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Modri S, Sharma M, Quigley E, Anca R, O'Hanlon B, Pyle E, Hussey A, Hamm R, Nagpal M, Trout KK. Code Crimson: A Postpartum Hemorrhage Bundled Intervention Quality Improvement Project. J Nurs Care Qual 2024; 39:286-292. [PMID: 38747711 DOI: 10.1097/ncq.0000000000000771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is a leading cause of maternity mortality in the United States. The Code Crimson project aimed to enhance PPH management by implementing a standardized intervention bundle to mitigate morbidity and mortality associated with PPH. LOCAL PROBLEM At a large Philadelphia tertiary hospital, health disparities existed for severe maternal morbidity and mortality, and PPH was a significant factor. METHODS A quality improvement design, using Plan-Do-Study-Act cycles and interrupted time series analysis, was undertaken. INTERVENTIONS The Code Crimson project implemented a standardized bundle to manage PPH, including blood product administration and massive transfusion protocol activation. RESULTS After implementing the Code Crimson bundle, there was a significant decrease in blood product use ( P < .001), with minor reductions in packed red blood cell administration over 4 units and mean blood loss. CONCLUSIONS The Code Crimson bundle effectively reduced blood product utilization for PPH treatment.
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Affiliation(s)
- Stefanie Modri
- Author Affiliations: Family and Community Health Department (Mrs. Modri), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania Pre-Health Post-Baccalaureate Program (Ms Sharma), University of Pennsylvania, Philadelphia, Pennsylvania Nursing Department (Mrs. Quigley), Labor and Delivery Unit (Mrs. Anca and Mrs. O'Hanlon), Mother-Baby Unit (Miss. Pyle and Mrs. Hussey), Women's Services Department (Dr. Hamm), Pennsylvania Hospital, Philadelphia, Pennsylvania University of Michigan Medical School (Ms Mohika), Ann Arbor, Michigan, Nursing Department (Dr Trout), Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania
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Mehta A, Spitz J, Sharma S, Bonomo J, Brewer LC, Mehta LS, Sharma G. Addressing Social Determinants of Health in Maternal Cardiovascular Health. Can J Cardiol 2024; 40:1031-1042. [PMID: 38387722 DOI: 10.1016/j.cjca.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.
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Affiliation(s)
- Adhya Mehta
- Department of Internal Medicine, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, New York, USA
| | - Jared Spitz
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA
| | - Sneha Sharma
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jason Bonomo
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA
| | - LaPrincess C Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Laxmi S Mehta
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Garima Sharma
- Department of Cardiovascular Medicine, Inova Health System, Falls Church, Virginia, USA.
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Hussein AM, Jauniaux E, Milani Coutinho C, Rijken M. Management of placenta accreta spectrum in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102475. [PMID: 38452606 DOI: 10.1016/j.bpobgyn.2024.102475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Fundación Valle Del Lili, Departamento de Ginecología y Obstetricia, Cra 98 No. 18 - 49, Cali, 760032, Colombia; Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands.
| | | | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt; Faculty of Medicine, Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, WC1E 6AU, UK
| | - Conrado Milani Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14040-900, SP, Brazil
| | - Marcus Rijken
- Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands; Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, 3584, the Netherlands; Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
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Bonnet MP, de Vries PLM, Levet S, Saucedo M, Morau E, Dreyfus M, Goffinet F, Deneux-Tharaux C. Trends in Maternal Mortality From Obstetric Hemorrhage in France: 15 Years of Confidential Enquiry Into Maternal Deaths. Anesth Analg 2024:00000539-990000000-00822. [PMID: 38781094 DOI: 10.1213/ane.0000000000006864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. METHODS Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. RESULTS The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. CONCLUSIONS Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.
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Affiliation(s)
- Marie-Pierre Bonnet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Anesthesia and Critical Care, Armand-Trousseau Hospital, Sorbonne Université, Paris, France
| | - Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Solène Levet
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Monica Saucedo
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
| | - Estelle Morau
- Department of Anesthesia and Critical Care, Nîmes University Hospital, Nîmes, France
| | - Michel Dreyfus
- Department of Gynecology and Obstetrics, Caen University Hospital, Caen, France
| | - François Goffinet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Catherine Deneux-Tharaux
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
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Meeks M, Voegtline K, Vaught AJ, Lawson SM. Differences in Surgery Classification and Indications for Peripartum Hysterectomy at a Major Academic Institution. Am J Perinatol 2024; 41:e623-e629. [PMID: 36307089 DOI: 10.1055/s-0042-1757276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Peripartum hysterectomy is associated with increased morbidity and mortality relative to elective gynecologic hysterectomy and its incidence has grown with the rising cesarean delivery rate. We sought to understand indications and perioperative outcomes for peripartum hysterectomy at our academic institution and to evaluate differences among racial/ethnic groups. STUDY DESIGN We performed a retrospective chart review of women at a tertiary care center who underwent delivery of a newborn and had a peripartum hysterectomy during the same admission between 2008 and 2018. Demographic, clinical, and socioeconomic characteristics of patients were compared with respect to patient's race/ethnic group. RESULTS A total of 112 hysterectomies were included in our study. White women undergoing peripartum hysterectomy were more likely to have had an elective/anticipated peripartum hysterectomy (vs. a nonelective/emergent peripartum hysterectomy) than Black women. There were racial differences detected in the indication for peripartum hysterectomy; White women were more likely to have abnormal placentation (75 vs. 54% in Black women, p = 0.036), whereas Black women were more likely to present with postpartum hemorrhage (27 vs. 2%, p = 0.002). Black women were also more likely to undergo reoperation after peripartum hysterectomy (15 vs. 2% in White women, p = 0.048). There were no differences in any other perioperative outcomes including blood transfusion, accidental laceration, and 30-day readmission. CONCLUSION Differences exist among elective versus nonelective peripartum hysterectomy by race/ethnicity and in indications for peripartum hysterectomy by race/ethnicity. Further investigation should be performed to determine whether the differences identified are due to disparate management of atony/postpartum hemorrhage or inequitable referral patterns for suspected abnormal placentation by race/ethnicity. KEY POINTS · White patients were more likely to have an elective hysterectomy when compared with Black women.. · Abnormal placentation was the indication more often for White patients; hemorrhage for Black ones.. · Black patients were likely to be nulliparous or at greater gestational age at the time of hysterectomy..
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Affiliation(s)
- Monica Meeks
- Department of Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Kristin Voegtline
- Department of Pediatrics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Arthur J Vaught
- Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland
| | - Shari M Lawson
- Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland
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Bruce KE, Desai S, Reilly K, Keil A, Swanson M, Cobb B, Zahn K, McKenzie C, Coviello E, Mallampati D, Tully KP, Kolarczyk L, Maaske S, Quist-Nelson J. Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study. Am J Perinatol 2024. [PMID: 38452794 DOI: 10.1055/a-2282-8923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..
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Affiliation(s)
- Katharine E Bruce
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Shivani Desai
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly Reilly
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Arianna Keil
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Michelle Swanson
- Department of Women's Services, University of North Carolina Health, Chapel Hill, NC
| | - Benjamin Cobb
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katelin Zahn
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Christine McKenzie
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth Coviello
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA
| | - Kristin P Tully
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shannon Maaske
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
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Vanderlaan J, Shen JJ, McDonough IK. Validation of a measure of hospital maternal level of care for the United States. BMC Health Serv Res 2024; 24:286. [PMID: 38443900 PMCID: PMC10916325 DOI: 10.1186/s12913-024-10754-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/19/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Lack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers. METHODS This was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method. RESULTS The sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%-58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% - 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%). CONCLUSIONS This method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.
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Affiliation(s)
- Jennifer Vanderlaan
- University of Nevada Las Vegas School of Nursing, 4505 S. Maryland Parkway, Box 453018, Las Vegas, Nevada, 89154, USA.
| | - Jay J Shen
- School of Public Health, Center for Health Disparities and Research, University of Nevada Las Vegas, 4700 S. Maryland Parkway Suite #335, Las Vegas, Nevada, 89154, USA
| | - Ian K McDonough
- Department of Economics, Lee Business School, University of Nevada Las Vegas, 4505 S. Maryland Parkway, Box 6005, Las Vegas, Nevada, 89154, USA
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Escobar MF, Echavarría MP, Carvajal JA, Lesmes MC, Porras AM, Mesa V, Ávila-Sánchez FA, Gallego JC, Riascos NC, Hurtado D, Fernández PA, Posada L, Hernández AM, Ramos I, Irurita MI, Loaiza JS, Echeverri D, Gonzalez L, Peña-Zárate EE, Libreros-Peña L, Galindo JS, Granados M. Hospital padrino: a collaborative strategy model to tackle maternal mortality: a mixed methods study in a middle-income region. LANCET REGIONAL HEALTH. AMERICAS 2024; 31:100705. [PMID: 38445021 PMCID: PMC10912672 DOI: 10.1016/j.lana.2024.100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/07/2024]
Abstract
Background Reducing maternal mortality ratio (MMR) remains a paramount goal for low- and middle-income countries (LMICs), especially after COVID-19's devastating impact on maternal health indicators. We describe our experience implementing the Hospital Padrino Strategy (HPS), a collaborative model between a high-complexity hospital (Fundación Valle del Lili) and 43 medium- and low-complexity hospitals in one Colombian department (an administrative and territorial division) from 2021 to 2022, to sustain the trend towards reducing MMR. The study aimed to assess the effects of implementing HPS on both hospital performance and maternal health indicators in Valle del Cauca department (VCD). Methods A mixed-methods study was conducted, comprising two phases. In the first phase, we investigated a cohort of hospitals through prospective follow-up to assess the outcomes of HPS implementation on hospital performance and maternal health indicators in VCD. In the second phase, qualitative data were collected through focus groups with 131 health workers from 33 hospitals to explore the implications of the HPS implementation on healthcare personnel. All data were obtained from records within the HPS implementation and from the Health Secretary of VCD. Findings Evidence shows that in the context of HPS, 51 workshops involved 980 healthcare workers, covering the entire territory. Substantial improvements were observed in hospital conditions and healthcare personnel's technical competencies when providing obstetric care. Seven hundred eighty-five pregnant women with obstetric or perinatal emergencies received care through telehealth systems, with a progressive increase in technology adoption. Nine percent required Intensive Care Unit (ICU) admission, and none died. The MMR decreased from 78.8 in 2021 to 12.0 cases per 100,000 live births by 2022. Improvements in indicators and conducted training sessions instilled confidence and empowerment among the healthcare teams in the sponsored hospitals, as evidenced in focus groups derived from a sample of 131 healthcare workers from 33 hospitals. Interpretation Implementing the Hospital Padrino Strategy led to a significant MMR reduction, and consolidated a model of social healthcare innovation replicable in LMICs. Funding The Hospital Padrino Strategy was funded by the Fundación Valle del Lili and the Health Secretary of Valle del Cauca. Furthermore, this study received funding from a general grant for research from Tecnoquimicas S.A.
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Affiliation(s)
- María Fernanda Escobar
- Unidad de Equidad Global en Salud, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - María Paula Echavarría
- Unidad de Equidad Global en Salud, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Javier Andrés Carvajal
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
| | | | | | - Viviana Mesa
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Fernando A Ávila-Sánchez
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Juan Carlos Gallego
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Natalia C Riascos
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - David Hurtado
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Paula A Fernández
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | - Leandro Posada
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | | | - Isabella Ramos
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 No. 122-135, Cali, Colombia
| | | | | | - Daniel Echeverri
- Fundación para el Desarrollo Integral del Pacífico - Propacífico, Cali, Colombia
| | - Luisa Gonzalez
- Unidad de Responsabilidad Social, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
| | - Evelyn Elena Peña-Zárate
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
| | - Laura Libreros-Peña
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
| | - Juan Sebastián Galindo
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
| | - Marcela Granados
- Subdirección General, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Colombia
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Braund S, Deneux-Tharaux C, Sentilhes L, Seco A, Rozenberg P, Goffinet F. Induction of labor and risk of postpartum hemorrhage in women with vaginal delivery: A propensity score analysis. Int J Gynaecol Obstet 2024; 164:732-740. [PMID: 37568268 DOI: 10.1002/ijgo.15043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE To explore the association between induction of labor (IOL) and postpartum hemorrhage (PPH) after vaginal delivery. METHODS We included women from the merged database of three randomized prospective trials (TRACOR, CYTOCINON, and TRAAP) that measured postpartum blood loss precisely, with standardized methods. IOL was considered overall and according to its method. The association between IOL and PPH was tested by multivariate logistic regression modeling, adjusted for confounders, and by propensity score matching. The role of potential intermediate factors, i.e. estimated quantity of oxytocin administered during labor and operative vaginal delivery, was assessed with structural equation modeling. RESULTS Labor was induced for 1809 of the 9209 (19.6%) women. IOL was associated with a significantly higher risk of PPH of 500 mL or more (adjusted odds ratio 1.56, 95% confidence interval 1.42-1.70) and PPH of 1000 mL or more (adjusted odds ratio 1.51, 95% confidence interval 1.16-1.96). The risk of PPH increased similarly regardless of the method of induction. The results were similar after propensity score matching (odds ratio for PPH ≥500 mL 1.57, 95% confidence interval 1.33-1.87, odds ratio for PPH ≥1000 mL 1.57, 95% confidence interval 1.06-2.07). Structural equation modeling showed that 34% of this association was mediated by the quantity of oxytocin administered during labor and 1.3% by women who underwent operative vaginal delivery. CONCLUSION Among women with vaginal delivery, the risk of PPH is higher in those with IOL, regardless of its method, and after accounting for indication bias. The quantity of oxytocin administered during labor may explain one third of this association.
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Affiliation(s)
- Sophia Braund
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
- Department of Obstetrics and Gynecology, Charles Nicolle University Hospital, Rouen, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Pellegrin University Hospital, Bordeaux, France
| | - Aurélien Seco
- Clinical Research Unit of Paris Descartes Necker Cochin, APHP, Paris, France
| | | | - François Goffinet
- Université Paris Cité, INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Center for Research in Epidemiology and Statistics (CRESS), Paris, France
- Department of Obstetrics and Gynecology, Cochin Port-Royal Hospital, APHP, Paris, France
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10
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de Vries PLM, Deneux-Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D'Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG 2023; 130:1639-1652. [PMID: 37259184 DOI: 10.1111/1471-0528.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/15/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN Comparative study. SETTING High-resource countries. POPULATION Women with PPH. METHODS Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
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Affiliation(s)
- Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
| | - David Baud
- Department of Gynaecology and Obstetrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kenneth K Chen
- Departments of Medicine & ObGyn, Brown University, Providence, Rhode Island, USA
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, Rome, Italy
| | - Francois Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rohan D'Souzah
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Departments of Obstetrics & Gynaecology and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Obstetrics and Gynaecology, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marieke Sueters
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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11
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Riascos N, Loaiza-Osorio S, Monroy A, Barona JS, Carvajal J, Echavarria MP, Nasner D, Escobar MF. Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America. Int J Gynaecol Obstet 2023; 163:291-301. [PMID: 37269178 DOI: 10.1002/ijgo.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/12/2023] [Accepted: 05/09/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. METHODS Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. RESULTS We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). CONCLUSION The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.
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Affiliation(s)
- Natalia Riascos
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza-Osorio
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Angelica Monroy
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan Sebastián Barona
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Javier Carvajal
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | | | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - María Fernanda Escobar
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
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12
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Ghose I, Wiley RL, Ciomperlik HN, Chen HY, Sibai BM, Chauhan SP, Mendez-Figueroa H. Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage. Am J Obstet Gynecol MFM 2023; 5:101106. [PMID: 37524259 DOI: 10.1016/j.ajogmf.2023.101106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. OBJECTIVE Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. STUDY DESIGN This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. RESULTS Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). CONCLUSION Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.
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Affiliation(s)
- Ipsita Ghose
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Rachel L Wiley
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Hailie N Ciomperlik
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Han-Yang Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX.
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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13
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Handley SC, Formanowski B, Passarella M, Kozhimannil KB, Leonard SA, Main EK, Phibbs CS, Lorch SA. Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole. Health Aff (Millwood) 2023; 42:1266-1274. [PMID: 37669487 PMCID: PMC10901240 DOI: 10.1377/hlthaff.2023.00398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.
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Affiliation(s)
- Sara C Handley
- Sara C. Handley , Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Ciaran S Phibbs
- Ciaran S. Phibbs, Palo Alto Veterans Affairs Medical Center, Menlo Park, California; and Stanford University
| | - Scott A Lorch
- Scott A. Lorch, Children's Hospital of Philadelphia and University of Pennsylvania
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14
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Batra P, Alvarado G, Bird CE. The "Birth-Centered Outcomes Research Engagement (B-CORE) in Medi-Cal" Project: Community-Generated Recommendations to Decrease Maternal Mortality and Severe Maternal Morbidity. Womens Health Issues 2023; 33:474-480. [PMID: 37169636 DOI: 10.1016/j.whi.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Through applied research and health care quality improvement, California has achieved a maternal mortality (MM) rate significantly lower than that measured nationally. However, Medicaid (Medi-Cal)-insured births in the state continue to experience disproportionate shares of MM and severe maternal morbidity (SMM), which often precedes death. Failure to engage the Medi-Cal community in this work may impede efforts to increase equity. METHODS This community engagement project used deliberative democracy methods to engage stakeholders with lived experience in California's Medi-Cal perinatal care system to generate an actionable and specific agenda of recommendations to decrease MM and SMM in the Medi-Cal population. FINDINGS A total of 37 Medi-Cal stakeholders-representing birthing people, providers, health plan administrators, and advocates-participated in longitudinal co-learning sessions on the topics of MM/SMM in Medi-Cal. Most of these stakeholders (75.7%) then participated in deliberation sessions. Deliberation recommendations fell into five distinct categories: Medi-Cal perinatal covered benefits, data collection and dissemination, patient experience and its link to care quality, Medi-Cal reimbursement rates, and accountability with respect to racism in perinatal care. Stakeholders identified the Medi-Cal system actors best positioned to implement specific recommendations to directly impact MM/SMM. CONCLUSIONS This project demonstrates the feasibility and success of using deliberative democracy methods to generate local and community-generated solutions to critical problems in health equity. Active and engaged stakeholders were keen to identify both immediate actions and long-term research and quality improvement paradigm shifts to support birth equity in Medi-Cal.
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Affiliation(s)
- Priya Batra
- The RAND Corporation, Santa Monica, California.
| | | | - Chloe E Bird
- The RAND Corporation, Santa Monica, California; Center for Health Equity Research, Tufts Medical Center, Boston, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
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15
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Hamm RF, Moniz MH, Wahid I, Breman RB, Callaghan-Koru JA. Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers. Implement Sci Commun 2023; 4:83. [PMID: 37480135 PMCID: PMC10360260 DOI: 10.1186/s43058-023-00461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA. METHODS This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures. RESULTS Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research. CONCLUSIONS Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Inaya Wahid
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Rachel Blankstein Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Jennifer A Callaghan-Koru
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Springdale, AR, USA.
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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16
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Stierman EK, O'Brien BT, Stagg J, Ouk E, Alon N, Engineer LD, Fabiyi CA, Liu TM, Chew E, Benishek LE, Harding B, Terhorst RG, Latif A, Berenholtz SM, Mistry KB, Creanga AA. Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas. Qual Manag Health Care 2023; 32:177-188. [PMID: 36913770 PMCID: PMC10290572 DOI: 10.1097/qmh.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.
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Affiliation(s)
- Elizabeth K Stierman
- Departments of International Health (Drs Stierman and Creanga) and Health Policy and Management (Drs Engineer and Berenholtz), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Oklahoma Perinatal Quality Improvement Collaborative, Oklahoma City, (Mss O'Brien and Ouk); The University of Oklahoma Health Sciences Center, Oklahoma City (Mss O'Brien and Ouk); Community Health Improvement Division, Texas Department of State Health Services, Austin (Ms Stagg); Alliance for Innovation on Maternal Health, American College of Obstetricians and Gynecologists, Washington, District of Columbia (Ms Alon); Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Engineer, Benishek, Latif, and Berenholtz, Ms Liu, and Mr Terhorst); Departments of Anesthesiology and Critical Care Medicine (Drs Engineer, Benishek, Latif, and Berenholtz) and Gynecology and Obstetrics (Dr Creanga), Johns Hopkins School of Medicine, Baltimore, Maryland; and Agency for Healthcare Research and Quality, Rockville, Maryland (Drs Fabiyi and Mistry and Mss Chew and Harding)
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17
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Turkoglu O, Friedman P. Evaluation During Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:357-366. [PMID: 37130377 DOI: 10.1097/grf.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Postpartum hemorrhage is an obstetric emergency that is the leading and the most preventable cause of maternal death that occurs on the day of birth. The treatment of postpartum hemorrhage in a timely fashion is crucial to prevent morbidity and mortality. The accurate assessment of blood loss during delivery and the postpartum period remains a major challenge. Hence, it is imperative to have a standardized evaluation strategy for accurate assessment of blood loss, adequate classification of hemorrhage, and timely initiated interventions. The multidisciplinary evaluation strategy should be in place regardless of the delivery route.
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Affiliation(s)
- Onur Turkoglu
- Beaumont Hospital, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Perry Friedman
- Beaumont Hospital, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
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18
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Eid J, Stahl D. Blood Product Replacement for Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:408-414. [PMID: 36730283 DOI: 10.1097/grf.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5 L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.
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Affiliation(s)
- Joe Eid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center
| | - David Stahl
- Division of Critical Care Medicine, Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Samuelson Bannow B, Federspiel JJ, Abel DE, Mauney L, Rosovsky RP, Bates SM. Multidisciplinary care of the pregnant patient with or at risk for venous thromboembolism: a recommended toolkit from the Foundation for Women and Girls with Blood Disorders Thrombosis Subcommittee. J Thromb Haemost 2023; 21:1432-1440. [PMID: 36972785 PMCID: PMC10192106 DOI: 10.1016/j.jtha.2023.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
The care of pregnant persons with/at risk of venous thromboembolism is complex and often challenging. Although guidelines have been published regarding the use of specific therapies, such as anticoagulants; in this population, none have provided guidance on how to coordinate multidisciplinary care of these patients. Here we provide an expert consensus on the role of various providers in the care of this patient population, as well as necessary resources and suggestions for best practices.
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Affiliation(s)
| | - Jerome J Federspiel
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - David E Abel
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Logan Mauney
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D’Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC. ADVANCES 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D’Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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State Perinatal Quality Collaborative for Reducing Severe Maternal Morbidity From Hemorrhage: A Cost-Effectiveness Analysis. Obstet Gynecol 2023; 141:387-394. [PMID: 36649352 DOI: 10.1097/aog.0000000000005060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/10/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the cost effectiveness of California's statewide perinatal quality collaborative for reducing severe maternal morbidity (SMM) from hemorrhage. METHODS A decision-analytic model using open source software (Amua 0.30) compared outcomes and costs within a simulated cohort of 480,000 births to assess the annual effect in the state of California. Our model captures both the short-term costs and outcomes that surround labor and delivery and long-term effects over a person's remaining lifetime. Previous studies that evaluated the effectiveness of the CMQCC's (California Maternal Quality Care Collaborative) statewide perinatal quality collaborative initiative-reduction of hemorrhage-related SMM by increasing recognition, measurement, and timely response to postpartum hemorrhage-provided estimates of intervention effectiveness. Primary cost data received from select hospitals within the study allowed for the estimation of collaborative costs, with all other model inputs derived from literature. Costs were inflated to 2021 dollars with a cost-effectiveness threshold of $100,000 per quality-adjusted life-year (QALY) gained. Various sensitivity analyses were performed including one-way, scenario-based, and probabilistic sensitivity (Monte Carlo) analysis. RESULTS The collaborative was cost effective, exhibiting strong dominance when compared with the baseline or standard of care. In a theoretical cohort of 480,000 births, collaborative implementation added 182 QALYs (0.000379/birth) by averting 913 cases of SMM, 28 emergency hysterectomies, and one maternal mortality. Additionally, it saved $9 million ($17.78/birth) due to averted SMM costs. Although sensitivity analyses across parameter uncertainty ranges provided cases where the intervention was not cost saving, it remained cost effective throughout all analyses. Additionally, scenario-based sensitivity analysis found the intervention cost effective regardless of birth volume and implementation costs. CONCLUSION California's statewide perinatal quality collaborative initiative to reduce SMM from hemorrhage was cost effective-representing an inexpensive quality-improvement initiative that reduces the incidence of maternal morbidity and mortality, and potentially provides cost savings to the majority of birthing hospitals.
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22
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Clarke-Deelder E, Opondo K, Achieng E, Garg L, Han D, Henry J, Guha M, Lightbourne A, Makin J, Miller N, Otieno B, Borovac-Pinheiro A, Suarez-Rebling D, Menzies NA, Burke T, Oguttu M, McConnell M, Cohen J. Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001670. [PMID: 36963063 PMCID: PMC10022124 DOI: 10.1371/journal.pgph.0001670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 02/08/2023] [Indexed: 03/06/2023]
Abstract
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya
- Vayu Global Health Foundation, Boston, MA, United States of America
| | | | - Lorraine Garg
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
| | - Dan Han
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore
| | - Junita Henry
- Economics Department, Massachusetts Institute of Technology, Cambridge, MA, United States of America
| | - Moytrayee Guha
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
- Brown University, Providence, RI, United States of America
| | - Alicia Lightbourne
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
- Duke University, Durham, North Carolina, United States of America
| | - Jennifer Makin
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Nora Miller
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
| | | | - Anderson Borovac-Pinheiro
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
| | - Daniela Suarez-Rebling
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
- Department of Emergency Medicine, Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States of America
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23
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Gonte MR, Peifer HG, Meara G, Otieno B, Oguttu M, Burke TF. Feasibility and impact of a postpartum hemorrhage emergency care package using a bundle approach in Migori County, Kenya. Int J Gynaecol Obstet 2022; 161:969-978. [PMID: 36511785 DOI: 10.1002/ijgo.14612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate the impact of the PPH Emergency Care package (PPH EmC)-a holistic intervention that uses a bundle approach that has been implemented in Kenya, India, Nepal, Bangladesh, and Central America-in a low-resource setting. METHODS The feasibility and impact of PPH EmC implementation in Migori County, Kenya was studied using a qualitative research design. In March and April 2022 key informants were identified using purposive sampling. Semi-structured interviews were conducted over Zoom from March to May 2022 until thematic saturation was reached. Interviews were transcribed, coded, and analyzed for emerging themes. RESULTS PPH EmC has positively impacted facility and health system preparedness, referral coordination, teamwork and communication, and overall capacity to provide quality PPH emergency care. Participants reported that PPH EmC is sustainable because of its low cost and support from local partners. CONCLUSION Implementation of PPH EmC in Migori County, Kenya was feasible and positively impacted PPH emergency care.
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Affiliation(s)
- Madeleine R Gonte
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Hannah G Peifer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Grace Meara
- Boston University, Boston, Massachusetts, USA
| | | | | | - Thomas F Burke
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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24
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Karlsson O. Protocol for postpartum haemorrhage including massive transfusion. Best Pract Res Clin Anaesthesiol 2022; 36:427-432. [PMID: 36513436 DOI: 10.1016/j.bpa.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/16/2022] [Accepted: 09/27/2022] [Indexed: 12/14/2022]
Abstract
Postpartum haemorrhage (PPH) is one of the most common causes of maternal mortality worldwide. Management of PPH depends on the severity of bleeding. If the bleeding is severe, aorta compression can reduce bleeding. It should be followed by insertion of two coarse needles for intravenous access and blood sampling for haemoglobin and haemostasis. Further on, monitoring of vital parameters, as well as provision of extra oxygen and warm crystalloids, should be performed. Uterine atony is the most common cause of PPH and local guidelines for uterotonic drug selection should be followed. Patients with ongoing bleeding should immediately receive surgical care for bleeding control. During severe ongoing bleeding, haemostasis care includes early tranexamic acid, transfusion in ratio 4:4:1 (blood:plasma:platelets), and extra fibrinogen intravenously. If not severe PPH, use goal-directed therapy. During general anaesthesia and uterine atony, stop volatile anaesthesia and change to intravenous anaesthesia.
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Affiliation(s)
- Ove Karlsson
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Anaesthesiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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25
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Escobar MF, Echavarria MP, Gallego JC, Riascos N, Vasquez H, Nasner D, Pabon S, Castro ZA, Cardona DA, Castro AM, Ramos I, Hincapie MA, Kusanovic JP, Martínez-Ruíz DM, Carvajal JA. Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia. Digit Health 2022; 8:20552076221129077. [PMID: 36204705 PMCID: PMC9530555 DOI: 10.1177/20552076221129077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia. Methods A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL). Results A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease. Conclusion The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia,María Fernanda Escobar Vidarte, Fundación
Valle del Lili. Cra 98 Nro.18-49 Cali 760032, Colombia. Emails:
;
| | - María Paula Echavarria
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Juan Carlos Gallego
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Natalia Riascos
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Hilda Vasquez
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
| | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali,
Colombia
| | - Stephanie Pabon
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Zindy Alexandra Castro
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Didier Augusto Cardona
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Ana Milena Castro
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
| | - Isabella Ramos
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Antonia Hincapie
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Center for Research and
Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago,
Chile,Division of Obstetrics and Gynecology, School of Medicine,
Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and
Gynecology, Fundación Valle del Lili, Cali, Colombia,Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
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26
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Abstract
This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.
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27
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Davis R, Guo N, Bentley J, Sie L, Ansari J, Bateman B, Main E, Butwick AJ. Hospital-level variation in rates of postpartum hemorrhage in California. Transfusion 2022; 62:1743-1751. [PMID: 35920049 DOI: 10.1111/trf.17036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH). STUDY DESIGN AND METHODS We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC). RESULTS Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%). DISCUSSION Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.
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Affiliation(s)
- Rudolph Davis
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nan Guo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Lillian Sie
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jessica Ansari
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Brian Bateman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Elliot Main
- California Maternal Quality Care Collaborative, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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28
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Escobar MF, Echavarria MP, Vasquez H, Nasner D, Ramos I, Hincapié MA, Pabon S, Kusanovic JP, Martínez-Ruíz DM, Carvajal JA. Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia. BMC Pregnancy Childbirth 2022; 22:604. [PMID: 35906534 PMCID: PMC9336139 DOI: 10.1186/s12884-022-04935-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region. OBJECTIVES We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia. METHODS We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care. RESULTS There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia. CONCLUSIONS Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia.
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
| | - María Paula Echavarria
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Hilda Vasquez
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Daniela Nasner
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Isabella Ramos
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Antonia Hincapié
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Stephanie Pabon
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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29
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Admon LK, Ford ND, Ko JY, Ferre C, Kroelinger CD, Kozhimannil KB, Kuklina EV. Trends and Distribution of In-Hospital Mortality Among Pregnant and Postpartum Individuals by Pregnancy Period. JAMA Netw Open 2022; 5:e2224614. [PMID: 35904786 PMCID: PMC9338405 DOI: 10.1001/jamanetworkopen.2022.24614] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
This cross-sectional study investigates trends in death rates and proportion of deaths by pregnancy period among pregnant and postpartum individuals from 1994 to 2019.
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Affiliation(s)
- Lindsay K. Admon
- Department of Obstetrics and Gynecology and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicole D. Ford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jean Y. Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cynthia Ferre
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charlan D. Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katy B. Kozhimannil
- Department of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Elena V. Kuklina
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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30
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Perinatal quality collaboratives and birth equity. Curr Opin Anaesthesiol 2022; 35:299-305. [PMID: 35671016 DOI: 10.1097/aco.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss how state perinatal quality collaboratives are addressing birth equity to reduce disparities in maternal morbidity and mortality. RECENT FINDING Perinatal quality collaboratives are adopting core practices to advance birth equity, reduce disparities and confront racism and bias in obstetric care including securing leadership commitments to equity, providing education on the causes of inequities and mitigation strategies, collecting accurate race/ethnicity data, addressing social determinants of health, and integrating patient and community knowledge, experiences, and narratives in the quality improvement work. SUMMARY Inequities in maternal morbidity and mortality particularly affecting Black birthing people are driven by racism, inequities in the social determinants of health, and variations in care practices and quality. Perinatal quality collaboratives are an important resource for driving improvement changes to mitigate these factors and improve outcomes. VIDEO ABSTRACT Mason CL, Collier CH, Penny SC. Perinatal Quality Collaboratives and Birth Equity. Produced by CLMB Productions for use in this publication. January 10, 2022, http://links.lww.com/COAN/A86.
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Abstract
PURPOSE OF REVIEW A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions. RECENT FINDINGS Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death. SUMMARY Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).
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Garey CJ, Clements MA, McAuliffe-Fogarty AH, Obrynba KS, Weinstock RS, Majidi S, Ross CS, Rioles NA. The association between depression symptom endorsement and glycemic outcomes in adolescents with type 1 diabetes. Pediatr Diabetes 2022; 23:248-257. [PMID: 34779100 DOI: 10.1111/pedi.13290] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The prevalence of depression among adolescents with type 1 diabetes is estimated to be 2-3 times higher than in the general population. In adults with type 1 diabetes and depression, short-term outcomes are worse compared to individuals just diagnosed with type 1 diabetes. This study aims to determine if depressive symptom endorsement is associated with glycemic outcomes and short-term complications in adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS Analysis was conducted using electronic medical records from the T1D Exchange Quality Improvement Collaborative. Adolescents with type 1 diabetes, aged 12-18, receiving treatment in a diabetes clinic who had been screened for depression with the PHQ-9 between 2016 and 2018 were eligible for inclusion. Individuals must have also had HbA1c data available from the day of depression screening and from 10 to 24 weeks after screening; the final sample size was 1714. RESULTS Almost 30% of adolescents endorsed mild or greater (PHQ-9 ≥ 5) depressive symptoms. Endorsement of mild or greater depressive symptoms was associated with an 18% increased risk of an HbA1c ≥7.5% and a 42% increased risk of an HbA1c ≥9.0% on the day of screener administration. Depressive symptom endorsement was also associated with an 82% increased risk for DKA. CONCLUSIONS This study suggests that depression symptoms are associated with an increased risk for elevated HbA1c and short-term complications. With the rising incidence of type 1 diabetes in youth, routine screening, and appropriate management of depression is needed.
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Affiliation(s)
- Colleen J Garey
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mark A Clements
- Department of Pediatrics, Endocrinology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Kathryn S Obrynba
- Department of Pediatrics, Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ruth S Weinstock
- Department of Medicine, Endocrinology, Diabetes, and Metabolism Division, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Shideh Majidi
- Barbara Davis Center Pediatric Diabetes Division, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Craig S Ross
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Nicole A Rioles
- Quality Improvement & Population Health, T1D Exchange, Boston, Massachusetts, USA
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Limitations of Gravimetric Quantitative Blood Loss during Cesarean Delivery. AJP Rep 2022; 12:e36-e40. [PMID: 35141034 PMCID: PMC8816625 DOI: 10.1055/s-0041-1742267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/02/2021] [Indexed: 11/19/2022] Open
Abstract
Objective This study examined the accuracy, sources of error, and limitations of gravimetric quantification of blood loss (QBL) during cesarean delivery. Study Design Blood loss determined by assays of the hemoglobin content on surgical sponges and in suction canisters was compared with QBL in 50 parturients. Results QBL was moderately correlated to the actual blood loss ( r = 0.564; p < 0.001). Compared with the reference assay, QBL overestimated blood loss for 44 patients (88%). QBL deviated from the assayed blood loss by more than 250 mL in 34 patients (68%) and by more than 500 mL in 16 cases (32%). Assayed blood loss was more than 1,000 mL in four patients. For three of these patients, QBL was more than 1,000 mL (sensitivity = 75%). QBL was more than 1,000 mL in 12 patients. While three of these had an assayed blood loss of more than 1,000 mL, 9 of the 46 patients with blood losses of less than 1,000 mL by the assay (20%) were incorrectly identified as having postpartum hemorrhage by QBL (false positives). The specificity of quantitative QBL for detection of blood loss more than or equal to 1,000 mL was 80.4%. Conclusion QBL was only moderately correlated with the reference assay. While overestimation was more common than underestimation, both occurred. Moreover, QBL was particularly inaccurate when substantial bleeding occurred. Key Points QBL is inaccurate in cesarean delivery.QBL deviated from the assay result by more than 500 mL in 32% of cases.QBL sensitivity and specificity for hemorrhage is 75.0% (95% confidence interval [CI]: 0.19-0.93) and 80.4% (95% CI: 0.69-0.92), respectively.
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Perioperative Protection of the Pregnant Woman. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Current State and Future Direction of Postpartum Hemorrhage Risk Assessment. Obstet Gynecol 2021; 138:924-930. [PMID: 34736271 DOI: 10.1097/aog.0000000000004579] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/19/2021] [Indexed: 12/23/2022]
Abstract
In the United States, postpartum hemorrhage is a leading preventable cause of maternal mortality and morbidity. To reduce morbidity from postpartum hemorrhage, risk assessment is an important starting point for informing decisions about risk management and hemorrhage prevention. Current perinatal care guidelines from the Joint Commission recommend that all patients undergo postpartum hemorrhage risk assessment at admission and after delivery. Three maternal health organizations-the California Maternal Quality Care Collaborative, AWHONN, and the American College of Obstetricians and Gynecologists' Safe Motherhood Initiative-have developed postpartum hemorrhage risk-assessment tools for clinical use. Based on the presence of risk factors, each organization categorizes patients as low-, medium-, or high-risk, and ties pretransfusion testing recommendations to these categorizations. However, the accuracy of these tools' risk categorizations has come under increasing scrutiny. Given their low positive predictive value, the value proposition of pretransfusion testing in all patients classified as medium- and high-risk is low. Further, 40% of all postpartum hemorrhage events occur in low-risk patients, emphasizing the need for early vigilance and treatment regardless of categorization. We recommend that maternal health organizations consider alternatives to category-based risk tools for evaluating postpartum hemorrhage risk before delivery.
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Shah LM, Varma B, Nasir K, Walsh MN, Blumenthal RS, Mehta LS, Sharma G. Reducing disparities in adverse pregnancy outcomes in the United States. Am Heart J 2021; 242:92-102. [PMID: 34481757 DOI: 10.1016/j.ahj.2021.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
There is growing evidence that rural and racial disparities and social determinants of health (SDOH) impact adverse pregnancy outcomes (APOs) and overall maternal mortality in the United States. These APOs, such as preeclampsia, preterm birth, and intrauterine growth restriction, are in-turn associated with increased risk of future cardiovascular disease (CVD) later in life. Importantly, SDOH such as socioeconomic disadvantages, poor health literacy, transportation barriers, lack of access to adequate health care, food insecurity, and psychosocial stressors have cascading effects on APOs and downstream cardiovascular health. These SDOH are also deeply intertwined with and compounded by existing racial and rural disparities. Pregnancy thus provides a unique opportunity to identify at-risk women from a social determinants perspective, and provide early interventions to optimize long-term CVD and mitigate cardiovascular health disparities. Addressing the challenges posed by these disparities requires a multi-pronged approach and involves national, regional, and individual level solutions. Eliminating disparities will necessitate a nationwide obligation to ensure health care equity via enhanced health insurance coverage, resource investment, and public and clinician accountability.
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Mehta LS, Sharma G, Creanga AA, Hameed AB, Hollier LM, Johnson JC, Leffert L, McCullough LD, Mujahid MS, Watson K, White CJ. Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association. Circulation 2021; 144:e251-e269. [PMID: 34493059 DOI: 10.1161/cir.0000000000001000] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.
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Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland. Obstet Gynecol 2021; 138:583-592. [PMID: 34623072 DOI: 10.1097/aog.0000000000004540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates. METHODS This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance. RESULTS Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle. CONCLUSION The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.
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Metcalfe A, Sheikh M, Hetherington E. Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States. Am J Obstet Gynecol 2021; 225:422.e1-422.e11. [PMID: 33872591 DOI: 10.1016/j.ajog.2021.03.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.
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Bernstein SL, Kelechi TJ, Catchpole K, Nemeth LS. Prevention of Failure to Rescue in Obstetric Patients: A Realist Review. Worldviews Evid Based Nurs 2021; 18:352-360. [PMID: 34482602 DOI: 10.1111/wvn.12531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue. AIMS To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events. METHODS A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety. RESULTS Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork. LINKING EVIDENCE TO ACTION Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.
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Affiliation(s)
| | - Teresa J Kelechi
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth Catchpole
- S.C. SmartState endowed Chair in Clinical Practice and Human Factors, Anesthesia and Perioperative Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Rubenstein AF, Zamudio S, Douglas C, Sledge S, Thurer RL. Automated Quantification of Blood Loss versus Visual Estimation in 274 Vaginal Deliveries. Am J Perinatol 2021; 38:1031-1035. [PMID: 32052398 DOI: 10.1055/s-0040-1701507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of the study is to compare quantified blood loss measurement (QBL) using an automated system (Triton QBL, Menlo Park, CA) with visual blood loss estimation (EBL) during vaginal delivery. STUDY DESIGN During 274 vaginal deliveries, both QBL and EBL were determined. The automated system batch weighs blood containing sponges, towels, pads, and other supplies and automatically subtracts their dry weights and also the measured amount of amniotic fluid. Each method was performed independently, and clinicians were blinded to the device's results. RESULTS Median QBL (339 mL [217-515]) was significantly greater than median EBL (300 mL [200-350]; p < 0.0001). The Pearson's correlation between EBL and QBL was poor (r = 0.520) and the Bland-Altman's limits of agreement were wide (>900 mL). QBL measured blood loss >500 mL occurred in 73 (26.6%) patients compared with 14 (5.1%) patients using visual estimation (p < 0.0001). QBL ≥ 1,000 mL was recorded in 11 patients (4.0%), whereas only one patient had an EBL blood loss of 1,000 mL and none had EBL >1,000 mL (p = 0.002). CONCLUSION Automated QBL recognizes more patients with excessive blood loss than visual estimation. To realize the value of QBL, clinicians must accept the inadequacy of visual estimation and implement protocols based on QBL values. Further studies of clinical outcomes related to QBL are needed. KEY POINTS · QBL detects hemorrhage more frequently than visual estimation.. · Median QBL is significantly greater than median EBL.. · There is poor agreement between QBL and EBL..
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Affiliation(s)
- Andrew F Rubenstein
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
| | - Stacy Zamudio
- Division of Maternal-Fetal Medicine and Surgery, Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
| | - Claudia Douglas
- Institute for Evidence Based Practice and Nursing Research, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, New Jersey
| | - Sharon Sledge
- Center for Bloodless Medicine and Surgery, Department of Patient Safety and Quality, Hackensack Meridian Health, Hackensack, New Jersey
| | - Robert L Thurer
- Medical Department, Gauss Surgical, Inc., Menlo Park, California
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Callaghan-Koru JA, Moniz MH, Hamm RF. Prioritize implementation research to effectively address the maternal health crisis. Am J Obstet Gynecol 2021; 225:212-213. [PMID: 33567327 DOI: 10.1016/j.ajog.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jennifer A Callaghan-Koru
- Department of Sociology, Anthropology, and Public Health, University of Maryland, Baltimore County, Baltimore, MD; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Michelle H Moniz
- Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue. Obstet Gynecol 2021; 137:791-800. [PMID: 33831938 DOI: 10.1097/aog.0000000000004362] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends. METHODS This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed. RESULTS During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period. CONCLUSION Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.
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Taylor K, Noel E, Chapple AG, Buzhardt S, Sutton E. Risk factors for postpartum hemorrhage in a tertiary hospital in South-Central Louisiana. J Matern Fetal Neonatal Med 2021; 35:7353-7359. [PMID: 34304671 DOI: 10.1080/14767058.2021.1948528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is the most common cause of maternal mortality worldwide. Predicting PPH remains difficult, and risk factors vary among populations. We aimed to determine prevalence, risk factors, and causes for PPH in our obstetric population in South-Central Louisiana. METHODS We conducted a retrospective cohort study utilizing medical records for deliveries between October 2015 and September 2020 at Woman's Hospital, a tertiary hospital in South-Central Louisiana. PPH was defined by the current American College of Obstetricians and Gynecologists' (ACOG) criteria as cumulative blood loss greater than or equal to 1000 mL within 24 h after the birth process regardless of route of delivery. Logistic regression assessed the association of PPH and possible risk factors: anemia at the time of delivery, race, parity, delivery mode, body mass index, age, and health insurance. An additional logistic regression also investigated risk factors within our cohort for severe maternal morbidity among patients who experienced PPH including the same covariates. RESULTS A total of 30,674 deliveries were included in our cohort, among which PPH occurred in 12.3% (n = 3773). Patients experiencing PPH were more likely to be of Black race, Medicaid-eligible, deliver via cesarean section, and have lower hemoglobin and hematocrit at time of delivery compared to patients without PPH (all p < .001). Anemia at delivery (aOR = 1.28; 95%CI = 1.154-1.419), cesarean delivery (aOR = 8.796; 95%CI = 7.731-10.007), BMI > 40kg/m2 (aOR = 1.363; 95%CI = 1.186-1.567), and Black race (aOR = 1.233; 95%CI = 1.099-1.383) were the strongest predictors of PPH. Among cesarean cases (n = 10,888), Black race and BMI > 40 kg/m2 were the strongest predictors for PPH. Among patients who experienced PPH, anemia was associated with a higher likelihood of experiencing a severe maternal morbidity event (aOR = 2.587; 95%CI = 1.990-3.364). CONCLUSION Consistent with literature in the United States, Black race, increased BMI, cesarean delivery, and anemia were associated with risk of PPH. Anemia at delivery increased the risk for severe maternal morbidity among patients experiencing PPH.
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Affiliation(s)
- Kaitlyn Taylor
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Baton Rouge, LA, USA
| | - Emily Noel
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Andrew G Chapple
- Biostatistics Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Sarah Buzhardt
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Baton Rouge, LA, USA
| | - Elizabeth Sutton
- Woman's Hospital Research Center, Woman's Hospital, Baton Rouge, LA, USA
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Millington S, Edwards S, Clark RA, Dekker GA, Arstall M. The association between guidelines adherence and clinical outcomes during pregnancy in a cohort of women with cardiac co-morbidities. PLoS One 2021; 16:e0255070. [PMID: 34297761 PMCID: PMC8301645 DOI: 10.1371/journal.pone.0255070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background/Aims Maternal and infant morbidities associated with pregnant women with cardiac conditions are a global issue contingent upon appropriate care. This study aimed to describe the clinical variables and their association with the adherence scores to perinatal guidelines for pregnant women with cardiac conditions. The clinical variables included cardiac, perinatal, and neonatal outcomes and complications. Methods Using a retrospective cross-sectional medical record audit, data were abstracted and categorised as cardiac, obstetric, and neonatal predictors. Linear regression modelling was used to find the mean difference (MD) in adherence scores for each predictor, including a 95% confidence interval (CI) and a significance value for all the three categories’ clinical outcomes. Results This maternal cohort’s (n = 261) cardiac complications were primarily arrhythmias requiring treatment (29.9%), particularly SVT (28%), a new diagnosis of valvular heart disease and congenital heart disease (24%) and decompensated heart failure (HF) (16%). Women with HF had associated increased adherence scores (MD = 3.546, 95% CI: 1.689, 5.403) compared to those without HF. Elective LSCS mode of delivery was associated with a higher adherence score (MD = 5.197, 95% CI: 3.584, 6.811) than non-elective LSCS subgroups. Babies admitted to intensive /special care had greater adherence to the guidelines (MD = 3.581, 95% CI: 1.822, 5.340) than those not requiring the same care. Conclusions Some pregnancy associated complications and morbidities were associated with higher adherence scores, reflecting that a diagnosis, identification of morbidities or risk factors, initiation of appropriate multidisciplinary involvement and adherence to guidelines were associated. Conversely, potentially avoidable major complications such as sepsis were associated with a low adherence score. Trial registration ACTRN12617000417381.
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Affiliation(s)
- Sandra Millington
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- * E-mail:
| | - Suzanne Edwards
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Robyn A. Clark
- College of Nursing and Health Science, Flinders University, Adelaide, South Australia, Australia
| | - Gustaaf A. Dekker
- Women’s and Children’s Division Northern Adelaide Health Local Network (NAHLN) and Obstetrics and Gynaecology, University of Adelaide, Adelaide, South Australia, Australia
| | - Margaret Arstall
- Cardiology Unit NAHLN, University of Adelaide, Adelaide, South Australia, Australia
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47
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Admon LK, Daw JR. Evidence From New York: Perinatal Insurance Expansions as a Lever to Address Maternal Morbidity. Anesth Analg 2021; 133:338-339. [PMID: 34257194 DOI: 10.1213/ane.0000000000005468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lindsay K Admon
- From the Department of Obstetrics & Gynecology.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Jamie R Daw
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York
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48
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Goals for Collaborative Management of Obstetric Hemorrhage. Obstet Gynecol Clin North Am 2021; 48:151-171. [PMID: 33573784 DOI: 10.1016/j.ogc.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.
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49
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Escobar MF, Valencia P, Jaimes LM, Hincapié LC, Pulgarín EE, Nasner D, Carvajal J, Echavarría MP, Burke T, Prada S. Resource use decrease after implementation of care bundles for treatment of postpartum hemorrhage. J Matern Fetal Neonatal Med 2021; 35:7874-7881. [PMID: 34112062 DOI: 10.1080/14767058.2021.1937989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate whether the implementation of care bundles has an impact on resource utilization in the care of patients with postpartum hemorrhage (PPH). METHODS Retrospective, cross-sectional, observational study of 404 patients with stage II or greater PPH. Periods 2011-2014 and 2015-2017, before and after the introduction of care bundles, were compared. Billing reports were analyzed, and all services provided to treat these events were extracted. Use of resources within the two periods was computed. RESULTS The amount billed per episode decreased 18.66% from the first to the second period. Most PPH cases used fewer resources after introduction of care bundles. The greatest reduction was in the use of medications, with a decrease of charges by 56.3%. Diagnostic procedure charges decreased by 47.6% and consultation charges decreased by (37.7%). CONCLUSIONS The use of PPH care bundles may be associated with lower resource use and fewer interventions.
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Affiliation(s)
- María Fernanda Escobar
- Department of Obstetrics and Gynecology, High Complexity Obstetric Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Paola Valencia
- Department of Obstetrics and Gynecology, High Complexity Obstetric Unit, Fundación Valle del Lili, Cali, Colombia
| | | | | | | | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Javier Carvajal
- Department of Obstetrics and Gynecology, High Complexity Obstetric Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Paula Echavarría
- Department of Obstetrics and Gynecology, High Complexity Obstetric Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Thomas Burke
- Department of Emergency Medicine Global Health Innovation Laboratory, Massachusetts General Hospital, Boston, MA, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Sergio Prada
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia.,Centro PROESA, Universidad Icesi, Cali, Colombia
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50
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Saeed H, Coviello E, Amgalan A, Thomas A, Kawakita T. Evaluation of blood transfusion rates by blood loss estimation techniques. J Matern Fetal Neonatal Med 2021; 35:6961-6966. [PMID: 34098851 DOI: 10.1080/14767058.2021.1932805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a major cause of maternal morbidity and mortality. Though the American College of Obstetricians and Gynecologists and quality improvement initiatives recommend the use of a quantitative measurement of blood loss, it is not known if the quantitative measurement compared to visual estimation of blood loss improves maternal outcomes. OBJECTIVE To compare rates of red blood cell transfusion between a quantitative measurement and visual estimation of blood loss. STUDY DESIGN This was a retrospective cohort study of all women who underwent cesarean delivery at a single academic institution from January 2012 to June 2018. Women were excluded if they received a preoperative transfusion or had missing data. Our institution implemented a quantitative measurement of blood loss in September 2015. Our primary outcome was red blood cell transfusion (intraoperative or postoperative). Women who had the quantitative measurement of blood loss (October 2015 to June 2018) were compared with those who had a visual estimation of blood loss (January 2012 to August 2015). Coarsened Exact Matching with a k-to-k solution was performed using predefined variables. RESULTS In total, 4068 had a visual estimation of blood loss and 3117 had the quantitative measurement of blood loss; 1101 women with the quantitative measurement of blood loss were matched to 1101 women with a visual estimation of blood loss. In the unmatched cohort, women who had the quantitative measurement of blood loss compared to those who had a visual estimation of blood loss were more likely to have an increased amount of blood loss (734 ml vs. 700 ml, p < .001) and red blood cell transfusion (7.2% [223/3117] vs. 5.4% [221/4068]; crude odds ratio 1.34; 95% confidence interval 1.11-1.63). This increase in the amount of blood loss (717 ml vs. 700 ml, p < .05) and the rate of red blood cell transfusion (4.5% [49/1101] vs. 2.7% [30/1101]; crude odds ratio 1.66; 95% confidence interval 1.05-2.64) remained statically significant after matching. CONCLUSION Women who had the quantitative measurement compared with those who had a visual estimation of blood loss were more likely to have an increased amount of blood loss and red blood cell transfusion.
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Affiliation(s)
- Haleema Saeed
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Elizabeth Coviello
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Tetsuya Kawakita
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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