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    Lessons of severe maternal morbidity



    The screening criteria (ICU admission or 4 or more units of blood transfused) are not intended to be used as quality metrics.

    An SMM is not necessarily a sentinel event. The definition of a sentinel event is one in which the morbidity or death is unexpected (ie, not a result of the usual disease process) and causes death or permanent or temporary severe harm.21 For example, by this definition most SMM resulting from a placenta accreta would not meet such a definition. It is possible, however, that the review committee could determine that an SMM was, in fact, a sentinel event. In that case, the hospital should proceed with its usual sentinel event process.

    Severe morbidity review is not the same as a debriefing after a case. A debriefing is an organized, efficient meeting soon after the event that includes the providers who were directly involved in the case to specifically discuss what went well and what did not. The benefits of debriefings include learning information about the event that might not be written in the chart and having a time to support staff if the outcome warrants. Several debriefing tools are available.3,17

    Fortunately, we do not have enough maternal deaths in the United States to be able to systematically study, implement change, and see reduction in deaths in any individual center. We have, however, an estimated 60,000 cases of SMM annually (1 out of every 70 births), a number that has been increasing.11,12 Similar to maternal deaths, almost half of these cases of SMM have preventable factors.10

    If we use the CDC paradigm for reviewing maternal deaths to follow the mandate to systematically review all cases of SMM at every hospital doing obstetrics, we are likely to identify areas for improvement in care. The process of review by the multidisciplinary committee is likely to raise awareness of a variety of issues throughout the obstetric unit.

    It is hoped that just as we have seen a reduction in deaths from hemorrhage due to the introduction of hemorrhage toolkits, the knowledge gained by evaluating more cases of SMM will be translated into interventions that continue to reduce morbidity and mortality for women.



    1. Centers for Disease Control and Prevention. Pregnancy related-deaths. Updated January 12, 2016. www.cdc.gov/reproductivehealth/MaternalInfantHealth/Pregnancy-relatedMor.... Accessed May 6, 2016.

    2. Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015;125(2):521–525.

    3. California Maternal Quality Care Collaborative. OB Hemorrhage Toolkit V 2.0. Improving health care response to obstetric hemorrhage, version 2.0: A California toolkit to transform maternity care. www.cmqcc.org/ob_hemorrhage. Accessed May 6, 2016.

    4. California Maternal Quality Care Collaborative. Preeclampsia Toolkit. Improving health care response to preeclampsia: A California toolkit to transform maternity care. www.cmqcc.org/preeclampsia_toolkit. Accessed May 6, 2016.

    5. Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt). 2014;23(1):3–9.

    6.Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5–12.

    7. Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Updated January 21, 2016. www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html. Accessed May 6, 2016.

    8. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005;106(6):1228–1234.

    9. Panting-Kemp A, Geller SE, Nguyen T, et al. Maternal deaths in an urban perinatal network, 1992-1998. Am J Obstet Gynecol. 2000;183(5):1207–1212.

    10. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol. 2004;191(3):939–944.

    11. Callaghan WM, Mackay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. Am J Obstet Gynecol. 2008;199(2):133.e1–e8.

    12. Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029–1036.

    13. Grobman WA, Bailit JL, Rice MM, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol. 2014;123(4):804–810.

    14. Geller SE, Rosenberg D, Cox S, et al. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol. 2004;57(7):716–720.

    15. Main EK, Abreo A, McNulty J, et al. Measuring severe maternal morbidity: validation of potential measures. Am J Obstet Gynecol. 2016;214(5):643.e1–643.e10.

    16. Callaghan WM, Grobman WA, Kilpatrick SJ et al. Facility-based identification of women with severe maternal morbidity: it is time to start. Obstet Gynecol. 2014;123(5):978–981.

    17. Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol. 2014;124(2 Pt 1):361–366.

    18. Berg CJ. From identification and review to action--maternal mortality review in the United States. Semin Perinatol. 2012;36(1):7–13.

    19. Council on Patient Safety in Women’s Health Care: Safe Health Care for Every Woman. www.safehealthcareforeverywoman.org. Accessed May 6, 2016.

    20. 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(1):21–24.

    21. American College of Obstetricians and Gynecologists, Association of Women’s Health, Obstetric and Neonatal Nurses, Joint Commission, Society for Maternal-Fetal Medicine. Severe Maternal Morbidity: Clarification of the New Joint Commission Sentinel Event Policy. January 2015. www.acog.org/About-ACOG/News-Room/Statements/2015/Severe-Maternal-Morbid.... Accessed May 6, 2016.

    Sarah J. Kilpatrick, MD, PhD
    Dr. Kilpatrick is the Helping Hand Endowed Chair in the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los ...
    Cynthia J Berg, MD, MPH
    Dr Berg is a medical epidemiologist in the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.


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