Deeper Than the Headlines: Maternal Health IHS

The OIG has added a new item to its work plan in July 2019. It’s about the quality of maternal healthcare in Indian Health Service Hospitals. Maternal mortality and morbidity are increasing in the United States, and up to 60 percent of maternal deaths may be preventable. The American College of Obstetricians and Gynecologists issue guidance on safe practices during labor and delivery intended to help reduce maternal mortality and other complications.

Early analysis of medical record review results for the study Adverse Events in Indian Health Service Hospitals (OEI-06-17-00530) identified instances in which Indian Health Service (IHS) hospital providers did not follow recommended practices and may have put patients at unnecessary risk. Failure to follow recommended practices is not necessarily improper and does not always cause patient harm, but it may indicate a substandard quality of care.

The OIG will use medical record reviews by an obstetrician/gynecologist specializing in patient safety to identify and describe examples of potentially substandard care during labor and delivery in IHS hospitals. These anecdotes may help IHS to target hospital improvement efforts. OIG will also identify factors that may be related to potentially substandard care. According to one study cited by the OIG, severe morbidity rates for delivery and postpartum increased by 75% and 114% for delivery and postpartum hospitalizations, respectively when comparing the time period of 1998–1999 to 10 years later in 2008–2009 (i). That same study found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations.

The American College of Obstetricians and Gynecologists or ACOG, has published clinical guidance for obstetric care and severe maternal morbidity screening and review. (ii) This guide may be of substantial assistance for hospital compliance and/or quality programs dealing with these issues. For example, this guidance document discusses answers to the following questions:

• What is severe maternal morbidity?
• What process can be used to identify cases with potential severe maternal
morbidity that merit review?
• When does severe maternal morbidity represent a sentinel event?

The ACOG guidance document also provides a grading system, known as “Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Recommendations.” The OIG also cited a 76-page report from the CDC, entitled “Building U.S. Capacity to Review and Prevent Maternal Deaths: Report from Nine Maternal Mortality Review Committees.” (iii) The CDC report states the Nine Committees estimated that over 60% of pregnancy-related deaths were preventable. The most common factors identified as contributing to the death of patients were patient/family factors (e.g., lack of knowledge on warning signs and need to seek care) followed by the provider (e.g., misdiagnosis and ineffective treatments) and systems of care factors (e.g., lack of coordination between providers). Even if your organization is not an Indian Health Service Hospital, it might be useful to review these cited resources in the context of your organization’s quality efforts, as well as review the OIG after it is completed and published.

Sources

i Callaghan, WM, "Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States." Obstetrics and Gynecology, Nov. 2012. Accessed at https://journals.lww.com/greenjournal/Fulltext/2012/11000/Severe_Maternal_Morbidity_Among_Delivery_and.8.aspx#pdf-link on June 17, 2019.

ii American College of Obstetricians and Gynecologists, "Obstetric Care Consensus," Sept. 2016 (reaffirmed 2018). Accessed at https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Severe-Maternal-Morbidity-Screening-and-Review?IsMobileSet=false July 17, 2019.

iii Centers for Disease Control and Prevention Foundation, "Building U.S. Capacity to Review and Prevent Maternal Deaths: Report from Nine Maternal Mortality Review Committees." Accessed at https://www.cdcfoundation.org/sites/default/files/files/ReportfromNineMMRCs.pdf on July 17, 2019.