rate in the United States, according to a new perspective from leading obstetricians published in the New England Journal of Medicine.
The authors, including Kimberlee McKay, MD, president of the American College of Obstetricians and Gynecologists (ACOG), also call for collaboration with family physicians to increase access to obstetric care in rural areas.
The president of the American Academy of Family Physicians (AAFP), John S. Cullen, MD, in a separate statement, welcomed the opportunity for collaboration in addressing the maternal mortality crisis. However, some distance still lies between the finer points of how the two organizations see family physicians helping curb the crisis.
“Women in the United States are more likely to die from childbirth- or pregnancy-related causes than women in any other high-income country, and black women die at a rate three to four times that of white women,” noted Susan Mann, MD, along with her coauthors of the obstetric perspective, calling increasing maternal mortality a “tragedy.”
In an interview, Dr. Cullen concurred, calling the current situation “unconscionable.” One of the primary reasons he sought AAFP leadership, he said, was to bring experiences learned during his 25 years of obstetric practice in rural Alaska to bear on the current crisis.
A set of maternal care bundles created by the Alliance for Innovation on Maternal Health (AIM) provides the framework for the first action recommended by Dr. Mann and her coauthors. The AIM bundles focus on protocols that improve readiness, recognition, response, and reporting in maternal care. The protocols are institution specific. For example, the authors noted, antihypertensive medications should be readily available around the clock, because not all facilities will have a pharmacist in-house at all times, and hypertensive emergencies are among the gravest obstetric complications.
“Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7,” said Dr. Mann, a physician in private practice in Boston, and her coauthors.
Dr. Susan Mann
The second recommended action revolves around multidisciplinary staff meetings to perform individual assessments for each woman’s obstetric risk factors. These huddles should include assessing hemorrhage risk by using the California Maternal Quality Care Collaborative guidelines, and briefings with the full care team to “develop shared understandings of the patient and the procedure” before elective or nonurgent cesarean deliveries, said Dr. Mann and her colleagues. Patients should be informed of any safety concerns, and caregivers should use shared decision-making moving forward.
“Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services,” Dr. Mann and her coauthors noted.
Third, simulation of obstetric emergencies lets all members of the team understand the speed at which decisions must be made and actions taken when minutes, or even seconds, count. Dr. Mann and her coauthors pointed out that logistics problems come out during a well-run simulation, giving such examples as a lag in receiving blood products or a poorly placed hemorrhage cart.
Drawing an analogy to the extensive time pilots spend in flight simulators, Dr. Mann and her coauthors noted that “because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events.”