Safe Maternal Care

Dr Niamh Hayes

CAI Education & PCS Chair

Dept. of Anaesthesia, Rotunda Hospital

HISTORICAL CONTEXT Throughout history, it has been recognised that pregnancy and childbirth is a dangerous time for both mother and child. Although many other episodes of medical illness were associated with high death rates too, at least those patients had usually been sick beforehand, in contrast to young, healthy women who often had dependent children at home to be cared for. Maternal mortality or severe morbidity is devastating for the women themselves but also for their broader family. In Western Europe at the beginning of the 20th century, maternal mortality was largely due to puerper-al fever, obstetric haemorrhage, toxaemia of pregnancy and complications of illegal abortion. Alt-hough Ignaz Semmelweis correctly identified that the obstetric “sepsis arose from the inoculation of cadaver particles” when medical students and practising physicians went between autopsies and deliveries (several decades before germ theory was proposed), and even implemented a successful intervention of hand-washing with chlorinated lime-water before attending to women in the labour ward, this simple method of infection prevention and control took many decades to become estab-lished practice (although hand-washing does get a positive nudge in the wake of disease outbreaks including following SARS CoV—1 in Hong Kong in 2003 — clean fingers crossed that the same will happen after SARS CoV—2!).

A sudden and dramatic decrease in maternal mortality occurred after the First World War as the re-sult of effective antimicrobial therapy for puerperal infection. Deaths continued to decrease through the 1900s for a number of reasons: better overall heath and improved education of women, availabil-ity of effective contraception, uterotonic drugs and transfusion medicine to limit haemorrhage, and effective antenatal care to monitor for pre-eclampsia and intervene if necessary. The professional training and registration of medical practitioners and midwives has also been important. Specifical-ly, there has been a significant reduction in anaesthesia-related deaths in obstetrics in the past 50 years and anaesthesia for caesarean delivery in the UK is 30 times safer today than it was 50 years ago (Maternal Death Enquiry Reports).

GLOBAL ISSUES Currently, maternal mortality ratios (MMR) are little changed in the developing world from where they were in Western Europe a century ago — in 1928 the MMR was 400 per 100,000 pregnancies in England, this is the same as that in Low and Middle Income Countries (LMIC) today. A staggering 95% of maternal deaths worldwide occur in LMIC and 95% of these are deemed preventable (if we could reduce the MMR in these countries to the same as the European Union). Given that 140 mil-lion women give birth each year, there are approximately 800 preventable maternal deaths per day. Coupled with 4 million neonatal deaths per annum and a similar number of miscarriages, the toll on the developing world and on women in general is drastic. The direct causes of maternal mortality are still puerperal fever, obstetric haemorrhage, toxaemia of pregnancy and complications of illegal abortion. For the world’s poorest, access to skilled birth assistance is the major issue, with poverty, distance to healthcare unit, lack of birth information, inadequate services, and cultural beliefs and practices all contributing (https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality). The WHO has set an ambitious sustainable development goal by 2030: reducing global MMR to less than 70 per 100,000 births, with no country having a maternal mortality rate of more than twice the global average. Overall, the world is a much safer place to give birth than the past, but it is still awful in the poorest countries, and we can and must do better from a social justice point of view.

“FIRST” WORLD

"There is no statistic that can quantify what it's like to tell an 18-month-old that his mother is never coming home” — the words of Charles Johnson whose wife Kira died from preventa-ble postpartum haemorrhage.

Maternal Death Enquiry Reports from the UK and Ireland continue to identify significant inequalities in maternity care in our setting. In recent reports, the most disadvantaged women (unemployed, single, poor members of ethnic minority groups) were 20 times more likely to die in pregnancy than women from higher socio-economic groups. Evaluation of factors contributing to deaths is a particu-lar feature of reports that can offer an opportunity for healthcare practitioners to change our practice for the better. Recognition of the specific vulnerabilities of some women in our care is important, but so too is looking at how and why some births are not as safe as they should be — looking at sub-standard care to try to address preventable harm to others in the future.

A maternal mortality report from London in 1924 highlighted that many of the deaths were deemed “a burden of avoidable suffering”. Those women did not have to die. The direct causes of maternal mortality (puerperal sepsis , etc.) are matched with a set of consistent themes of substandard care: failure to recognise problems, failure to escalate care to senior colleagues, poor team working and failure of non-technical skills — communication in particular. In 2012, the death of Savita Halappa-navar resulted from a general lack of provision of basic care, failure to recognise the risk of clinical deterioration, and failure to escalate concerns. Depressingly, the report into the care of Savita reads almost exactly along the lines of the HSE report into the death of Tania McCabe and her son Zach, who both died 5 years previously. We owe it to those women and their families who have suffered from preventable harm in our care to learn from these reports, and not just repeat the same mistakes over and over again. More than a half of maternal deaths are deemed to be preventable, and this proportion has not changed much in a century.

MATERNAL SAFETY Patient safety in general is challenging. Problems of underuse and/or omission of care are very evident in the developing world with lack of access to skilled midwifery and obstetric care. They are also evident in the Irish reports above when failure to escalate care to the level proportionate to evolving critical illness were contributory to devastating outcomes. Misdiagnosis is not uncommon in pregnancy where “normal” adaptive physiologic changes can overlap indicators of evolving pa-thology. Unfortunately, misdiagnosis can be exacerbated by carers’ implicit bias which likely con-tributes to the vulnerability of certain pregnant patient cohorts — in the USA black mothers do worse in terms of morbidity and mortality even when corrections are made for educational attain-ment and socio-economic status. Trying to understand this discrimination and specifically address-ing social, cultural and ethnic barriers to care is important. Potential overuse of care processes can also be problematic. Caesarean section rates have increased dramatically in the developed world. It is not clear that this has contributed to a decrease in maternal or perinatal mortality, but it has con-tributed significantly to maternal morbidity. Importantly, trying to achieve low caesarean targets can also contribute to disastrous poor maternal and neonatal outcomes (https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf).

High reliability organisations operate in situations that have the potential for large-scale harm but manage to balance efficiency, effectiveness and safety. Given the uncertainty, intractability and complexity of modern healthcare, the Agency for Healthcare Research and Quality (AHRQ) are seeking to adopt characteristics of high reliability organisation theory (HROT) to improve maternity care in the USA where potential problems are anticipated, detected early, and responded to quickly so that dire outcomes are avoided (https://psnet.ahrq.gov/primer/maternal-safety). This can be summarised as the “4Rs”: readiness for, recognition of, response to, and reporting (learning from) when care goes wrong. It is an accurate summary of where things did go wrong in recent re-ports of maternal deaths in Ireland (vide supra), and the emphasis in AHRQ maternal safety bundles is on standardisation of care and effective teamwork. Opportunities for improvement in mothers’ safety exists at multiple levels: nationally in terms of poli-cies and frameworks, locally within maternity units, and with individual clinicians and patients. At every level, a preoccupation with safety and commitment to resilience on behalf of our patients should exist. Things are changing for the better in the past decade. An emerging picture of what “good” maternal care looks like has been described in the National Maternity Strategy and relevant maternity standards outlined by the Health Information and Quality Authority (https://assets.gov.ie/18835/ac61fd2b66164349a1547110d4b0003f.pdf, https://www.hiqa.ie/sites/default/files/2017-02/national-standards-maternity-services.pdf). Clarity of descriptors of complications are collated by the National Perinatal Epidemiology Centre (https://www.ucc.ie/en/npec/), and coordinated annual quality and safety indicators, maternity safety statements and national claims analysis are published by the National Women and Infants Health Programme (https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/). Assess-ment of individual units against standards shows some elements of good practice in relation to re-sponse to obstetric emergencies but identifies areas for improvement in workforce arrangements and training of clinical staff to manage obstetric emergencies among others. There is still a long way to go to implement the National Maternity Strategy and to guarantee the highest standards of care. However, anaesthesiologists at every level can show leadership in facilitating effective safety culture in their own workplace and progressing training (including multiprofessional team training), and consider how the 4Rs above relate to their practice in a real sense. Finally, there is an attempt to actually listen to women themselves and both appreciate and learn from their personal stories of maternity care (https://yourexperience.ie/wp-content/uploads/2020/09/National-Maternity-Experience-Survey-results.pdf). BROAD-SPECTRUM SAFETY Acknowledging that patients and their loved ones can provide valuable insights into their care is im-portant for carers, and not just because it provides better health outcomes across all measures of clinical quality. The potential for emotional harm to patients, even when ostensibly nothing has “gone wrong” is evident from the anaesthesiology commentary in the Maternity Experience Survey. While much went right for mothers in their interactions — we know this because we hear genuine expressions of gratitude every day in practice and women have taken time to praise outstanding care in the survey— some things went wrong, particularly in the domain of building relationships, with multiple opportunities to improve rapport (demonstrating empathy), gathering and giving infor-mation. The perception of unkindness makes patients feel small, vulnerable and unsafe. Commu-nication is a trainable skill. The National Healthcare Communication Programme (https://www.hse.ie/nhcprogramme) have developed tools to develop empathy: https://bit.ly/3a9xc32; https://bit.ly/3ap15MV. Remember that in every interaction, the patient will never care how much you know until they know how much you care. Whatever about casual or thoughtless unkindness when there has been no adverse event in care, consider the situation when patients or their loved ones have been seriously harmed by care and are treated without respect. How much must this compound the hurt they feel? Serious adverse events will always happen, for various reasons often beyond the control of an individual clinician, but by managing them empathetically and respectfully you don’t fail that patient or family in the aftermath — and better protect the next patient that you care for. From the Ockenden report it is clear that we all share the same future goals and concerns for safe maternity care: “The families who have contributed to this review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past”. Listen to women. Respectful care is an essential compo-nent not just of quality and safety but of basic human rights and dignity. Help to prevent repeating the mistakes of the past. And help ourselves to cope with inevitable poor outcomes.