Sentinel Event Alert: Maternal Mortality

The Joint Commission, the organization that accredits and certifies more than 17,000 health care organizations and programs in the United States, has issued a Sentinel Event Alert focused on Preventing Maternal Death. Joint Commission accreditation and certification is recognized nationwide as proof of a health care facility's adherence to certain performance standards. More importantly, its accreditation has become a condition of licensure, and subsequently, of Medicaid reimbursement.

Here are some highlights from the Alert:

Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S., despite the rarity of the incidence of maternal death – deaths that occur within 42 days of birth or termination of pregnancy. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in 2004, 2005 and 2006. According to the National Center for Health Statistics of the Centers for Disease Control and Prevention, in 2006, the national maternal mortality rate was 13.3 deaths per 100,000 live births.

"There clearly has been no decrease in maternal mortality in recent years, and we are not moving toward the U.S. government’s Healthy People 2010 target of no more than 3.3 maternal deaths per 100,000 live births,” says William M. Callaghan, M.D., M.P.H., senior scientist, Division of Reproductive Health, Centers for Disease Control and Prevention.

The leading causes of maternal death are: hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease). (Research) also indicated a four-fold increased risk of pregnancy-related death for black women, and increased risks for older women and women with no prenatal care. The numbers of deaths related to hemorrhage are declining, while deaths attributable to other medical conditions – including cardiovascular, pulmonary and neurologic problems – have significantly increased.

Several studies determined that from 28 to 50 percent of maternal deaths were preventable. In 2008, Hospital Corporation of America (HCA) looked at individual causes of maternal deaths among 1.5 million births within 124 hospitals in the previous six years. According to the HCA study, the most common preventable errors are:

-Failure to adequately control blood pressure in hypertensive women
-Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia
-Failure to pay attention to vital signs following Cesarean section
-Hemorrhage following Cesarean section

“Pregnancy is a known major risk factor for venous thrombosis and pulmonary embolism. HCA now advocates for the universal use of pneumatic compression devices for all pregnant women undergoing Cesarean section.” Unlike nearly all other adult patients undergoing major surgery, pregnant women undergoing Cesarean delivery have traditionally not received prophylactic measures for the prevention of venous thromboembolism afforded similar surgical patients who lack this risk factor.

Each case of maternal death needs to be identified, reviewed, and reported in order to develop effective strategies for preventing pregnancy-related mortality and severe morbidity. To this end, The Joint Commission encourages participation by hospital physicians, including obstetrician-gynecologists, in state-level maternal mortality review and collaboration with such review committees in sharing data and records needed for review. The following suggested actions can help hospitals and providers prevent maternal death:

1.Educate physicians and other clinicians who care for women with underlying medical conditions about the additional risks that could be imposed if pregnancy were added; how to discuss these risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual care and counseling. Communicate identified pregnancy risks to all members of the health care delivery team.

2.Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care.

3.Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.

Additional suggested actions for hospitals and providers to take for patients identified as high-risk (for example, those with pre-existing medical conditions such as hypertension, diabetes, morbid obesity):

4.Refer high-risk patients to the care of experienced prenatal care providers with access to a broad range of specialized services.

5.Make pneumatic compression devices available for patients undergoing Cesarean section who are at high risk for pulmonary embolism.

6.Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin for postpartum care.

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This is a huge step in the right direction. However, two of the four main preventable causes of maternal death result from cesarean sections. In light of research showing the correlation of elective cesareans to increased maternal death, what seems glaringly missing from the Joint Commission's suggested course of action is a campaign to educate patients (and physicians!) on the risks of elective cesarean section surgery. Instead of education, the Joint Commission suggests the universal use of pneumatic compression devices and prophylactic embolism prevention for women who undergo c-section surgery.

Dr. Steven Clark, medical director for women and newborn services for HCA, says in the Alert that "the only cause of maternal death amendable to nationwide systematic prevention efforts is pulmonary embolism." I urge Dr. Clark to take this statement further. Any maternal death that resulted from an unnecessary intervention or surgery was preventable. Proper nationwide systematic prevention efforts MUST include universal prenatal education about risks of and treatment following obstetric interventions.