Episode #22 Part 2: Maternal Safety Bundles

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

We are venturing out side of the operating room and up to the labor and delivery suite once again to discuss maternal patient safety from the perspective of what then and what now.  This is the exciting sequal to our 2 part show on maternal safety bundles.

Before we dive into today’s episode, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

I also want to remind you about an exciting research opportunity.  The APSF is working with the Foundation for Anesthesia Education and Research or FAER to help promote the upcoming Mentored Research training grant. This is a two-year, $300,000 award that aims to help anesthesiologists develop the skills and preliminary data they need to become independent investigators in the field of anesthesia patient safety. If you are interested in pursuing the APSF/FAER mentored research training grant will need to submit a Letter of Intent prior to submitting a full application. The LOI submissions will open December 1, 2020 and close January 1, 2021. More information can be found on our website and I will include a link in the show notes.  https://www.apsf.org/grants-and-awards/apsf-faer-mentored-research-training-grant/

We are going to return to the 35^th Anniversary APSF Newsletter to discuss the updated 2020 article, “National Partnership for Maternal Safety— Maternal Safety Bundles” by Jennifer Banayan and Barbara Scavone. You can find the article at APSF.org by clicking on the Newsletter heading, first one down is the current issue. Then scroll down and you will see the article listed on the left. I will include a link to the article in the show notes.

Back in 2016, the authors wrote that it was important to understand that many cases of maternal morbidity and mortality could be prevented and they left us with a call to action for anesthesia professionals to play an important role on the obstetric care team and can help to manage patients with life-threatening emergencies.

So, what has changed in the past 4 years? We can look at the October 2020 35^th Anniversary APSF Newsletter to find out What’s Next. Banayan and Scavone provide this update as well.  In 2007, the US maternal mortality rate or MMR was 12.7 per 100,000.  I will warn you, the next statistic is not good news. The National Vital Statistics Report from the National Center for Health Statistics provided an updated maternal mortality rate from 2018, that was published in January 2020. We continue to have the worst rate of all the developed countries and the MMR has increased to 17.4 per 100,000. Women 40 years and older have the highest mortality rate with a rate of 81.9 per 100,000 births. In addition, African American women have a higher risk as well with an MMR of 37.1 deaths per 100,000 which is 2.5 times higher than non-Hispanic white women who have an MMR of 14.7 and it is 3 times higher than Hispanic women who have an MMR of 11.8. The highest mortality risk involves advanced age and black race and a black woman over the age of 40 has a 1 in 700 chance of dying during her delivery hospitalization. It is hard just to read these statistics aloud, but it is important because we have to figure out what happened and why maternal mortality did not improve after the bundles started to be created back in 2015. The maternal safety bundles did lead to changes across the country with the creation of hemorrhage kits, carts, protocols, checklists, response teams and participation in huddles and debriefing to improve patient care at the system level, so maybe just not enough time has passed for these changes to impact patient outcomes. But maybe it is not just the time interval since many institutions did not implement or adhere to the recommended protocols.  Places with widespread adoption of the bundles such as the state of California have seen improvements in outcomes with differences in hemorrhage severity, transfusions, and emergency hysterectomies.

Let’s take a look at the Center for Disease Control and Prevention’s Pregnancy Mortality Surveillance System which reveals that minority groups including non-Hispanic black and non-Hispanic American Indian Alaska native women have significantly higher mortality rates than all other racial and ethnic groups. Even when controlling for education and socioeconomic status, Black women have a higher mortality rate so that African American women with relative social and economic advantages, such as a college degree, have higher risks for morbidity and mortality in pregnancy than white women who do not have these relative social and economic advantages. This is a significant healthcare disparity for Black Women. It may be due to chronic stress due to unrelenting systemic racism experiences by black women in this country leading to physiological strain and higher rates of hypertension and pre-eclampsia and higher rates of maternal deaths. The authors tells us that “In other words, the everyday stressors experienced simply by being a Black woman in America increases the likelihood of experiencing illness and dying from it, and this extends to the pregnancy and postpartum periods.” In addition, healthcare workers may fail to recognize and act on important concerns and symptoms reported by black patients due to racism and implicit bias. In order to prevent maternal death, health care workers must recognize and act early even though symptoms may be vague. The racial disparity for maternal patient safety is very concerning.

Another threat to maternal patient safety involves opioid-use disorders and mental health and suicide-related deaths. Pregnant women may be at increased risk for opioid overdose and we have seen the rate of pregnancy-associated mortality related to medication overdose double between 2007 and 2016. In 2019, a retrospective, population-based cohort study  of over one million women who delivered a live-born infant in California revealed that deaths due to drugs was the 2^nd highest cause of death and deaths from suicide was the 7^th leading cause during the postpartum time period. This is not a unique finding in the United States as Japan and the United Kingdom have also reported high rates for postpartum suicide and mental health disorders for postpartum women.

Obstetric patients with opioid dependency who have developed tolerance and hyperalgesia are likely to report higher postpartum pain scores. These patients may require higher doses for opioids for pain control but care must be taken to monitor for the sedative and respiratory depressive effects as well. In the past 4 years, we have seen that women with substance abuse are more likely to need a cesarean delivery and a blood transfusion during delivery. They also have an increased risk of death. Patient who present for delivery and are opioid-naïve are not exempt from risk since women who are opioid-naïve are at risk for developing an opioid dependence if they are prescribed opioids at the time of discharge. Risk factors for this include patients with a history of psychiatric illness, use of other illicit substances, and patients with chronic pain disorders. Multimodal pain management is an important strategy to help decrease opioid administration. Going forward, it will be important to evaluate pregnancy-associated deaths from opioid-use disorders and suicide along with other causes of maternal death so that we can work towards improved prevention of these deaths in the future. More work is definitely needed to address maternal mental health and substance abuse in obstetric patients.

The authors leave us with a vital call to action…we do indeed have a lot of work still to do. As more maternal safety bundles are created, it is important for clinicians to adopt these practices into the standard work at their institutions. Since the original 2016 article, new bundles have been released by the National Partnership for Maternal Safety including the Bundle on Racial and Ethnic Disparities and the bundle on Obstetric Care for Women with Opioid Use Disorder. In addition, in 2017, the Bundle on Surgical Site Infections and the Bundle on Maternal Mental Health were created and in 2018, the Bundle on Safe Reduction of Primary Cesarean Births was published. I will include a list of the available bundles and a link to the website in the show notes. Are you using these bundles at your institution? Also, if you check out the website, you will see that more bundles are still be created with 2 currently in development for Cardiac Conditions in Obstetrical Care and Postpartum Discharge Transition.

Where are we now? There is awareness of the scope of the problem, that the United States has the highest MMR of all the high-resource countries. In addition, there is an action plan for helping to make changes, but our MMR has continued to climb.  It may be just that pregnant women in the US are older and have more significant medical comorbidities and maybe we just need more time to see an improved MMR.  But let’s not wait, anesthesia professionals have an important part in helping to implement these bundles to help make obstetric care safer for our patients. Our scope of practice is not limited to spinal and epidural procedures. The authors remind the readers that anesthesia professionals must act as peripartum clinicians and work on multidisciplinary teams to help improve maternal safety.

Before we wrap up for today, Banayan leaves us with some final thoughts. I asked her what does she envision for the future with regards to maternal safety and anesthesia care.

[Jennifer Banayan] “I’m actually really optimistic about the future. I think that we’ve done a really good job of getting out the message that we need to focus on maternal care in this country. We’ve done a really good job of hemorrhage protocols and incorporating hemorrhage kits and bundles into all the birthing centers in this country and I think it is just going to take more.”

Thank you for sharing your thoughts with us and we are looking forward to seeing improved and safer maternal care going forward.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  If you are enjoying listening to this podcast, please take a minute to rate us and leave us a review and you can share this podcast with your friends, families, and colleagues and anyone you know who is committed to anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation