Obstetric Care Consensus
Number 5, September 2016


This document was developed by the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine in collaboration with Sarah K. Kilpatrick, MD, PhD; Jeffrey L. Ecker, MD; and the Centers for Disease Control and Prevention’s representative member William M. Callaghan, MD. The views do not necessarily represent those of the Centers for Disease Control and Prevention or the U.S. government.

The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.


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Severe Maternal Morbidity: Screening and Review

ABSTRACT: This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. 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. 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. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.


Introduction

This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Different groups have offered different definitions of severe morbidity (1–4) and proposed lists of conditions and complications that constitute severe morbidity (4, 5). These definitions share the concept that severe maternal morbidity can be thought of as unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a woman’s health. The American College of Obstetricians and Gynecologists (the College) and the Society for Maternal–Fetal Medicine (SMFM) have not yet created or endorsed a single, comprehensive definition of severe maternal morbidity. Creating a consensus definition of severe maternal morbidity is beyond the scope of this document and may be the focus of future work. In the interval, however, using this recommended process to identify potential cases of severe maternal morbidity for further review, with a focus on outcomes and complications, is an important step toward promoting safe obstetric care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. The purpose of identifying and evaluating these cases is to facilitate opportunities for improvement in care. However, neither intensive care unit (ICU) admission or transfusion of 4 or more units of blood should be used as quality metrics because some cases of morbidity reflect the underlying health of a woman or her pregnancy and, thus, are unavoidable.

Background

Like maternal mortality, severe maternal morbidity is increasing in the United States (3, 6, 7). Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality (7). 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. Responding to these concepts, multidisciplinary expert groups have called for all obstetric hospitals to review their cases of severe maternal morbidity to look for opportunities for improvement in care that could lead to improved maternal outcomes and fewer maternal deaths (8, 9). These calls are supported by the College; SMFM; the Association of Women’s Health, Obstetric and Neonatal Nurses; the American College of Nurse–Midwives; and other groups.

Clinical Considerations and Management

  • What is severe maternal morbidity?

Severe maternal morbidity can be thought of as unintended outcomes of the process of labor and delivery that result in significant short-term or long-term consequences to a woman’s health. To date, there is not complete consensus among systems and professional organizations as to what conditions should represent severe maternal morbidity. Developing such a list in the future has clear utility. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review. Such lists may be based on the institutions’ evaluations of which adverse outcomes are consequential to their population. Table 1 presents an example of a list of conditions that represent severe maternal morbidity. In some cases, however, an identified morbidity actually may not prove to be severe morbidity after chart review (10). For example, if a parturient with complex congenital heart disease has a planned ICU admission to receive safe intrapartum care and does not ultimately require any significant intervention aside from observation, she would not be categorized as a patient with a severe morbidity. In contrast, a woman who develops acute heart failure requiring ICU admission and significant interventions to manage her heart failure would be considered a patient with a severe maternal morbidity. Identifying an outcome as a severe maternal morbidity does not suggest blame, nor does it mean that there will always be an opportunity for improvement. Reviewing such cases in detail to determine whether the morbidity may have been avoidable and whether it should prompt changes in systems for care provision is, however, a necessary and important step in efforts to ensure quality obstetric care. For example, although amniotic fluid embolisms are “unpredictable and unavoidable” (11), reviewing all such cases to evaluate responses to these unexpected life-threatening emergencies potentially can improve future responses.

  • What process can be used to identify cases with potential severe maternal morbidity that merit review?

Quality improvement efforts are predicated in part on identifying cases with potential severe maternal morbidity that merit review (10). Identifying such cases, however, is more complicated than reviewing maternal mortality, which is clearly defined and readily captured in death certificates and other reporting. Severe maternal morbidity, in contrast, is not always reported and may not be well coded in, or otherwise readily extracted from, record systems. Definitions of severe maternal morbidity that rely on diagnosis codes, such as the Centers for Disease Control and Prevention’s definition, may miss cases, have a relatively low positive predictive value (0.40) and, at a practical level, may be difficult for facilities to operationalize (10). Facilities should have a screening process in place to detect cases of severe maternal morbidity for review. The College and SMFM recommend using two criteria to screen for severe maternal morbidity: 1) transfusion of 4 or more units of blood and 2) admission of a pregnant or postpartum woman to an ICU. Investigators have demonstrated that these criteria have high sensitivity and specificity for identifying women with severe morbidity and a high positive predictive value (0.85) for identifying severe maternal morbidity (10, 12, 13).

Facilities should review all cases that meet at least one of these screening criteria to determine whether the case is truly a severe maternal morbidity; to characterize the events, diagnoses, and outcomes involved; and to determine if an identified morbidity is judged to have been potentially avoidable and, thus, present opportunities for system change and improved future performance. Not all cases that meet criteria for review will represent preventable severe morbidity; some cases of morbidity reflect the underlying health of a woman or her pregnancy and are thus unavoidable. The concept that not all cases meeting screening criteria will be true cases of severe maternal morbidity underscores the importance of reviewing each “screen-positive” case to identify those with true morbidity and, especially, those that may be deemed upon review to have been potentially avoidable.

  • When does severe maternal morbidity represent a sentinel event?

Table 1

The Joint Commission defines a sentinel event as “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm, or temporary harm.” Simply screening positive for one of the two recommended screening criteria does not constitute a sentinel event. Instead, the Joint Commission noted that upon review of any case, the ultimate assessment may be that the case is not a sentinel event (14). For example, hemorrhage due to placenta previa would not qualify as a sentinel event because bleeding in this context is part of the natural course of the illness. As such, screen-positive cases or individual outcomes and diagnoses should not automatically be considered sentinel events. Context determined from detailed review is needed to determine if an individual case and outcome was correctly classified as a sentinel event. Just as the rate of ICU admission and transfusion of 4 or more units of blood should not automatically be labeled as sentinel events, their rates of occurrence should not be used as a quality metric. These screening criteria are the minimum recommended criteria and institutions may choose to incorporate additional screening criteria to highlight cases for detailed review at their own discretion.

Conclusions

Screening for and detection of severe maternal morbidity is an important step toward promoting safe obstetric care. 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.

Recommendations

  • Like in cases of maternal mortality, cases of severe maternal morbidity merit quality review. (1C)
  • Facilities should have a screening process in place to detect cases of severe maternal morbidity for review. (1C)
    • — The College and SMFM recommend using two criteria to screen for severe maternal morbidity: 1) transfusion of 4 or more units of blood and 2) admission of a pregnant or postpartum woman to an ICU. (1B)
    • — Institutions may choose to incorporate additional screening criteria to highlight cases for detailed review. (1C)
  • Facilities should review all cases that meet at least one of these screening criteria to determine whether the case is truly a severe maternal morbidity; to characterize the events, diagnoses, and outcomes involved; and to determine if an identified morbidity is judged to have been potentially avoidable and, thus, present opportunities for system change and improved future performance. (1C)
  • Not all cases that meet criteria for review will represent preventable severe morbidity; some cases of morbidity reflect the underlying health of a woman or her pregnancy and are thus unavoidable. Therefore, simply screening positive for one of the two recommended screening criteria does not constitute a sentinel event, and the rates of occurrence of either criterion (ICU admission and transfusion of 4 or more units of blood) should not be used as a quality metric. (1C)

For More Information

The American College of Obstetricians and Gynecologists and SMFM have identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/more-info/SevereMaternalMorbidity.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s web site, or the content of the resource. The resources may change without notice.

References

  1. Mantel GD, Buchmann E, Rees H, Pattinson RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998;105:985–90. [PubMed
  2. Pattinson R, Say L, Souza JP, Broek N, Rooney C. WHO maternal death and near-miss classifications. WHO Working Group on Maternal Mortality and Morbidity Classifications. Bull World Health Organ 2009;87:734. [PubMed] [Full Text]
  3. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012;120:1029–36. [PubMed] [Obstetrics & Gynecology]
  4. Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Available at: http://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Retrieved May 23, 2016.
  5. Public Health Agency of Canada. Severe maternal morbidity in Canada. Ottawa (ON): PHAC; 2013. Available at: http://sogc.org/wp-content/uploads/2013/05/Morbidity-EN-Final-PDF.pdf. Retrieved May 25, 2016.
  6. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015;125:5–12. [PubMed] [Obstetrics & Gynecology]
  7. Geller SE, Rosenberg D, Cox SM, Brown ML, Simonson L, Driscoll CA, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004;191:939–44. [PubMed] [Full Text]
  8. Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D’Alton M. Facility-based identification of women with severe maternal morbidity: it is time to start. Obstet Gynecol 2014;123:978–81. [PubMed] [Obstetrics & Gynecology]
  9. Kilpatrick SJ, Berg C, Bernstein P, Bingham D, Delgado A, Callaghan WM, et al. Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol 2014;124:361–6. [PubMed] [Obstetrics & Gynecology]
  10. Main EK, Abreo A, McNulty J, Gilbert W, McNally C, Poeltler D, et al. Measuring severe maternal morbidity: validation of potential measures. Am J Obstet Gynecol 2016;214:643.e1–10. [PubMed] [Full Text]
  11. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008;199:36.e1–5; discussion 91–2, e7–11. [PubMed] [Full Text]
  12. Geller SE, Rosenberg D, Cox S, Brown M, Simonson L, Kilpatrick S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol 2004;57:716–20. [PubMed] [Full Text]
  13. You WB, Chandrasekaran S, Sullivan J, Grobman W. Validation of a scoring system to identify women with near-miss maternal morbidity. Am J Perinatol 2013;30:21–4. [PubMed] [Full Text]
  14. American College of Obstetricians and Gynecologists, Association of Women’s Health, Obstetric and Neonatal Nurses, The Joint Commission, Society for Maternal-Fetal Medicine. Severe maternal morbidity: clarification of the new Joint Commission sentinel event policy. Washington, DC: American College of Obstetricians and Gynecologists, AWHONN, SMFM; Oakbrook Terrace (IL): Joint Commission; 2015. Available at: http://www.acog.org/About-ACOG/News-Room/Statements/2015/Severe-Maternal-Morbidity-Clarification-of-the-New-Joint-Commission-Sentinel-Event-Policy. Retrieved May 25, 2016.

 

Society for Maternal–Fetal Medicine Grading System: Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Recommendations

Obstetric Care Consensus documents will use the Society for Maternal–Fetal Medicine’s grading approach: http://www.ajog.org/article/S0002-9378%2813%2900744-8/fulltext. Recommendations are classified as either strong (Grade 1) or weak (Grade 2), and quality of evidence is classified as high (Grade A), moderate (Grade B), and low (Grade C)*. Thus, the recommendations can be one of the following six possibilities: 1A, 1B, 1C, 2A, 2B, 2C.

Society of Maternal Fetal Medicine Grading System

*Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. GRADE Working Group. BMJ 2008;336:924–6.

Chauhan SP, Blackwell SC. SMFM adopts GRADE (Grading of Recommendations Assessment, Development, and Evaluation) for clinical guidelines. Society for Maternal–Fetal Medicine [editorial]. Am J Obstet Gynecol 2013;209:163–5.

Full-text document published concurrently in the September 2016 issue of the American Journal of Obstetrics and Gynecology.

Copyright September 2016 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

Severe maternal morbidity: screening and review. Obstetric Care Consensus No. 5. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e54–60.

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