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Using Improvement Science to Address Maternal Mortality in the United States

By: Sue Gullo, Director, Institute for Healthcare Improvement

Where do you think the United States ranks in the world on maternal mortality? Would it surprise you to learn that it ranks 46th — behind most other Organization for Economic Cooperation and Development nations? Currently in the United States, 600 women die annually from pregnancy-related complications, while 60,000 women experience severe morbidity. Unlike in most countries around the world, the maternal mortality rate in the United States has risen over the last decade. The IHI Maternal and Infant Health team can’t help but ask why.

Implementing approaches to drive quality care

To address this problem, the Institute for Healthcare Improvement (IHI) partnered with key stakeholders to host “Eradicating Avoidable Maternal Mortality with Improvement Science,” an event held in conjunction with the IHI National Forum on 5 December 2016 in Florida. Leaders at the system, individual facility and clinical unit levels gathered from across the United States to talk about gaps in evidence-based care and promising strategies for reversing the maternal mortality trend.

In 2010, The Joint Commission issued a sentinel event alert identifying hemorrhage as a leading cause of maternal deaths. Since then, considerable resources have been developed to foster standardization in care, including maternal safety bundles, which are sets of evidence-based tools and practices for managing postpartum hemorrhage, pre-eclampsia/eclampsia and embolism.

“Eradicating Avoidable Maternal Mortality with Improvement Science” focused on implementation of these maternal safety bundles and the use of improvement science to ensure high quality, effective maternal health care. Representatives from organizations that received direct support from Merck for Mothers to develop and implement safety bundles discussed their efforts, successes and ongoing challenges. More than 300 hospitals in five states have implemented safety bundles to improve the quality of their emergency obstetric care. The goal is to implement these lifesaving safety bundles in every hospital nationwide.

Identifying and overcoming barriers to implementing safety bundles

During the event, participants discussed the types of support that care providers need to successfully implement the bundles. Many cited scarce resources for frontline staff to build improvement capability as a barrier, and others expressed the need to engage both leaders and clinical staff in supporting and driving evidence-based care.

The need for greater alignment between regional, state and national actors involved in pushing improvement efforts forward was also identified as a challenge. The group highlighted the need to develop and improve maternal mortality and morbidity indicators measuring structure, process and outcome to be used for research and quality improvement.

The striking racial and ethnic disparities in maternal health outcomes in the United States was another important discussion topic. Almost half of all births in the United States are among minority women. Black American women are at three to four times greater risk of dying from pregnancy or childbirth-related complications compared to white women. National leaders participated in a special session at the event to explore these racial inequalities and design potential solutions. Participants also focused on identifying low-resource settings that may need to implement changes in process and practice to decrease maternal mortality — especially settings in which the birthing population has a high proportion of black women. A working group continues to think about potential solutions in this area of focus and identify national partners with whom to collaborate and develop a plan for pilot testing interventions. The IHI team predicts that more reliable delivery of care to at-risk women, along with a focus on better chronic disease screening, prevention and management (e.g., cardiovascular disease), would significantly cut disparities in maternal mortality.

Defining a path forward

The mission statement developed at the event, which continues to be refined over time, captures the spirit of the discussion:

“We come together and commit to work together in order to eradicate avoidable maternal morbidity and mortality and eliminate racial and ethnic disparities in the United States. We commit to improve outcomes for all women and not leave any woman, community, hospital or state behind.”

IHI acknowledges that no one group or organization can achieve this mission alone. The maternal health community has a lot to do to reduce maternal mortality across the globe. With existing evidence of effective care practices — combined with the application of scientific methods to help identify priority areas for improvement, as well as a practical and proven approach — the time for action is now.

To learn more about the maternal safety bundles and national efforts to reduce maternal mortality in the United States, please visit:

Sue Gullo, a Director at the Institute for Healthcare Improvement, leads much of IHI’s domestic and global work on improving maternal and child health. She co-chaired this event with Dr. Debra Bingham and other members of the IHI Maternal and Infant Health Team.

Read about the Disparities in U.S. Maternal Health project, a collaboration between the MHTF and Merck for Mothers.

Learn more about maternal health in the United States.

Explore the MHTF’s blog series, Inequities in Maternal Mortality in the U.S.

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