Comparing State-Level and Facility-Based Review to Assess Quality of Severe Maternal Morbidity Reviews.

OBJECTIVE: To compare results from facility-level and state-level severe maternal morbidity (SMM) reviews in Illinois. DESIGN: We report descriptive characteristics about SMM cases and compare the results of both review processes, including the primary cause, assessment of preventability, and factors that contributed to the severity of the SMM cases. SETTING: All birthing hospitals in Illinois. PARTICIPANTS: A total of 81 SMM cases were reviewed by a facility-level committee and the state-level review committee. SMM was defined as any intensive care or critical care unit admission and/or transfusion of 4 or more units of packed red blood cells from conception to 42 days postpartum. RESULTS: Among the cases reviewed by both committees, hemorrhage was the primary cause of morbidity, with 26 (32.1%) and 38 (46.9%) hemorrhage cases identified by the facility-level and state-level committees, respectively. Both committees identified infection/sepsis (n = 12) and preeclampsia/eclampsia (n = 12) as the next most common causes of SMM. State-level review found more cases potentially preventable (n = 29, 35.8% vs n = 18, 22.2%) and more cases not preventable but improvement in care needed (n = 31, 38.3% vs n = 27, 33.3%). State-level review found more provider and system opportunities to alter the SMM outcome and fewer patient opportunities than facility-level review. CONCLUSION: State-level review found more SMM cases potentially preventable and identified more opportunities to improve care than facility-level review. State-level review has the potential to strengthen facility-level reviews by identifying opportunities to improve the review process and develop recommendations and tools to aid facility-level reviews.

Examining the potential preventability of adverse fetal/neonatal outcomes associated with severe maternal morbidity.

BACKGROUND: Severe maternal morbidity (SMM) occurs in 1-2% of pregnancies. Despite the knowledge that a SMM event can contribute to poor fetal/neonatal outcomes, little is known about the preventability of these adverse outcomes. AIMS: To examine adverse fetal/neonatal outcomes associated with SMM to determine if these outcomes were potentially preventable. MATERIALS AND METHODS: A New Zealand national retrospective cohort study examining cases of SMM with an adverse fetal/neonatal outcome. Maternity and initial neonatal care were explored by multidisciplinary panels utilising a preventability tool to assess whether the fetal/neonatal harm was potentially preventable. Adverse fetal/neonatal outcomes were defined as fetal or early neonatal death, Apgar score <7 at five minutes, admission to neonatal intensive care unit or special care baby unit and neonatal encephalopathy. RESULTS: Of 85 cases reviewed, adverse fetal/neonatal outcome was deemed potentially preventable in 55.3% of cases (n = 47/85). Preventability was related to maternal antenatal/peripartum care (in utero) in 39% (n = 33/85), to initial neonatal care (ex utero) in 36% (n = 29/80), and to both maternal and neonatal care in 20% (16/80) of cases. Main contributors to potential preventability were factors related to healthcare providers, particularly lack of recognition of high risk, delayed or failure to diagnose, and delayed or inappropriate treatment. CONCLUSIONS: Multidisciplinary panels found that over half of adverse fetal/neonatal harm associated with SMM was potentially preventable. The novel approach of examining both maternal and neonatal care identifies opportunities to improve fetal/neonatal outcomes associated with SMM at multiple points on the perinatal continuum of care.

Reaching under-screened/never-screened indigenous peoples with human papilloma virus self-testing: A community-based cluster randomised controlled trial.

BACKGROUND: Indigenous women in the high-income countries of Canada, Australia, New Zealand and USA, have a higher incidence and mortality from cervical cancer than non-Indigenous women. Increasing cervical screening coverage could ultimately decrease cervical cancer disparities. AIMS: To increase cervical screening for under-screened/never-screened Maori women. MATERIALS AND METHODS: This study was a cluster randomised controlled trial. Inclusion criteria were women aged 25-69, last screened ≥4 years ago, in Northland, New Zealand. The intervention arm was the offer of a human papilloma virus (HPV) self-test and the control arm was the usual offer of standard care - a cervical smear. The primary outcome was rate of cervical screening in the intervention group compared to control in Maori, the Indigenous peoples of New Zealand. Six primary care clinics were randomly allocated to intervention or control. RESULTS: Of 500 eligible Maori women in the intervention arm, 295 (59.0%) were screened. Of 431 eligible Maori women in the control arm, 94 (21.8%) were screened. Adjusting for age, time since last screen, deprivation index, Maori women in the intervention arm were 2.8 times more likely to be screened than women in the control arm (95% CI: 2.4-3.1, P-value <0.0001). CONCLUSIONS: Offer of HPV self-testing could potentially halve the number of under-screened/never-screened Maori women and decrease cervical morbidity and mortality. These results may be generalisable to benefit Indigenous peoples facing similar barriers in other high-income countries.

Severe maternal morbidity due to obstetric haemorrhage: Potential preventability.

BACKGROUND: Haemorrhage in pregnancy may be life-threatening to woman and infant. The impact of severe obstetric haemorrhage can be reduced by detecting high-risk women, implementing guidelines and treatment plans, early detection of hypovolaemia and timely appropriate treatment. AIMS: To describe cases of severe maternal morbidity caused by obstetric haemorrhage in New Zealand and investigate the potential preventability of these cases. MATERIALS AND METHODS: A multidisciplinary expert review panel was established to review cases of obstetric haemorrhage admitted to intensive care or high-dependency units over an 18-month span in New Zealand. Cases were critically analysed by a multidisciplinary team of clinicians to determine the potential preventability. RESULTS: One hundred and twenty cases were identified, most commonly due to postpartum haemorrhage with 36% (n = 43) deemed potentially preventable, mainly due to delay or failure of diagnosis (65%, 28/43) and/or failure or delay in treatment (91%, 39/43). Twenty-three per cent of cases (28/120) resulted in peripartum hysterectomy of which one-third were deemed potentially preventable. CONCLUSIONS: Prompt recognition and treatment in accordance with evidence-based guidelines is imperative to decrease the burden of morbidity from obstetric haemorrhage. An emphasis on training clinicians to identify haemorrhage in a timely way may avoid unnecessary obstetric emergencies and can improve maternity and neonatal outcomes.

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity.

BACKGROUND: While there is a global focus on severe maternal morbidity (SMM), less is known about the impact of SMM on fetal and neonatal outcomes. AIMS: To examine fetal/neonatal outcomes associated with SMM. MATERIALS AND METHODS: A national New Zealand (NZ) retrospective cohort study describing fetal/neonatal outcomes of all women with SMM admitted to a NZ Intensive Care Unit (ICU) or High Dependency Unit (HDU) in 2014. Adverse fetal/neonatal outcomes were defined as one or more of the following: fetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score less than seven at five minutes, admission to Neonatal Intensive Care Unit or Special Care Baby Unit. RESULTS: There were 400 women with SMM admitted to NZ ICU/HDU units in 2014, and 395 (98.8%) had complete birth/pregnancy outcome information. Of these, 49.4% (195/395) were associated with an adverse fetal/neonatal outcome. Indigenous Maori women had a 30% higher rate of adverse fetal/neonatal outcome compared to NZ European women (63.7% and 48.9% respectively; relative risk = 1.30, 95% CI 1.04-1.64). Pre-eclampsia was associated with an adverse fetal/neonatal outcome in 67% (81/120). Perinatal-related mortality rate was 53.1 per 1000 total births compared to NZ perinatal mortality of 11.2 per 1000 total births for 2014. CONCLUSION: SMM events are associated with high rates of adverse fetal/neonatal outcomes with a higher burden of adverse events for Maori. Further research is needed to explore opportunities in maternal and neonatal care pathways to improve fetal/neonatal outcomes and address inequities.

Preventability review of severe maternal morbidity.

INTRODUCTION: Severe maternal morbidity (SMM) is rising globally. Assessing SMM is an important quality measure. This study aimed to examine SMM in a national cohort in New Zealand. MATERIAL AND METHODS: This is a national retrospective review of pregnant or postpartum women admitted to an Intensive Care Unit or High Dependency Unit during pregnancy or recent postpartum. Outcomes were rates of SMM and assessment of potential preventability. Preventability was defined as any action on the part of the provider, system or patient that may have contributed to progression to more severe morbidity, and was assessed by a multidisciplinary review team. RESULTS: Severe maternal morbidity was 6.2 per 1000 deliveries (95% confidence interval 5.7-6.8) with higher rates for Pacific, Indian and other Asian racial groups. Major blood loss (39.4%), preeclampsia-associated conditions (23.3%) and severe sepsis (14.1%) were the most common causes of SMM. Potential preventability was highest with sepsis cases (56%) followed by preeclampsia and major blood loss (34.3% and 30.9%). Of these cases, only 36.4% were managed appropriately as determined by multidisciplinary review. Provider factors such as inappropriate diagnosis, delay or failure to recognize high risk were the most common factors associated with potential preventability of SMM. Pacific Island women had over twice the rate of preventable morbidity (relative risk 2.48, 95% confidence interval 1.28-4.79). CONCLUSIONS: Multidisciplinary external anonymized review of SMM showed that over a third of cases were potentially preventable, being due to substandard provider care with increased preventability rates for racial/ethnic minority women. Monitoring country rates of SMM and implementing case reviews to assess potential preventability are appropriate quality improvement measures and external review of anonymized cases may reduce racial profiling to inform unbiased appropriate interventions and resource allocation to help prevent these severe events.

Pre-eclampsia causing severe maternal morbidity - A national retrospective review of preventability and opportunities for improved care.

INTRODUCTION: Pre-eclampsia and related sequelae are a leading cause of severe maternal and neonatal morbidity and mortality. A significant proportion of these poor outcomes may be preventable with improvements along the continuum of maternal and neonatal care. AIMS: The aim of this study was to review cases of pre-eclampsia resulting in severe maternal morbidity, describing the maternal and neonatal outcomes and the potential preventability of severe maternal morbidity (SMM). MATERIALS AND METHODS: This was a retrospective cohort study of cases of SMM associated with severe pre-eclampsia - a subset of a national SMM review study. Inclusion criteria for this subset were women who were pregnant or within 42 days of delivery with severe pre-eclampsia as the main reason for admission to an intensive care unit or high dependency unit in New Zealand between 1 August 2013 and 31 January 2015 inclusive. A multidisciplinary expert panel reviewed cases for preventability using a validated preventability tool. RESULTS: Of the 89 severe morbidities that were reviewed, 10 had eclampsia (11%) and there were four neonatal mortalities (4.3%). Multidisciplinary committees assessed the severe morbidity as potentially preventable in 31% (28) of cases with the majority due to delays in diagnosis and suboptimal treatment. CONCLUSION: We found a high level of preventable morbidity in cases of severe pre-eclampsia with a concerning number of preventable eclampsia. Implementation of evidence-based guidelines reinforced with education would assist clinicians to improve risk recognition, timely diagnosis and treatment and decrease potentially preventable severe morbidity associated with pre-eclampsia.

Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population.

BACKGROUND: Human papillomavirus (HPV), the causative agent of cervical cancer, can be screened for using self-collected vaginal samples (self-testing). This may overcome barriers to screening for Maori women who suffer a greater burden of cervical disease than New Zealand European women. AIMS: This study aimed to explore the potential acceptability of HPV self-testing for never/under-screened (self-reported no cervical screen in 4+ years, aged 25+) Maori women by Kaupapa Maori (by, with and for Maori) mixed methods, involving hui (focus groups/interviews) and survey. MATERIALS AND METHODS: Community-based researchers ran hui with women in four regions (N = 106) and supported hui participants to collect survey data (N = 397). Healthcare providers (HCPs) were also interviewed (N = 17). Hui data were thematically analysed. Survey data were analysed by age group, rural/urban, primary health organisation (PHO) enrolment, and time since last cervical screen. RESULTS: Most survey participants were PHO-enrolled (87.15%) and attended regularly (71.79%), but did not attend regular cervical screening. A desire for bodily autonomy, including whakama (embarrassment/shyness/reticence), was the most frequently cited barrier. Three in four women reported being likely/very likely to do an HPV self-test. Nine in ten women reported being likely/very likely to attend follow up if they receive a positive HPV test result. Women and HCPs in the hui emphasised the importance of health literacy, cultural competence and empathetic support. CONCLUSION: The findings indicate that with a culturally competent introduction of HPV self-testing, many currently never/under-screened Maori women would be willing to be screened and followed up if necessary. HPV self-testing has the potential to save lives.

Physical activity and masculinity in rural men: a qualitative study of men recruited from churches.

The majority of rural US men fail to meet physical activity (PA) guidelines and are at risk for chronic diseases. This study sought to understand rural men's perceptions about PA and PA engagement and the influence of masculinity and social norms. From 2011 to 2014, 12 focus groups were conducted with men prior to a church-based health promotion intervention. Men were recruited from Illinois' rural, southernmost seven counties, where 40% of men report no exercise in the past 30 days. We used inductive content analysis methods to identify PA-related themes, and subsequently used elements of the Health, Illness, Men, and Masculinities framework as a lens to explore subthemes. We identified four themes: (i) knowledge of the positive impact of PA on health, (ii) perceptions of appropriate types of PA for men, (iii) the importance of purposeful PA and (iv) the desire to remain strong and active, particularly during aging. These findings can inform strategies for messaging and interventions to promote PA among rural men. Health promotion efforts should consider the intersections between rurality and masculinity as it relates to rural men's perceptions of PA, include information about purposeful PA and encourage them to engage in PA with a support person.

He Tamariki Kokoti Tau-Tackling Preterm: a data-linkage methodology to explore the clinical care pathway in preterm deliveries.

BACKGROUND: Significant health inequities exist around maternal and infant health for Maori, the indigenous people of Aotearoa New Zealand - and in particular around a premature (preterm) delivery. Maori babies are more likely to be born preterm (8.1%, compared to an overall rate of 7.4%) and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study. DESIGN: This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Maori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Maori whanau (family). SIGNIFICANCE OF THE STUDY: Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries - both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities.

A global view of severe maternal morbidity: moving beyond maternal mortality.

BACKGROUND: Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES: Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment. SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES: The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS: Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. CONCLUSION: Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

The Relationship between Body Mass Index in Pregnancy and Adverse Maternal, Perinatal, and Neonatal Outcomes in Rural India and Pakistan.

OBJECTIVE: The objective of this study was to describe the relationship between early pregnancy body mass index (BMI) and maternal, perinatal, and neonatal outcomes in rural India and Pakistan. STUDY DESIGN: In a prospective, population-based pregnancy registry implemented in communities in Thatta, Pakistan and Nagpur and Belagavi, India, we obtained women's BMI prior to 12 weeks' gestation (categorized as underweight, normal, overweight, and obese following World Health Organization criteria). Outcomes were assessed 42 days postpartum. RESULTS: The proportion of women with an adverse maternal outcome increased with increasing maternal BMI. Less than one-third of nonoverweight/nonobese women, 47.2% of overweight women, and 56.0% of obese women experienced an adverse maternal outcome. After controlling for site, maternal age and parity, risks of hypertensive disease/severe preeclampsia/eclampsia, cesarean/assisted delivery, and antibiotic use were higher among women with higher BMIs. Overweight women also had significantly higher risk of perinatal and early neonatal mortality compared with underweight/normal BMI women. Overweight women had a significantly higher perinatal mortality rate. CONCLUSION: High BMI in early pregnancy was associated with increased risk of adverse maternal, perinatal, and neonatal outcomes in rural India and Pakistan. These findings present an opportunity to inform efforts for women to optimize weight prior to conception to improve pregnancy outcomes.

Severe maternal morbidity due to sepsis: The burden and preventability of disease in New Zealand.

BACKGROUND: Sepsis is a life-threatening systemic condition that appears to be increasing in the obstetric population. Clinical detection can be difficult and may result in increased morbidity via delays in the continuum of patient care. AIMS: To describe the burden of severe maternal morbidity (SMM) caused by sepsis in New Zealand and investigate the potential preventability. METHODS: A multidisciplinary expert review panel was established to review cases of obstetric sepsis admitted to intensive care or high-dependency units over an 18 month span in New Zealand. Cases were then analysed for the characteristics of infection and their preventability. RESULTS: Fifty cases met the inclusion criteria, most commonly due to uterine, respiratory or kidney infection. Fifty per cent (25) of these cases were deemed potentially preventable, predominantly due to delays in diagnosis and treatment. CONCLUSIONS: A high index of suspicion, development of early recognition systems and multi-disciplinary training are recommended to decrease preventable cases of maternal sepsis.

Implementing Statewide Severe Maternal Morbidity Review: The Illinois Experience.

CONTEXT: Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines. IMPLEMENTATION: Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement. EVALUATION: Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases). DISCUSSION: Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Addressing maternal deaths due to violence: the Illinois experience.

Homicide, suicide, and substance abuse accounted for nearly one fourth of all pregnancy-associated deaths in Illinois from 2002 through 2013. Maternal mortality review in Illinois has been primarily focused on obstetric and medical causes and little is known about the circumstances surrounding deaths due to homicide, suicide, and substance abuse, if they are pregnancy related, and if the deaths are potentially preventable. To address this issue, we implemented a process to form a second statewide maternal mortality review committee for deaths due to violence in late 2014. We convened a stakeholder group to accomplish 3 tasks: (1) identify appropriate committee members; (2) identify potential types and sources of information that would be required for a meaningful review of violent maternal deaths; and (3) revise the Maternal Mortality Review Form. Because homicide, suicide, and substance abuse are closely linked to the social determinants of health, the review committee needed to have a broad membership with expertise in areas not required for obstetric maternal mortality review, including social service and community organizations. Identifying additional sources of information is critical; the state Violent Death Reporting System, case management data, and police and autopsy reports provide contextual information that cannot be found in medical records. The stakeholder group revised the Maternal Mortality Review Form to collect information relevant to violent maternal deaths, including screening history and psychosocial history. The form guides the maternal mortality review committee for deaths due to violence to identify potentially preventable factors relating to the woman, her family, systems of care, the community, the legal system, and the institutional environment. The committee has identified potential opportunities to decrease preventable death requiring cooperation with social service agencies and the criminal justice system in addition to the physical and mental health care systems. Illinois has demonstrated that by engaging appropriate members and expanding the information used, it is possible to conduct meaningful reviews of these deaths and make recommendations to prevent future deaths.

Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative.

Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage. Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 (n = 64 before training initiative) and 2010 (n = 71 after training initiative) were identified by a two-factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related. Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p < 0.01) and delay or inappropriate treatment (76.5 vs. 39.5%, p < 0.01). System factors also differed (32.4 vs. 7.9%, p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p < 0.01) between 2006 and 2010. Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.

Barriers to Intrauterine Device Uptake in a Rural Setting in Ghana.

Long-acting reversible contraception is an underutilized method in low-resource areas. Our study aims to: (a) assess knowledge and attitudes around contraception; (b) identify barriers to intrauterine device (IUD) uptake; and (c) develop interventions to address this gap in contraceptive care. We conducted focus group discussions with pregnant, postpartum, and reproductive-aged women, males, and health care workers in rural Ghana. Lack of IUD-specific knowledge, provider discomfort with insertion, and incomplete contraceptive counseling contribute to lack of IUD use. Participant- and provider-related barriers contribute to poor uptake of IUDs within the community. Targeted interventions are necessary to improve IUD use.

Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois.

OBJECTIVES: To compare the results of two maternal death review processes conducted from 2002 to 2012 by Illinois regionalized perinatal centers with those conducted by the Illinois Department of Public Health's (IDPH's) statewide multidisciplinary external Maternal Mortality Review Committee (MMRC). METHODS: This is a retrospective record review linking MMRC case assessment forms to the IDPH's Maternal Mortality Review Form database to compare causes of death and potential preventability as determined by both review processes. RESULTS: MMRC records for 76 maternal death reviews were linked to the IDPH maternal mortality review form database. Most deaths reviewed by the statewide MMRC were due to pregnancy-related causes. The statewide MMRC differed from the regional perinatal centers on cause of death in 55.3% (n = 42) of cases and on the disposition of potential preventability in 48.7% (n = 37) of cases. The statewide MMRC judged 69.7% (n = 53) of cases potentially preventable, compared with 40.8% (n = 31) for the regional perinatal centers. The MMRC identified more preventable provider and systems factors for potentially preventable deaths compared with regional perinatal centers which identified more preventable patient factors. CONCLUSIONS FOR PRACTICE: The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews.

Assessing preventability of maternal mortality in Illinois: 2002-2012.

OBJECTIVE: We sought to describe the potential preventability of pregnancy-related deaths in Illinois from 2002 through 2012 as determined by perinatal centers following the Illinois maternal death review process. STUDY DESIGN: We conducted a retrospective review of all known maternal deaths in the state from 2002 through 2012 with complete records in the Illinois Department of Public Health's Maternal Mortality Review Form database. The association between causes of death and potential preventability was analyzed for pregnancy-related deaths. RESULTS: There were 610 maternal deaths in Illinois during the study period (31.8 per 100,000 live births). One-third of maternal deaths (n = 210) were directly or indirectly related to pregnancy, 7.0% (n = 43) were possibly related, and 52.6% (n = 321) were unrelated. Vascular causes were the most common cause of pregnancy-related death, followed by cardiac causes and hemorrhage. One-third of deaths directly or indirectly related to pregnancy were deemed potentially preventable. Hemorrhage and deaths due to psychiatric causes were most likely to be considered avoidable, while cancer and vascular-related deaths were generally not considered preventable. CONCLUSION: This analysis of pregnancy-related deaths in Illinois, the first in >60 years, found similar causes of death and potential preventability as pregnancy-related death reviews in other states. Analyzing the causes of pregnancy-related death is a critical and necessary step in improving maternal health outcomes, particularly in decreasing potentially preventable pregnancy-related deaths. Greater attention should be directed toward intervening on the provider, systems, and patient factors contributing to preventable deaths.