The Joint Commission introduced two new standards, effective July 1, 2020, to address complications in maternal hemorrhage and severe hypertension/preeclampsia. Their Quick Safety 51 Proactive prevention program provides background information around strategies for the management of maternal hemorrhage that are outlined in new Provision of Care, Treatment, and Services standard PC.06.01.01: Reduce the likelihood of harm related to maternal hemorrhage.
In the U.S., approximately 700 women die annually from pregnancy-related complications, even though most pregnancy-related deaths are preventable. The most frequent cause of severe maternal morbidity and preventable maternal mortality is obstetric hemorrhage — excessive blood loss from giving birth.
Recent data indicate that rates of maternal hemorrhage are increasing in developed countries, including the U.S. Also, the rate of hemorrhage-associated severe maternal morbidity (defined as the need for blood transfusion of four or more units of packed red blood cells and/or ICU level care during the birth process or immediate postpartum period) has exceeded the morbidities associated with other obstetric or medical conditions that may result in complications requiring higher level of care.
In addition, there are significant racial/ethnic disparities in pregnancy-related mortality; black women have a pregnancy-related mortality ratio approximately three times as high as that of white women. Fully addressing these unacceptable mortality rates will require truly understanding the contributing factors that lead to mortality in African American women and other disproportionately affected populations in order to develop focused solutions. Overall, better understanding is needed on the circumstances surrounding pregnancy-related deaths and strategies to prevent future deaths.
Maternal hemorrhage is defined by the American College of Obstetricians and Gynecologists (ACOG) as a cumulative blood loss of greater than or equal to 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia, within 24 hours after the birth process. Approximately three to five percent of obstetric patients will experience a postpartum hemorrhage. These preventable events are the cause of 27% of maternal deaths worldwide, and 11.2% of U.S. maternal deaths.
A review of the Joint Commission sentinel event database for cases coded as maternal death or severe maternal morbidity for 2010 through August 2019, indicate maternal hemorrhage is a causal factor in 51% of those reported sentinel events.
During 2011-2015, the Centers for Disease Control and Prevention (CDC) reports 3,410 pregnancy-related deaths occurred in the U.S., and the overall pregnancy-related mortality ratio was 17.2% pregnancy-related deaths per 100,000 live births. When combined, cardiovascular conditions were responsible for more than 33% of pregnancy-related deaths; these conditions include cardiomyopathy (10.8%), other cardiovascular conditions (15.1%), and cerebrovascular accidents (7.6%). Other leading causes of pregnancy-related death included other noncardiovascular medical conditions (14.3%), infection (12.5%), and obstetric hemorrhage (11.2%).
Strategies to reduce morbidity and mortality from postpartum hemorrhage have included the use of standardized, comprehensive, obstetric safety bundles. A patient safety bundle is a set of evidence-based recommendations for practice and care processes known to improve outcomes. Standardization and reduced variation have been shown to improve outcomes and quality of care.
To help promote standardization of health care processes, the Council on Patient Safety in Women’s Health Care — representing all major women’s healthcare professional organizations — has developed for dissemination an obstetric hemorrhage safety bundle. Implementing these evidence-based safety bundles has been shown to demonstrate significant reductions in maternal morbidity. The consensus bundle on obstetric hemorrhage is organized into four action domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning.
