Standardized Severe Maternal Morbidity Review: Rationale and Process

To begin a national effort to reduce maternal morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of 4 or more units of blood for routine review has been made.1 The increasing rates of maternal mortality and severe morbidity in the United States have been well-documented in recent publications.2–5 It is therefore appropriate that efforts should be focused on reducing maternal severe morbidity and death.6–8 Reviews of maternal deaths in order to identify likely preventable deaths and interventions to reduce preventable deaths have been widespread for years.9,10 However, the call to similarly implement routine standardized identification and evaluation of severe maternal morbidity cases by every birthing facility in the United States has only recently been highlighted.1 Although several methods have been proposed to identify women with severe maternal morbidity, the criteria proposed by Callaghan et al were admission of the mother to an intensive care unit (ICU) or receipt of 4 or more units of blood.1,11 These criteria were chosen because they are simple and have high sensitivity and specificity for identifying pregnant and recently postpartum women with severe morbidity.12,13 The sensitivities were 63% to 86% when each was used individually, but up to 100% if combined.12,13 It should be emphasized that while these criteria are reliable markers of potential severe maternal morbidity, the fact that a patient was admitted to an ICU or received 4 or more units of blood alone do not imply that care and systems were substandard. In fact, it is the review of the case that ultimately determines 1) if the case is a severe maternal morbidity and 2) whether there were improvements in processes or care necessary. While advocating for review of these cases, no specific guidance for the review process were provided.1 The aim of this document is to present a suggested standardized severe maternal morbidity review process to identify systems, professional, and facility factors that could be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician–gynecologists, maternal–fetal medicine subspecialists, certified nurse–midwives, and registered nurses. These individuals were appointed by their respective organizations, including the American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine, Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), American College of Nurse-Midwives, and Centers for Disease Control and Prevention, and all authors have state or national experience with maternal mortality review. The review process, organization, and forms were modeled after Illinois and California maternal mortality review processes and forms9 (personal communication, Elizabeth Lawton, CA Department of Public Health, Maternal Child and Adolescent Health Division, and Elliot Main, Department of Obstetrics and Gynecology, California Pacific Hospital; 2013). The following recommendations for the development and maintenance of a severe maternal morbidity review process are intended as guidelines and could be modified at individual centers. This process is consistent with The Joint Commission’s template for root cause analysis to be employed for sentinel events.14 Of note, maternal deaths are considered sentinel events and thus reviewed by root cause analysis. We suggest that the morbidity review process herein described could be modified and used for maternal death review if appropriate for local process.