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Actionable Patient Safety Solutions (APSS)

Obstetric Safety

Obstetric safety requires the dual consideration of both the mother and the child, therefore, the principles of obstetric and neonatal safety must be integrated cohesively. Our APSS Blueprints provide healthcare organizations with practical, evidence-based checklists for targeted initiatives for senior leaders and frontline staff.

Sub-Challenges

Reducing Unnecessary Cesarean Deliveries

Severe Hypertension in Pregnancy and Postpartum

Postpartum Hemorrhage

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Relevant Statistics

The risk of maternal death is 4 times higher in cesarean births, while amniotic fluid embolism is 2-3 times more likely. Other serious complications occur in cesarean birth at an overall rate that is 3 times higher than vaginal birth (2.7% vs. 0.9%)¹

Liu, S., Liston, R. M., Joseph, K., & Heaman, M. (2007). Maternal Mortality and Severe Morbidity Associated with Low-risk Planned Cesarean Delivery Versus Planned Vaginal Delivery at Term. Canadian Medical Association Journal, 176(4), 455-460

Approximately 1.2 million c-sections are performed annually²

Centers for Disease Control. (2019). Cesarean Delivery Rate by State. Retrieved from:

https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm

Studies show that between 50-70% of deaths due to severe preeclampsia are preventable³

Aukes, A. M., Wessel, I., Dubois, A. M., Aarnoudse, J. G., & Zeeman, G. G. (2007). Self-Reported Cognitive Functioning in Formerly Eclamptic Women. Obstetrical & Gynecological Survey, 197(4)

According to the most recent mortality data reported to the CDC in 2011-2012, PPH caused 11% of pregnancy-related deaths in the U.S.⁴

Berg, C., Atrash, H., Koonin, L., Tucker, M. (1996). Pregnancy-related Mortality in the United States 1987-1990. Obstetrics & Gynecology, 88(2)

In developing countries with high rates of maternal mortality, nearly one-fourth of deaths are attributable to PPH⁵

AbouZahr, C. (1998). Antepartum and Postpartum Hemorrhage. Retrieved from http://www.scirp.org/(S(vtj3fa45qm1ean45vvffcz55))/reference/ReferencesPapers.aspx? ReferenceID=1569986

Unnecessary C-sections also pose long-term health risks including subsequent uterine scar rupture, abnormal placentation, increased risk of hemorrhage, and hysterectomy where there is an exponential increase in such complications with the number of prior cesareans.⁶

Tihtonen, K. and Nyberg, R. (2014). [Long-term effects of uterine cesarean section scar]. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24730196.

In the United States, one-third of patients give birth surgically and international experts have identified this high cesarean rate as a significant maternal health safety issue. Short term complications from this form of invasive surgery include blood loss, infection, and venous thrombosis with the small but real risk of maternal mortality.⁷

Lothian, J. (2014). Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game. The Journal of Perinatal Education, 23(3), pp.115-118.

Harvard’s Shah points out that C-sections are major surgery, with all of the risks of any hospital procedure. “Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis [a life-threatening complication of certain infections] to hemorrhage to organ injury,” he says.⁸

Haelle, Tara. (2017). Your Biggest C-Section Risk May Be Your Hospital.

The rate of caesarean section births in the U.S. was 32.7 percent in 2013, which is above the WHO’s ideal “medically necessary” target of 10-15 percent.⁹

Gibbons, L., Belizán, J. M., Lauer, J. A., Betrán, A. P., Merialdi, M., & Althabe, F. (2010). The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage (World Health Report, Rep.). World Health Organization. Retrieved from http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

Using C-section data reported by 1,318 hospitals through the voluntary 2016 Leapfrog Hospital Survey, Leapfrog found that over 55% of reporting hospitals had excessive rates of C-sections. That means that far too many women are undergoing a major abdominal surgery without medical necessity.¹⁰

10.

The Leapfrog Group. Rate of C-Sections. http://www.leapfroggroup.org/ratings-reports/rate-c-sections

Recent statistics from 150 countries show a global C-section rate of 18.6% for all births. Almost 1 in 5 women around the world will give birth via C-section.¹¹

11.

McCulloch, Sam. (2016). Highest C-section Rates by Country. (Cited 2016 December 9).

With a projected C-section rate of 19.5 percent in 2012, 250 of every 100,000 mothers died during childbirth. A death rate more common in countries with C-section rates below 7 percent.¹²

12.

Palmer, Katie M. (2015). How Many C-Sections is Too Many C-Sections?. (Cited 2015 December 1).

C-sections are a major surgery and encompass all the risks of any hospital procedure. Unnecessary C-sections may be responsible for up to 20,000 major surgical complications a year, including everything from sepsis, a life-threatening complication, to hemorrhage or organ injury.¹³

13.

Haelle, Tara. (2017). Your Biggest C-Section Risk May Be Your Hospital. (Cited 2017 May 16).

11.1% of pregnancy-related deaths in the U.S. resulted from “hypertensive disorders of pregnancy,” including preeclampsia.¹⁴

14.

https://www.nichd.nih.gov/news/resources/spotlight/Pages/101812-preeclampsia.aspx

Pre-eclampsia is the cause of 15% of premature births in the U.S.¹⁵

15.

Jeyabalan, A. (2013). Epidemiology of preeclampsia: Impact of obesity. Nutrition Reviews, 71(0 1), 10.1111/nure.12055. http://doi.org/10.1111/nure.12055

Obstetric hemorrhage and pre-eclampsia account for over 70% of cases of severe maternal morbidity.¹⁶

16.

California Maternal Quality Care Collaborative. Project Overview/FAQs. Retrieved from: https://www.cmqcc.org/resource/2900/download

Over the past decade, severe maternal morbidity in the United States has increased by 75% for complications associated with delivery and, specifically, 114% for postpartum hemorrhage.¹⁷

17.

Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe maternal morbidity among delievey and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029-36.

125,000 women a year are affected by postpartum hemorrhage.¹⁸

18.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

Postpartum hemorrhage is a leading cause of pregnancy-related complications, with an estimated 2.9% of the women who give birth in the U.S. will bleed too much.¹⁹

19.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

Approximately 50% of hospital risk management budgets are allocated for obstetric events, and birth-related events account for more than 75% of claims paid in amounts over $1 million.²⁰

20.

Perinatal Safety Intervention Program (PSIP): Design and Development: AHRQ’s 2012 Annual Conference Slide Presentation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2012/track_a/106_hendrich_kamerow/kamerow.html

Anemia is estimated to be responsible for 17-46% of cases in maternal death.²¹

21.

Fawzia Ahmed Habib, Intessar Sultan and Shaista Salman (2012). Morbidity and Mortality in Anemia, Anemia, Dr. Donald Silverberg (Ed.), ISBN: 978-953-51-0138-3, InTech, Available from: http://www.intechopen.com/books/anemia/morbidity-and-mortality-in-anemia

Over the past decade, severe maternal morbidity in the United States has increased by 75% for complications associated with delivery and, specifically, 114% for postpartum hemorrhage.²²

22.

Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029–36.

Obstetric hemorrhage and preeclampsia account for over 70% of cases of severe maternal morbidity.²³

23.

California Maternal Quality Care Collaborative. Project Overview/FAQs. Retrieved from: https://www.cmqcc.org/resource/2900/download

The United States is the one of the only countries where maternal deaths and injuries have increased.²⁴

24.

Gaskin, I. M. (2008). Maternal Death in the United States: A Problem Solved or a Problem Ignored? The Journal of Perinatal Education, 17(2), 9–13. http://doi.org/10.1624/105812408X298336

Every 10 minutes, a woman in the United States almost dies of pregnancy-related complications.²⁵

25.

The AWHONN Postpartum Hemorrhage Project. Maternal Morbidity & Mortality.

30-40% of “near misses” and severe maternal morbidities may be preventable through changes in patient, health care provider, and system factors.²⁶

26.

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