at the time of publication. More real-time, population surveillance and case-review data are needed to support nurses and physicians, public
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C 2012 AWHONN, the Association of Women’s Health, Obsteric and Neonatal Nurses
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Obstetric hemorrhage-related mortality is amenable to change: 54% to 93% of the deaths reviewed were deemed preventable.
preventable and why. For example, timely and accurate data are needed to assess why the percentage of hemorrhage-related deaths decreased compared to other causes of death and whether the increased percentage in maternal deaths due to cardiovascular conditions reflect better case ascertainment of cardiovascular deaths or an actual increase in the number of cardiovascular deaths. Maternal deaths in the United States are still quite rare and likely represent only the “tip of the iceberg” of the impact of obstetric hemorrhage. According to the best estimates available, 2.9% of all births are complicated by hemorrhage (Bateman, Berman, Riley, & Leffert, 2010; Callaghan et al., 2010). Based on the data analysis of Callaghan et al., 2.9% of births translate into 124,708 women who suffered a postpartum hemorrhage in 2006. The findings of Bateman et al. are consistent with those of Callaghan et al. and demonstrated that the number of women giving birth in the United States experiencing hemorrhage increased 27.5% from 1995 to 2004. Assuming consistency of data limitations and coding practices between 1995 and 2004, these findings demonstrated that uterine atony was the leading cause of the 27.5% increase in postpartum hemorrhage despite the fact that the number of women with recorded risk factors had not changed (Bateman et al., 2010). Because maternal risks remained statistically similar between 1995 and 2004, these findings raise the question: What changed to increase the rate of uterine atony that has contributed to the increased rate of postpartum hemorrhage? The answer to this question is likely multifaceted. Part of the answer may be that the administrative data used by Bateman et al. did not include maternal characteristics, such as obesity, that affect rates of uterine atony or take into account that coding practices may have changed to better identify maternal hemorrhage. In addition, these data did not include information on the changes in clinical practices that are known to expose more women to higher rates of uterine atony, such as increased rates of oxytocin induction (indicated and not medically indicated induction). When Callaghan et al. analyzed the causes of the increase in postpartum hemorrhage in 1994 com-
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pared to 2006, they too found that the percentage of women with uterine atony increased significantly (p < .001) from 1.6% (58,597 women) to 2.4% (99,904 women) (Callaghan et al., 2010). They described differences in the characteristics of the women. The women giving birth in 2006 were older, more often using government insurance, having more cesareans, fewer vaginal births after previous cesareans, more inductions of labor, more multiple gestations, and more medical comorbidities such as diabetes and hypertension. However, the prevalence of postpartum hemorrhage (PPH) risk factors did not explain the increase (Callaghan et al.). Labor induction, regardless of the mode of birth, was found to have the strongest correlation to the overall 50% increase in uterine atony. Also, the method by which the woman gave birth was correlated to PPH. The women at the greatest overall risk for PPH were those who had a vaginal birth and an induction of labor. However, in 2005 and 2006 the percent of uterine atony for women who gave birth by cesarean compared to vaginal birth was essentially the same. It is interesting to note that Bateman et al. (2010) found that higher rates of cesarean with and without labor were a risk factor for hemorrhage. This finding may be explained by the fact that women who have an induction of labor also have been shown to be twice as likely to have a cesarean (Zhang et al., 2010). Callaghan et al. (2010) found that women whose labor was induced had the highest risk of postpartum hemorrhage caused by uterine atony regardless of whether they give birth surgically or vaginally. Other causes of obstetric hemorrhage are placenta accreta, increta, percreta, and previa (Tadesse et al., 2011). If a woman has a placenta that invades her uterine muscle or other internal organs such as her bowels and bladder, she will most likely experience extensive bleeding and most likely need a hysterectomy immediately after she gives birth (Knight, Kurinczuk, Spark, & Brocklehurst, 2008; Stivanello et al., 2010). The connection between a surgical birth in a prior pregnancy and the presence of a placenta implantation abnormality in a subsequent pregnancy has been well established (Belfort, 2010; Clark, Koonings, & Phelan, 1985). Women with a placenta previa, a placenta partially or completely covering the cervix, are also at great risk for bleeding and may need to spend weeks in the hospital to reduce the associated perinatal morbidity and mortality risks. The emotional and financial toll on the mother and
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her family are obvious, and the costs to society are great. For example, if the infant is born prematurely, even by a few weeks, the infant has increased morbidity and mortality, such as difficulty feeding, recurrent respiratory illnesses, asthma, and so on (Tita et al., 2011). Women also experience short- and long-term morbidity, such as a greater risk of a deep vein thrombosis (from bed rest and surgery) and the strong possibility that they will experience a massive hemorrhage severe enough to require peripartum hysterectomy (Pacheco & Gei, 2011). The fact that more than one third of the women who give birth in the United States undergo major surgery, and many women do not have the option to attempt a vaginal birth after cesarean (resulting in an overuse of cesarean) means more women are suffering preventable harm. Of the lowrisk women who gave birth in 2007 and had also previously given birth surgically, 90.8% had a cesarean (Centers for Disease Control and Prevention [CDC], 2007).
Prevention of Obstetric Hemorrhage Mortality In 2005, researchers in conjunction with the North Carolina Maternal Mortality Review Committee determined that 93% of obstetric hemorrhagerelated deaths in North Carolina that occurred between 1995 and 1999 were preventable (Berg et al., 2005). In another study published in 2011, an interdisciplinary expert panel reported the results of a retrospective chart review of the obstetric hemorrhage maternal mortality and morbidity in 11 hospitals in Illinois; they found that 54% of the mortality and morbidity were preventable (Della Torre et al., 2011). State Department of Health communications and maternal mortality reports indicate that women do not have consistent access to what are known to be effective treatments for obstetric hemorrhage. For example, the New York State Department of Health (NYSDH) issued two separate health advisories. The 2004 alert sent to clinicians and hospital administrators stated that most of the women who died from obstetric hemorrhage in New York State were hospitalized at the time of death (NYSDH, 2004). The 2009 alert showed that despite the prior health advisory, the ratio of maternal deaths in New York State increased from 15.9/100,000 live births to 20.5/100,000 lives births (NYSDH, 2009). The 2009 alert stated that “generally hemorrhage is a preventable cause
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Data have demonstrated that 2.9% of all births were complicated by obstetric hemorrhage and that uterine atony was the leading etiology. of mortality” (NYSDH, 2009, p. 1). The 2004 health advisory recommended some basic solutions for hospital leaders to reduce these higherthan-expected ratios of deaths in New York State: creation of effective protocols, prompt recognition of the gravity of the situation, and prompt response from an interdisciplinary team to treat the hemorrhage. The 2009 alert reiterated some of these same recommendations but added the recommendations that there be a prenatal risk assessment and that teams perform hemorrhage drills. Currently no data are available to show the number of hospitals in New York State that have heeded these health advisory recommendations. In addition, no data are available to indicate how many hospitals in the United States have protocols and run hemorrhage drills. The 2002–2003 Pregnancy-Associated Mortality Review report of the CDPH (2011) stated that 70% of the obstetric hemorrhage-related deaths reviewed had a strong or good chance of being prevented. In 2008, one year after the mortality reviews began, the California Maternal Quality Care Collaborative (CMQCC) performed a baseline survey of hemorrhage practices in California hospitals to serve as an adjunct to the mortality review data (Bingham et al., 2010). Out of 261 hospitals, 173 (66%) responded to the survey. Of the 173 hospitals that participated, 40% reported that they did not have any hemorrhage protocol, and 70% reported that they did not perform drills and if they did run drills the physicians did not regularly participate. In addition, although most hospitals reported access to uterotonics (oxytocin and methergine), some hospitals reported that they did not have access to alternative treatment methods, for example, intrauterine balloon catheters or clinicians skilled in B-Lynch suture techniques. The survey asked how hemorrhage was defined at these hospitals. Although most of the hospitals defined hemorrhage during cesarean as the standard of greater than 1000 milliliters of blood loss, some hospitals’ definitions varied from this standard. The California statewide survey of clinical practices was one of the sources of data used by the leaders at CMQCC to determine the most effective next steps for reducing preventable hemorrhage-related maternal mortality and morbidity in the state of California (Bingham, Lyndon, Lagrew, & Main, 2011).
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More than a half-century of data show African American women who give birth in the United States are 3 to 4 times more likely to die during childbirth than women of all other races and ethnicities (Berg, Chang, Callaghan, & Whitehead, 2003; CDPH, 2011). It is not well understood why Hispanic and Asian maternal mortality ratios, for example, are similar to those of White women, and Black maternal mortality ratios are worse. It is also beyond the scope of this article to explore this racial disparity in detail. However, a provocative study published by Tucker, Berg, Callaghan, and Hsia (2007) is worthy of mention. When comparing hemorrhage deaths, the authors reviewed 3,318 hospital discharge records from years 1988–1999 and found that Black women did not have a statistically significant higher prevalence of hemorrhage than White women, but Black women did have higher risk of death when hemorrhage occurred. To calculate whether there was a difference in case fatality rates, Tucker et al. used data from the Pregnancy Mortality Surveillance System. For the years 1988–1999, Black women had a pregnancyrelated mortality ratio (PRMR) of 0.976 deaths per 100,000 live births compared to White women who had 0.397 deaths per 100,000 live births. These facts indicate that more White women died of obstetric hemorrhage than Black women, but Black women had PRMRs that were 2.5 times higher than those for the White women who died from a postpartum hemorrhage. More data are needed to explain why the researchers found the 2.5 times higher hemorrhage-related case fatality rate among Black women compared to White women, even though no statistically significant differences in the rates of hemorrhage were found. Current data would particularly be helpful because hemorrhage rates have increased. Regardless of these data limitations, the Tucker et al. (2007) study suggests that the disparity in Black maternal mortality may be highly amenable to change. Until more data are available, working to eliminate all variation in access to effective hemorrhage treatments, regardless of the woman’s race or ethnicity, is a logical next step. Postpartum hemorrhages are also likely to be preventable if changes in clinical practices occur. For example, in the United States cesareans are overused. Unless women decide to have fewer children, or clinicians decrease the primary cesarean rate, or insurance companies, hospitals, and providers increase the access for women to vaginal birth after cesarean, the rates of obstetric hemorrhages related to placenta abnormal im-
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plantation will likely increase. Subsequently, the number of women who will require a peripartum hysterectomy to prevent death resulting from hemorrhage will also increase (Knight et al., 2008; Plante, 2006). Eliminating nonmedically indicated inductions for labor is also likely to reduce the number of women who experience uterine atony (Callaghan et al. 2010). Although we cannot know an exact number of obstetric hemorrhage deaths and injuries that could have been prevented, the timely development and implementation of initiatives to ensure that all women, regardless of their race or ethnicity, have equal access to what are known to be highly effective and relatively inexpensive treatments are needed. Using a quality improvement approach based on the best available evidence, a plan could be formulated that includes gathering postpartum hemorrhage data and evaluating the effectiveness of the plan based on process and outcome data. Developing and implementing hospital-based, state-based, and national quality improvement initiatives now will likely reduce hemorrhage-related deaths and injuries in the future.
Data Limitations Accurate and timely data are needed to guide leaders’ quality improvement initiatives. Currently in the United States, data are limited by a number of factors: variation in the definition of hemorrhage, variation and limitations in coding practices, lack of timely aggregate data, and lack of data on clinical practices. Data limitations leave nurses, physicians, public health leaders, public policy leaders, women, families, patient advocates, and countless others wondering how to determine the full scope of the problem and how to implement the most effective next steps. The most fundamental data limitation is the variation in how clinicians define hemorrhage. For example, some define hemorrhage solely as the amount of blood lost, whereas others define it as blood loss in relation to mode of delivery (Bingham et al., 2011). The lack of a standard definition is compounded by the fact that it is well known that clinicians do not accurately estimate blood loss (Dildy, Paine, George, & Velasco, 2004). A second limitation is variation and limitations in coding practices (Atrash, Alexander, & Berg, 1995; Bateman et al., 2010; Lu et al., 2005). Some of the coding limitations are due to the variation in how hemorrhage is defined. For example, in the same situation and based on personal definitions of hemorrhage, one
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clinician may chart obstetric hemorrhage whereas a different clinician may not. Other coding limitations occur when coders interpret the hemorrhage codes and hospital-based billing practices in different ways. Last, coding is limited by the ability to discriminate between various types of obstetric hemorrhage etiology and severity. A third limitation is that maternal hemorrhage data are not always available in a timely manner. Actual rates of births complicated by hemorrhage are difficult to track and respond to because of a multiyear gap between when the events occurred and when the studies are published. For example, it is not unusual for it to take researchers four years to publish their data on births complicated by postpartum hemorrhage (Callaghan et al., 2010). Because of this substantial delay, leaders and clinicians do not have the data necessary to track the effect of clinical practice on health outcomes. Finally, data on actual hemorrhage-related practices are limited, including the number of hospitals where clinicians quantify blood loss rather than estimate blood loss, the number of hospitals that routinely perform hemorrhage drills, the number of clinicians who are trained to perform BLynch suturing or intrauterine tapenade, and how often these procedures are performed. Lack of data about clinical practices makes it impossible to determine whether women received timely administration of efficacious treatments consistently. Obstetric hemorrhage-related national quality measures to track data on processes that affect outcomes are needed.
Limitations of Maternal Morbidity and Mortality Data at State and National Levels Currently only 21 states perform maternal mortality reviews (Amnesty International, 2010) despite the fact that mortality review data offer essential surveillance and population information on the contribution of obstetric hemorrhagerelated deaths to overall maternal mortality ratios. The United Kingdom has demonstrated the commitment to review maternal deaths for several decades and develop targeted strategies based on lessons learned from these reviews. Therefore, the United Kingdom has maintained one of the lowest maternal mortality ratios in the world and has shown the ability to consistently decrease maternal death to birth ratios (Cantwell et al., 2011). Indeed, mortality and morbidity data limitations
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The efforts of nurse leaders, researchers, and reviewers are essential for the United States to eliminate preventable, obstetric hemorrhage-related mortality and morbidity.
constrain our ability to address why in 2000 the United States ranked 30th in the world for maternal mortality but (Tucker et al., 2007) currently ranks 50th (World Health Organization, 2010). In addition, lack of data limits our ability to suggest why the ratio of maternal deaths to live births began to increase in 2000 and has nearly doubled, with ratios between 12 and 15 per 100,000 live births (MacKay et al., 2011; U.S. Department of Health and Human Services, 2009). Last, no data exist to explain the wide variations in state maternal mortality ratios. For example, five states (Maine, Vermont, Massachusetts, Indiana, and Minnesota) have maternal mortality ratios between 1.2 to 3.7 deaths per 100,000 live births (Amnesty International). Yet in Georgia the ratio is reported to be 20.5 maternal deaths per 100,000 live births, and in the District of Columbia the ratio is 34.9 per 100,000 (Amnesty International). An additional benefit of performing reviews is to determine what data were miscoded, because miscoded data makes it difficult to interpret and act on national and state maternal mortality surveillance statistics. For example, the California Pregnancy-Association Mortality Review committee found that even basic data on cause of death and whether a death was pregnancy-related (aggravated or caused by the pregnancy) or not were not always accurately coded (CDPH, 2011). The miscoding resulted in over- and underreporting of whether a death was pregnancy related. Overall, approximately 24% of the 2002 to 2003 cases reviewed in California that were ultimately determined to be pregnancy-related deaths had originally been miscoded as nonpregnancy-related deaths. The findings in California are not atypical, and there has been some progress toward improving coding practices, such as the addition of a pregnancy check-box to death certificates (MacKay et al., 2011). However, it is important to note that the number of obstetric hemorrhage-coded causes of death in California remained consistent prior to and after review. A lack of consistency also occurs in how deaths are reviewed. Currently, very few recommendations exist on review methodology, which cases to review, and the data specifications for data
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extraction and analysis (Berg, Danel, Atrash, Zane, & Bartlett, 2001). Lack of a consistent data review methodology limits the ability to gather, review, and publish data nationally and to make state-by-state comparisons. Although it took decades to develop, the systematic approach now used by the Fetal Infant Mortality Review (FIMR) is recognized as a valuable, coordinated, and collaborative approach (Hutchins, Grason, & Handler, 2004). Given the limited resources available and lessons learned from the FIMR, national organizations such as Association of Women’s Health, Obstetrics, Neonatal Nursing (AWHONN), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse Midwives (ACNM) should be active equal participants in the development of review standards including each of their unique professional perspectives.
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Limited Data on Maternal Morbidity Maternal deaths in the United States are rare or sentinel events. Thus, a more robust maternal morbidity data surveillance system is needed. The morbidity surveillance system would be most useful if it captured data on the prevalence of specific types of obstetric conditions, such as obstetric hemorrhage and peripartum hysterectomy and published these data more frequently than current studies are published.
Clinical Implications
When reviews do occur, the results are not always published in a timely, predictable manner. The United Kingdom Confidential Inquiry can serve as a useful model because the review of data is confidential, but the data are published every 3 years. During the 3-year cycle, there is flexibility to adjust some of the review methods, but there are also data that are consistently shared and trended over time. The United Kingdom does not experience the same delays as the United States in disseminating maternal mortality findings to clinicians and to the public. Indeed, health professions in the United States must insist on enhanced transparency in how these reviews are conducted as well as standard methods and standard deadlines for publication of data.
The Institute of Medicine (2001) estimated that it takes approximately 17 years to transform research into clinical practice. In the case of obstetric hemorrhage, the lag time has been much longer. In 2011, the results of phone interviews conducted by department of health leaders indicated that at least seven states (California, Delaware, Florida, Illinois, Massachusetts, New Mexico, and New York) reported obstetric hemorrhage as a priority for action in their states. In California, the state-based maternal death reviews are directly linked to an interdisciplinary maternal quality improvement collaborative so that the lessons learned from the mortality reviews are incorporated into quality improvement initiatives (Bingham et al., 2011). As indicated by Bingham et al., the hard work at the patient and clinician transaction level requires dedicated nursing leadership and intraprofessional teamwork. It is too early to determine how effective statewide efforts will be or whether they could be more effective if they were connected nationally.
Reviews are also likely to be more effective if the reviewers are linked with standard-setting professional organizations. For example, if each review team had one official representative from AWHONN, the ability to more rapidly translate review findings into action at lower cost would increase because AWHONN currently publishes books and journals, develops position statements and evidence-based guidelines, and organizes national and state conferences to improve outcomes. Reviewers would benefit from additional opportunities to collaborate with other experts in their professional disciplines. Reviewers linked to a professional organization such as AWHONN are more likely to be aware of national nursing standards. Currently, only California’s Maternal Mortality Review Committee has requested an official AWHONN representative to serve on its committee.
The strategies and interventions developed to improve outcomes will be more effective if they are tailored to the different causes or types of obstetric hemorrhage (Bingham & Main, 2010). Thus, understanding the etiology of the hemorrhage and tracking data based on etiology are important to determine solutions. For example, postpartum hemorrhage (a subset of obstetric hemorrhage) is not a diagnosis of an actual disease state (Callaghan et al., 2010). Postpartum hemorrhage is caused by one or more of several types of situations, such as poor uterine tone or uterine atony, retained placental tissue, abnormal placenta implantation, genital tract trauma, or coagulation abnormalities. Understanding the underlying etiology of the hemorrhage is crucial for the data collection that guides quality improvement implementation efforts.
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A shift in research priorities, or at least a recognition and allocation of resources to support implementation science research for situations such as obstetric hemorrhage, is needed if the United States is going to ensure that all women, regardless of race, ethnicity, or economic status, receive basic, evidence-based, effective treatments. Resources are needed to track current clinician practice and interventions implemented in clinical practice to improve outcomes. Nurses are often the leaders of the implementation initiatives to eliminate obstetric-related preventable mortality and morbidity. For example, nurses lead practice change in health care systems by bringing together multiple providers and disciplines to collaborate on improving patient outcomes. These efforts may be coordinating changes in the electronic medical records and order sets, ensuring necessary supplies are available at the bedside, or identifying variations in practice and opportunities for communication and operational improvements. For nurses to be effective leaders and patient advocates, they need resources, implementation tools, and data to understand the extent of the problem, recognize the cause of maternal death, and be involved and included actively at the hospital, community, state, and national level. Nurses must be included on hospital committees and at the state and national level as key collaborators with providers such as midwives, nurse practitioners, and physicians to develop evidence-based protocols and to lead activities such as improving team functioning. The recommendations for action are summarized in Table 1.
Conclusion The fact that obstetric hemorrhage is the leading cause of maternal mortality in the United States is troubling given the fact that the United States spends more on health care than any other country (17.4% of gross domestic product compared to the next highest country that spends 12%) and that known, effective treatments are not being performed consistently (Bingham & Main, 2010; Organization for Economic Co-operation and Development, 2011). Access to timely data, adoption and use of consistent definitions, consistent coding practices, improved discrete codes, data on clinical practices, and more robust mortality and morbidity surveillance and reviews are all needed to guide and evaluate system-wide changes. Without timely
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Table 1: Recommendations for Preventing Mortality and Morbidity Related to Maternal Hemorrhage 1 Standardize hemorrhage definitions 2 Standardize coding practices 3 Track clinician’s hemorrhage-related knowledge, attitudes, and practices 4 Track morbidity data 5 Decrease the time it takes to make data available 6 Review all hemorrhage-related maternal deaths 7 Standardize state review and data analysis methodologies to identify professional specific improvement opportunities that can be tracked nationally 8 Disseminate review data more frequently and on a regular schedule 9 Disseminate review data more effectively, e.g., connect review efforts to national professional organizations 10 Implement quality improvement initiatives
and detailed feedback, nurses, physicians, public health leaders, and others will have limited knowledge of how their care affects outcomes and whether implementation efforts have been effective at improving outcomes. Women who die from obstetric hemorrhage must be honored by ensuring that their deaths will be counted and reviewed accurately and that lessons learned will prevent injury and the possibly of other deaths. One strategy to improve maternal outcomes is to implement obstetric hemorrhage-related quality improvement initiatives to ensure that all women, regardless of their race or ethnicity, have equal access to what are known to be highly effective and relatively inexpensive treatments. Nurse involvement is a key step toward ensuring that the quality improvement initiatives are effective, because much of the care provided to women is delivered by nurses. Nurses are readily at the bedside and are often the first provider responsible for assessing and responding to a maternal hemorrhage and determining which members of the team need to be mobilized. Nurses are ideally qualified to evaluate and identify practice solutions to improve maternal outcomes. Nursing involvement, nursing scrutiny, and nursing scholarship are necessary for the United States to eliminate preventable death and injury related to obstetric hemorrhage.
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Maternal Death from Obstetric Hemorrhage Debra Bingham and Rene´e Jones
Correspondence Debra Bingham, DrPH, RN, Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), 2000 L Street, NW, Suite 740, Washington, DC 20036. [email protected]
ABSTRACT Obstetric hemorrhage remains the leading cause of maternal death in the United States, and 54% to 93% of these deaths may have been preventable. Leaders must honor the lives of women who die from obstetric hemorrhage by reviewing their deaths and sharing lessons learned. Shortening the current 3 to 7 year data gap will allow for timely initiation of quality improvement efforts. Designated leaders and researchers from the Association of Women’s Health, Obstetric, and Neonatal Nurses are ideally positioned to lead these quality initiatives.
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Keywords maternal mortality maternal morbidity obstetric hemorrhage quality improvement state-wide maternal mortality reviews nurse leadership data limitations
Debra Bingham, DrPH, RN, is the Vice President of Research, Education, and Publications for the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Washington, DC. Rene´e Jones, MSN, WCNP-BC, is a nurse practitioner at the Women’s Link-Specialty Obstetrical Referral Center, Plano, TX.
bstetric hemorrhage has consistently remained the most common cause of maternal death (Berg, Callaghan, Syverson, & Henderson, 2010), and more than 50% of the hemorrhagerelated deaths have been shown to be preventable with researchers indicating preventability ranges between 54% to 93% (Berg et al., 2005; California Department of Public Health [CDPH], 2011; Della Torre et al., 2011). Thousands of women each year suffer from an obstetric hemorrhage but do not die. In 2006 approximately 2.9% of the women who gave birth, or 124,708 women, suffered a postpartum hemorrhage (Callaghan, Kuklina, & Berg, 2010). The number of women affected by a postpartum hemorrhage has been increasing, and there was a 92% increase in the number of obstetric-related blood transfusions in 2004 to 2005 compared to 1998 to 1999 (Kuklina et al., 2009). Callaghan et al. reported a 26% increase in rates of postpartum hemorrhage between 1994 (2.3%) and 2006 (2.9%).
O
health leaders, and countless others to determine effective steps to eliminate preventable obstetric hemorrhage-related mortality and morbidity. There are two major purposes of this article. The first is to describe obstetric hemorrhage prevalence, etiology, and prevention. The second is to describe the necessity for enhanced data collection, case review, and data reporting methods to better support nurses’ ability to scrutinize the effect their practices have on the women under their care and to guide their quality improvement initiatives.
Prevalence and Etiology of Obstetric Hemorrhage Based on death certificate data, hemorrhage remained the leading cause of maternal death in the United States from 1998 to 2005 with 587 women dying from obstetric hemorrhage during those years (Berg et al., 2010). MacKay, Berg, Liu, Duran, and Hoyert (2011) also reported that the overall percent of hemorrhage deaths compared to other causes of death decreased. Reporting on the causes of death is an important first step in determining why women die; this leads to subanalyses to determine which deaths were most likely
The authors report no conflict of interest or relevant financial relationships.
Many of these studies were published in the past two years and represent the most current data available; however, these data were 4 to 7 years old at the time of publication. More real-time, population surveillance and case-review data are needed to support nurses and physicians, public
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C 2012 AWHONN, the Association of Women’s Health, Obsteric and Neonatal Nurses
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Obstetric hemorrhage-related mortality is amenable to change: 54% to 93% of the deaths reviewed were deemed preventable.
preventable and why. For example, timely and accurate data are needed to assess why the percentage of hemorrhage-related deaths decreased compared to other causes of death and whether the increased percentage in maternal deaths due to cardiovascular conditions reflect better case ascertainment of cardiovascular deaths or an actual increase in the number of cardiovascular deaths. Maternal deaths in the United States are still quite rare and likely represent only the “tip of the iceberg” of the impact of obstetric hemorrhage. According to the best estimates available, 2.9% of all births are complicated by hemorrhage (Bateman, Berman, Riley, & Leffert, 2010; Callaghan et al., 2010). Based on the data analysis of Callaghan et al., 2.9% of births translate into 124,708 women who suffered a postpartum hemorrhage in 2006. The findings of Bateman et al. are consistent with those of Callaghan et al. and demonstrated that the number of women giving birth in the United States experiencing hemorrhage increased 27.5% from 1995 to 2004. Assuming consistency of data limitations and coding practices between 1995 and 2004, these findings demonstrated that uterine atony was the leading cause of the 27.5% increase in postpartum hemorrhage despite the fact that the number of women with recorded risk factors had not changed (Bateman et al., 2010). Because maternal risks remained statistically similar between 1995 and 2004, these findings raise the question: What changed to increase the rate of uterine atony that has contributed to the increased rate of postpartum hemorrhage? The answer to this question is likely multifaceted. Part of the answer may be that the administrative data used by Bateman et al. did not include maternal characteristics, such as obesity, that affect rates of uterine atony or take into account that coding practices may have changed to better identify maternal hemorrhage. In addition, these data did not include information on the changes in clinical practices that are known to expose more women to higher rates of uterine atony, such as increased rates of oxytocin induction (indicated and not medically indicated induction). When Callaghan et al. analyzed the causes of the increase in postpartum hemorrhage in 1994 com-
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pared to 2006, they too found that the percentage of women with uterine atony increased significantly (p < .001) from 1.6% (58,597 women) to 2.4% (99,904 women) (Callaghan et al., 2010). They described differences in the characteristics of the women. The women giving birth in 2006 were older, more often using government insurance, having more cesareans, fewer vaginal births after previous cesareans, more inductions of labor, more multiple gestations, and more medical comorbidities such as diabetes and hypertension. However, the prevalence of postpartum hemorrhage (PPH) risk factors did not explain the increase (Callaghan et al.). Labor induction, regardless of the mode of birth, was found to have the strongest correlation to the overall 50% increase in uterine atony. Also, the method by which the woman gave birth was correlated to PPH. The women at the greatest overall risk for PPH were those who had a vaginal birth and an induction of labor. However, in 2005 and 2006 the percent of uterine atony for women who gave birth by cesarean compared to vaginal birth was essentially the same. It is interesting to note that Bateman et al. (2010) found that higher rates of cesarean with and without labor were a risk factor for hemorrhage. This finding may be explained by the fact that women who have an induction of labor also have been shown to be twice as likely to have a cesarean (Zhang et al., 2010). Callaghan et al. (2010) found that women whose labor was induced had the highest risk of postpartum hemorrhage caused by uterine atony regardless of whether they give birth surgically or vaginally. Other causes of obstetric hemorrhage are placenta accreta, increta, percreta, and previa (Tadesse et al., 2011). If a woman has a placenta that invades her uterine muscle or other internal organs such as her bowels and bladder, she will most likely experience extensive bleeding and most likely need a hysterectomy immediately after she gives birth (Knight, Kurinczuk, Spark, & Brocklehurst, 2008; Stivanello et al., 2010). The connection between a surgical birth in a prior pregnancy and the presence of a placenta implantation abnormality in a subsequent pregnancy has been well established (Belfort, 2010; Clark, Koonings, & Phelan, 1985). Women with a placenta previa, a placenta partially or completely covering the cervix, are also at great risk for bleeding and may need to spend weeks in the hospital to reduce the associated perinatal morbidity and mortality risks. The emotional and financial toll on the mother and
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her family are obvious, and the costs to society are great. For example, if the infant is born prematurely, even by a few weeks, the infant has increased morbidity and mortality, such as difficulty feeding, recurrent respiratory illnesses, asthma, and so on (Tita et al., 2011). Women also experience short- and long-term morbidity, such as a greater risk of a deep vein thrombosis (from bed rest and surgery) and the strong possibility that they will experience a massive hemorrhage severe enough to require peripartum hysterectomy (Pacheco & Gei, 2011). The fact that more than one third of the women who give birth in the United States undergo major surgery, and many women do not have the option to attempt a vaginal birth after cesarean (resulting in an overuse of cesarean) means more women are suffering preventable harm. Of the lowrisk women who gave birth in 2007 and had also previously given birth surgically, 90.8% had a cesarean (Centers for Disease Control and Prevention [CDC], 2007).
Prevention of Obstetric Hemorrhage Mortality In 2005, researchers in conjunction with the North Carolina Maternal Mortality Review Committee determined that 93% of obstetric hemorrhagerelated deaths in North Carolina that occurred between 1995 and 1999 were preventable (Berg et al., 2005). In another study published in 2011, an interdisciplinary expert panel reported the results of a retrospective chart review of the obstetric hemorrhage maternal mortality and morbidity in 11 hospitals in Illinois; they found that 54% of the mortality and morbidity were preventable (Della Torre et al., 2011). State Department of Health communications and maternal mortality reports indicate that women do not have consistent access to what are known to be effective treatments for obstetric hemorrhage. For example, the New York State Department of Health (NYSDH) issued two separate health advisories. The 2004 alert sent to clinicians and hospital administrators stated that most of the women who died from obstetric hemorrhage in New York State were hospitalized at the time of death (NYSDH, 2004). The 2009 alert showed that despite the prior health advisory, the ratio of maternal deaths in New York State increased from 15.9/100,000 live births to 20.5/100,000 lives births (NYSDH, 2009). The 2009 alert stated that “generally hemorrhage is a preventable cause
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Data have demonstrated that 2.9% of all births were complicated by obstetric hemorrhage and that uterine atony was the leading etiology. of mortality” (NYSDH, 2009, p. 1). The 2004 health advisory recommended some basic solutions for hospital leaders to reduce these higherthan-expected ratios of deaths in New York State: creation of effective protocols, prompt recognition of the gravity of the situation, and prompt response from an interdisciplinary team to treat the hemorrhage. The 2009 alert reiterated some of these same recommendations but added the recommendations that there be a prenatal risk assessment and that teams perform hemorrhage drills. Currently no data are available to show the number of hospitals in New York State that have heeded these health advisory recommendations. In addition, no data are available to indicate how many hospitals in the United States have protocols and run hemorrhage drills. The 2002–2003 Pregnancy-Associated Mortality Review report of the CDPH (2011) stated that 70% of the obstetric hemorrhage-related deaths reviewed had a strong or good chance of being prevented. In 2008, one year after the mortality reviews began, the California Maternal Quality Care Collaborative (CMQCC) performed a baseline survey of hemorrhage practices in California hospitals to serve as an adjunct to the mortality review data (Bingham et al., 2010). Out of 261 hospitals, 173 (66%) responded to the survey. Of the 173 hospitals that participated, 40% reported that they did not have any hemorrhage protocol, and 70% reported that they did not perform drills and if they did run drills the physicians did not regularly participate. In addition, although most hospitals reported access to uterotonics (oxytocin and methergine), some hospitals reported that they did not have access to alternative treatment methods, for example, intrauterine balloon catheters or clinicians skilled in B-Lynch suture techniques. The survey asked how hemorrhage was defined at these hospitals. Although most of the hospitals defined hemorrhage during cesarean as the standard of greater than 1000 milliliters of blood loss, some hospitals’ definitions varied from this standard. The California statewide survey of clinical practices was one of the sources of data used by the leaders at CMQCC to determine the most effective next steps for reducing preventable hemorrhage-related maternal mortality and morbidity in the state of California (Bingham, Lyndon, Lagrew, & Main, 2011).
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More than a half-century of data show African American women who give birth in the United States are 3 to 4 times more likely to die during childbirth than women of all other races and ethnicities (Berg, Chang, Callaghan, & Whitehead, 2003; CDPH, 2011). It is not well understood why Hispanic and Asian maternal mortality ratios, for example, are similar to those of White women, and Black maternal mortality ratios are worse. It is also beyond the scope of this article to explore this racial disparity in detail. However, a provocative study published by Tucker, Berg, Callaghan, and Hsia (2007) is worthy of mention. When comparing hemorrhage deaths, the authors reviewed 3,318 hospital discharge records from years 1988–1999 and found that Black women did not have a statistically significant higher prevalence of hemorrhage than White women, but Black women did have higher risk of death when hemorrhage occurred. To calculate whether there was a difference in case fatality rates, Tucker et al. used data from the Pregnancy Mortality Surveillance System. For the years 1988–1999, Black women had a pregnancyrelated mortality ratio (PRMR) of 0.976 deaths per 100,000 live births compared to White women who had 0.397 deaths per 100,000 live births. These facts indicate that more White women died of obstetric hemorrhage than Black women, but Black women had PRMRs that were 2.5 times higher than those for the White women who died from a postpartum hemorrhage. More data are needed to explain why the researchers found the 2.5 times higher hemorrhage-related case fatality rate among Black women compared to White women, even though no statistically significant differences in the rates of hemorrhage were found. Current data would particularly be helpful because hemorrhage rates have increased. Regardless of these data limitations, the Tucker et al. (2007) study suggests that the disparity in Black maternal mortality may be highly amenable to change. Until more data are available, working to eliminate all variation in access to effective hemorrhage treatments, regardless of the woman’s race or ethnicity, is a logical next step. Postpartum hemorrhages are also likely to be preventable if changes in clinical practices occur. For example, in the United States cesareans are overused. Unless women decide to have fewer children, or clinicians decrease the primary cesarean rate, or insurance companies, hospitals, and providers increase the access for women to vaginal birth after cesarean, the rates of obstetric hemorrhages related to placenta abnormal im-
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plantation will likely increase. Subsequently, the number of women who will require a peripartum hysterectomy to prevent death resulting from hemorrhage will also increase (Knight et al., 2008; Plante, 2006). Eliminating nonmedically indicated inductions for labor is also likely to reduce the number of women who experience uterine atony (Callaghan et al. 2010). Although we cannot know an exact number of obstetric hemorrhage deaths and injuries that could have been prevented, the timely development and implementation of initiatives to ensure that all women, regardless of their race or ethnicity, have equal access to what are known to be highly effective and relatively inexpensive treatments are needed. Using a quality improvement approach based on the best available evidence, a plan could be formulated that includes gathering postpartum hemorrhage data and evaluating the effectiveness of the plan based on process and outcome data. Developing and implementing hospital-based, state-based, and national quality improvement initiatives now will likely reduce hemorrhage-related deaths and injuries in the future.
Data Limitations Accurate and timely data are needed to guide leaders’ quality improvement initiatives. Currently in the United States, data are limited by a number of factors: variation in the definition of hemorrhage, variation and limitations in coding practices, lack of timely aggregate data, and lack of data on clinical practices. Data limitations leave nurses, physicians, public health leaders, public policy leaders, women, families, patient advocates, and countless others wondering how to determine the full scope of the problem and how to implement the most effective next steps. The most fundamental data limitation is the variation in how clinicians define hemorrhage. For example, some define hemorrhage solely as the amount of blood lost, whereas others define it as blood loss in relation to mode of delivery (Bingham et al., 2011). The lack of a standard definition is compounded by the fact that it is well known that clinicians do not accurately estimate blood loss (Dildy, Paine, George, & Velasco, 2004). A second limitation is variation and limitations in coding practices (Atrash, Alexander, & Berg, 1995; Bateman et al., 2010; Lu et al., 2005). Some of the coding limitations are due to the variation in how hemorrhage is defined. For example, in the same situation and based on personal definitions of hemorrhage, one
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clinician may chart obstetric hemorrhage whereas a different clinician may not. Other coding limitations occur when coders interpret the hemorrhage codes and hospital-based billing practices in different ways. Last, coding is limited by the ability to discriminate between various types of obstetric hemorrhage etiology and severity. A third limitation is that maternal hemorrhage data are not always available in a timely manner. Actual rates of births complicated by hemorrhage are difficult to track and respond to because of a multiyear gap between when the events occurred and when the studies are published. For example, it is not unusual for it to take researchers four years to publish their data on births complicated by postpartum hemorrhage (Callaghan et al., 2010). Because of this substantial delay, leaders and clinicians do not have the data necessary to track the effect of clinical practice on health outcomes. Finally, data on actual hemorrhage-related practices are limited, including the number of hospitals where clinicians quantify blood loss rather than estimate blood loss, the number of hospitals that routinely perform hemorrhage drills, the number of clinicians who are trained to perform BLynch suturing or intrauterine tapenade, and how often these procedures are performed. Lack of data about clinical practices makes it impossible to determine whether women received timely administration of efficacious treatments consistently. Obstetric hemorrhage-related national quality measures to track data on processes that affect outcomes are needed.
Limitations of Maternal Morbidity and Mortality Data at State and National Levels Currently only 21 states perform maternal mortality reviews (Amnesty International, 2010) despite the fact that mortality review data offer essential surveillance and population information on the contribution of obstetric hemorrhagerelated deaths to overall maternal mortality ratios. The United Kingdom has demonstrated the commitment to review maternal deaths for several decades and develop targeted strategies based on lessons learned from these reviews. Therefore, the United Kingdom has maintained one of the lowest maternal mortality ratios in the world and has shown the ability to consistently decrease maternal death to birth ratios (Cantwell et al., 2011). Indeed, mortality and morbidity data limitations
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The efforts of nurse leaders, researchers, and reviewers are essential for the United States to eliminate preventable, obstetric hemorrhage-related mortality and morbidity.
constrain our ability to address why in 2000 the United States ranked 30th in the world for maternal mortality but (Tucker et al., 2007) currently ranks 50th (World Health Organization, 2010). In addition, lack of data limits our ability to suggest why the ratio of maternal deaths to live births began to increase in 2000 and has nearly doubled, with ratios between 12 and 15 per 100,000 live births (MacKay et al., 2011; U.S. Department of Health and Human Services, 2009). Last, no data exist to explain the wide variations in state maternal mortality ratios. For example, five states (Maine, Vermont, Massachusetts, Indiana, and Minnesota) have maternal mortality ratios between 1.2 to 3.7 deaths per 100,000 live births (Amnesty International). Yet in Georgia the ratio is reported to be 20.5 maternal deaths per 100,000 live births, and in the District of Columbia the ratio is 34.9 per 100,000 (Amnesty International). An additional benefit of performing reviews is to determine what data were miscoded, because miscoded data makes it difficult to interpret and act on national and state maternal mortality surveillance statistics. For example, the California Pregnancy-Association Mortality Review committee found that even basic data on cause of death and whether a death was pregnancy-related (aggravated or caused by the pregnancy) or not were not always accurately coded (CDPH, 2011). The miscoding resulted in over- and underreporting of whether a death was pregnancy related. Overall, approximately 24% of the 2002 to 2003 cases reviewed in California that were ultimately determined to be pregnancy-related deaths had originally been miscoded as nonpregnancy-related deaths. The findings in California are not atypical, and there has been some progress toward improving coding practices, such as the addition of a pregnancy check-box to death certificates (MacKay et al., 2011). However, it is important to note that the number of obstetric hemorrhage-coded causes of death in California remained consistent prior to and after review. A lack of consistency also occurs in how deaths are reviewed. Currently, very few recommendations exist on review methodology, which cases to review, and the data specifications for data
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extraction and analysis (Berg, Danel, Atrash, Zane, & Bartlett, 2001). Lack of a consistent data review methodology limits the ability to gather, review, and publish data nationally and to make state-by-state comparisons. Although it took decades to develop, the systematic approach now used by the Fetal Infant Mortality Review (FIMR) is recognized as a valuable, coordinated, and collaborative approach (Hutchins, Grason, & Handler, 2004). Given the limited resources available and lessons learned from the FIMR, national organizations such as Association of Women’s Health, Obstetrics, Neonatal Nursing (AWHONN), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse Midwives (ACNM) should be active equal participants in the development of review standards including each of their unique professional perspectives.
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Limited Data on Maternal Morbidity Maternal deaths in the United States are rare or sentinel events. Thus, a more robust maternal morbidity data surveillance system is needed. The morbidity surveillance system would be most useful if it captured data on the prevalence of specific types of obstetric conditions, such as obstetric hemorrhage and peripartum hysterectomy and published these data more frequently than current studies are published.
Clinical Implications
When reviews do occur, the results are not always published in a timely, predictable manner. The United Kingdom Confidential Inquiry can serve as a useful model because the review of data is confidential, but the data are published every 3 years. During the 3-year cycle, there is flexibility to adjust some of the review methods, but there are also data that are consistently shared and trended over time. The United Kingdom does not experience the same delays as the United States in disseminating maternal mortality findings to clinicians and to the public. Indeed, health professions in the United States must insist on enhanced transparency in how these reviews are conducted as well as standard methods and standard deadlines for publication of data.
The Institute of Medicine (2001) estimated that it takes approximately 17 years to transform research into clinical practice. In the case of obstetric hemorrhage, the lag time has been much longer. In 2011, the results of phone interviews conducted by department of health leaders indicated that at least seven states (California, Delaware, Florida, Illinois, Massachusetts, New Mexico, and New York) reported obstetric hemorrhage as a priority for action in their states. In California, the state-based maternal death reviews are directly linked to an interdisciplinary maternal quality improvement collaborative so that the lessons learned from the mortality reviews are incorporated into quality improvement initiatives (Bingham et al., 2011). As indicated by Bingham et al., the hard work at the patient and clinician transaction level requires dedicated nursing leadership and intraprofessional teamwork. It is too early to determine how effective statewide efforts will be or whether they could be more effective if they were connected nationally.
Reviews are also likely to be more effective if the reviewers are linked with standard-setting professional organizations. For example, if each review team had one official representative from AWHONN, the ability to more rapidly translate review findings into action at lower cost would increase because AWHONN currently publishes books and journals, develops position statements and evidence-based guidelines, and organizes national and state conferences to improve outcomes. Reviewers would benefit from additional opportunities to collaborate with other experts in their professional disciplines. Reviewers linked to a professional organization such as AWHONN are more likely to be aware of national nursing standards. Currently, only California’s Maternal Mortality Review Committee has requested an official AWHONN representative to serve on its committee.
The strategies and interventions developed to improve outcomes will be more effective if they are tailored to the different causes or types of obstetric hemorrhage (Bingham & Main, 2010). Thus, understanding the etiology of the hemorrhage and tracking data based on etiology are important to determine solutions. For example, postpartum hemorrhage (a subset of obstetric hemorrhage) is not a diagnosis of an actual disease state (Callaghan et al., 2010). Postpartum hemorrhage is caused by one or more of several types of situations, such as poor uterine tone or uterine atony, retained placental tissue, abnormal placenta implantation, genital tract trauma, or coagulation abnormalities. Understanding the underlying etiology of the hemorrhage is crucial for the data collection that guides quality improvement implementation efforts.
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A shift in research priorities, or at least a recognition and allocation of resources to support implementation science research for situations such as obstetric hemorrhage, is needed if the United States is going to ensure that all women, regardless of race, ethnicity, or economic status, receive basic, evidence-based, effective treatments. Resources are needed to track current clinician practice and interventions implemented in clinical practice to improve outcomes. Nurses are often the leaders of the implementation initiatives to eliminate obstetric-related preventable mortality and morbidity. For example, nurses lead practice change in health care systems by bringing together multiple providers and disciplines to collaborate on improving patient outcomes. These efforts may be coordinating changes in the electronic medical records and order sets, ensuring necessary supplies are available at the bedside, or identifying variations in practice and opportunities for communication and operational improvements. For nurses to be effective leaders and patient advocates, they need resources, implementation tools, and data to understand the extent of the problem, recognize the cause of maternal death, and be involved and included actively at the hospital, community, state, and national level. Nurses must be included on hospital committees and at the state and national level as key collaborators with providers such as midwives, nurse practitioners, and physicians to develop evidence-based protocols and to lead activities such as improving team functioning. The recommendations for action are summarized in Table 1.
Conclusion The fact that obstetric hemorrhage is the leading cause of maternal mortality in the United States is troubling given the fact that the United States spends more on health care than any other country (17.4% of gross domestic product compared to the next highest country that spends 12%) and that known, effective treatments are not being performed consistently (Bingham & Main, 2010; Organization for Economic Co-operation and Development, 2011). Access to timely data, adoption and use of consistent definitions, consistent coding practices, improved discrete codes, data on clinical practices, and more robust mortality and morbidity surveillance and reviews are all needed to guide and evaluate system-wide changes. Without timely
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Table 1: Recommendations for Preventing Mortality and Morbidity Related to Maternal Hemorrhage 1 Standardize hemorrhage definitions 2 Standardize coding practices 3 Track clinician’s hemorrhage-related knowledge, attitudes, and practices 4 Track morbidity data 5 Decrease the time it takes to make data available 6 Review all hemorrhage-related maternal deaths 7 Standardize state review and data analysis methodologies to identify professional specific improvement opportunities that can be tracked nationally 8 Disseminate review data more frequently and on a regular schedule 9 Disseminate review data more effectively, e.g., connect review efforts to national professional organizations 10 Implement quality improvement initiatives
and detailed feedback, nurses, physicians, public health leaders, and others will have limited knowledge of how their care affects outcomes and whether implementation efforts have been effective at improving outcomes. Women who die from obstetric hemorrhage must be honored by ensuring that their deaths will be counted and reviewed accurately and that lessons learned will prevent injury and the possibly of other deaths. One strategy to improve maternal outcomes is to implement obstetric hemorrhage-related quality improvement initiatives to ensure that all women, regardless of their race or ethnicity, have equal access to what are known to be highly effective and relatively inexpensive treatments. Nurse involvement is a key step toward ensuring that the quality improvement initiatives are effective, because much of the care provided to women is delivered by nurses. Nurses are readily at the bedside and are often the first provider responsible for assessing and responding to a maternal hemorrhage and determining which members of the team need to be mobilized. Nurses are ideally qualified to evaluate and identify practice solutions to improve maternal outcomes. Nursing involvement, nursing scrutiny, and nursing scholarship are necessary for the United States to eliminate preventable death and injury related to obstetric hemorrhage.
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Maternal Death from Obstetric Hemorrhage
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