A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery.

BACKGROUND: The obstetric comorbidity index summarizes the burden of maternal comorbidities into a single number and holds promise as a maternal risk-assessment tool. OBJECTIVE: The aim of this study was to assess the clinical performance of this comorbidity-based screening tool to accurately identify women on labor and delivery who are at risk of severe maternal morbidity on labor and delivery in real time. STUDY DESIGN: All patients with pregnancies ≥23 weeks gestation presenting to labor and delivery at a single tertiary-care center from February through July 2018 were included in the study. The patient's primary labor and delivery nurse assessed patient comorbidities and calculated the patient's obstetric comorbidity index. The score was recalculated at each 12-hour shift change. A multidisciplinary panel of clinicians determined whether patients experienced severe maternal morbidity based on the American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine consensus definition, blinded to the patient's obstetric comorbidity index score. We analyzed the association between the obstetric comorbidity index score and the occurrence of severe maternal morbidity. RESULTS: The study included 2828 women, of whom 1.73% experience severe maternal morbidity (n=49). The obstetric comorbidity index ranged from 0-15 for women in the study cohort, with a median obstetric comorbidity index of 1 (interquartile range, 0-3). The median obstetric comorbidity index score for women who experienced the severe maternal morbidity was 5 (interquartile range, 3-7) compared with a median of 1 (interquartile range, 0-3) for those without severe maternal morbidity (P<.01). The frequency of severe maternal morbidity increased from 0.41% for those with a score of 0 to 18.75% for those with a score ≥9. For every 1-point increase in the score, patients experienced a 1.55 increase in odds of severe maternal morbidity (95% confidence interval, 1.42-1.70). The c-statistic for the obstetric comorbidity index score was 0.83 (95% confidence interval, 0.76-0.89), which indicated strong discrimination. CONCLUSION: The obstetric comorbidity index can prospectively identify women at risk of severe maternal morbidity in a clinical setting. A particular strength of the obstetric comorbidity index is its ability to integrate multiple compounding comorbidities and highlight the cumulative risk that is associated with the patients' conditions. Routine clinical use of the obstetric comorbidity index has the potential to identify at-risk women whose condition warrants increased surveillance and targeted care to prevent adverse maternal outcomes.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts.

OBJECTIVE: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.