March 12, 2015
Safety Initiatives Show Remarkable Success at Reducing Infant and Maternal Fatalities and Injuries Related to Childbirth
But Providers’ Implementation of Widely Recognized Best Practices Is Uneven
WASHINGTON, D.C. – Certain health care providers achieved striking reductions in mortalities and other tragic outcomes related to childbirth through initiatives undertaken over the past 15 years, but the practices they used have not yet been comprehensively implemented, a new Public Citizen report documents.
The report, “Solutions in Sight,” summarizes important safety initiatives relating to childbirth undertaken by four health care organizations and recounts remarkable results. For example:
- Hospital Corporation of America reported reducing maternal fatalities systemwide from post-cesarean pulmonary embolism by 86 percent and reducing obstetrics-related litigation claims by two-thirds;
- New York Presbyterian Hospital-Weill Cornell Medical Center reported that its patients’ incidence of a type of brain injury caused by oxygen deprivation was 98 percent lower than the national average and that its obstetrics-related litigation was reduced by 99 percent;
- Ascension Health reported that it reduced neonatal fatalities by nearly 50 percent in the first two years after broadening its initiative to all 43 of its hospitals; and
- Premier Inc. reported that an initiative undertaken at 16 of its facilities resulted in a 74 percent reduction in preventable birth trauma to full-term newborns.
“News that certain institutions have made remarkable progress in reducing tragic events related to childbirth is cause for celebration,” said Taylor Lincoln, research director of Public Citizen’s Congress Watch division and author of the report. “But the success of these programs suggests that otherwise avoidable fatalities and injuries are likely still occurring at health care facilities that have not instituted reforms like these.”
The elements of the initiatives undertaken by the institutions highlighted in the report were overlapping and included:
- Training to reduce communications problems, which figure in about 65 percent of catastrophic events during childbirth;
- The use of simulations to conduct training in emergency situations;
- Implementation of “bundles,” which are groups of essential practices;
- Efforts to eliminate early-elective deliveries, which have been shown to pose a significantly greater risk of complications; and
- Admonitions to rely on the best scientific evidence in deciding to conduct cesarean-section deliveries, which pose health risks to mothers and babies.
The Ascension and Premier programs, which began last decade, were given a boost in 2010, when the federal Agency for Healthcare Research and Quality (AHRQ) issued three-year, $3 million grants to each of them to continue and expand their initiatives. Results from these grants have been released only anecdotally, but papers offering significantly more details are forthcoming, individuals involved with the grants told Public Citizen.
Relatedly, in 2011, AHRQ issued a five-year, $5.4 million contract to North Carolina-based Research Triangle Institute (RTI) to use findings from the grant-funded projects to create a childbirth safety program and implement it in 50 hospitals. Details on this project have not yet been publicly released.
The providers highlighted in the report are not the only ones that have implemented obstetrics safety programs. But numerous experts have said that practice patterns within the obstetrics’ profession are inconsistent, and that adherence to recognized best practices is not comprehensive. In a statement to Public Citizen, the American Congress of Obstetricians and Gynecologists said, “Adoption of updated and new best practices is variable across the country.”
One example of inconsistency in practice patterns is illustrated by the wildly disparate use of cesareans, the report said. For example, a nationwide study in 2013 found that cesarean use varied by provider from 7 to 70 percent. Nonmedical considerations, including convenience and compensation, have been blamed for some providers’ heavy use of cesareans.
“A key issue flagged in this report is that delivery needs to be allowed to occur on the mother’s schedule, not the provider’s,” said Lisa Gilbert, director of the Congress Watch division of Public Citizen. “Changing payment policies appears to be one of the best ways to ensure that providers’ incentives are aligned with the best interests of their patients.”
The U.S. infant mortality rate is among the highest in the developed world and its maternal mortality rate has risen in the past decade. Reducing the U.S. infant mortality rate to the levels of France, Italy and Spain would save 10,000 lives a year, the report said.