The American College of Obstetricians and Gynecologists, with the Society for Maternal-Fetal Medicine, has released new guidance on the screening and review of maternal morbidity, recommending a two-step process to identify severe cases.
Published in Obstetrics & Gynecology, the new guidance is the fifth in the joint ACOG and SMFM Obstetric Care Consensus Series.
“Like maternal mortality, severe maternal morbidity is increasing in the United States,” Sarah K. Kilpatrick, MD, PhD, of Cedars-Sinai Medical Center, in Los Angeles, and colleagues wrote. “Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality, because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries.”
According to the ACOG, different groups have offered varying definitions of severe morbidity, and have proposed lists of conditions and complications that represent such cases. In the aggregate, these definitions of severe maternal morbidity can be summed up as “unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a women’s health,” Kilpatrick and colleagues wrote.
However, the researchers noted that the ACOG and SMFM have not yet created, nor have they endorsed, any single, comprehensive definition of severe maternal morbidity, leaving that task to future work. The researchers instead sought to build upon previous recommendations from multidisciplinary expert groups — which called on all obstetric hospitals to review their cases of severe maternal morbidity to find areas of care in need of improvement— to outline a process for identifying cases that should be reviewed.
The ACOG and SMFM recommend that facilities have a two-step screen and review process in place to detect potential cases of severe maternal morbidity. They recommend the following criteria to screen for morbidity, although institutions may opt to use additional criteria:
- transfusion of 4 or more units of blood; and
- admission of a pregnant or postpartum woman to an ICU.
According to the recommendation, facilities should then review all cases that met at least one of these screening criteria to determine whether the case represents severe maternal morbidity. Facilities should also use this information to analyze the related events, diagnoses and outcomes, and judge whether and how the morbidity could have potentially been avoided.
The researchers noted that not all cases of severe maternal morbidity are preventable, as some cases reflect the underlying health of the patient or her pregnancy. Therefore, simply screening positive for one of the two criteria does not constitute a sentinel event, and occurrence rates should not be used as a quality metric.
“Screening for and detection of severe maternal morbidity is an important step toward promoting safe obstetric care,” Kilpatrick and colleagues wrote. “The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care.” – by Jason Laday