Obstetric Hemorrhage Initiative
The Florida Perinatal Quality Collaborative, in partnership with the District XII American College of Obstetricians and Gynecologists (ACOG), Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Florida Council of Nurse Midwives, Florida Hospital Association, and the Florida Department of Health, has developed this Obstetric Hemorrhage Initiative (OHI).
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Hemorrhage, or severe bleeding, is the leading cause of pregnancy-related mortality worldwide and in the United States (Bingham et al, 2011; American College of Obstetricians and Gynecologists (ACOG) 2006). Postpartum hemorrhage has been defined as blood loss in excess of 500 mL following a vaginal birth or more than 1,000 mL following a cesarean birth (ACOG, 2006). It is estimated that one woman dies every four minutes from postpartum hemorrhage worldwide (ACOG, 2006). ). The pregnancy-related mortality ratio in the United States has increased to its highest levels in decades from 11.1 to 15.7 deaths per 100,000 live births from 1993 to 2006 (Creanga, 2012). Further, between 1994 and 2004 there was a 27.5% increase in postpartum hemorrhage deaths, primarily due to uterine atony, and a 92% increase in maternal blood transfusions (Bingham et al, 2011; Callaghan et al, 2010). Recent research indicates that “54 to 93% of these hemorrhage deaths may have been preventable” (Bingham and Jones, 2012).
Maternal hemorrhage is considered to be the most preventable cause of maternal mortality (Burke, 2010). Improved quality of medical care is the most important factor for the prevention of mortality due to obstetric hemorrhage. More than 90% of the potentially preventable morbidity and mortality due to hemorrhage is because of provider-related factors, notably incomplete or inappropriate management (Della Torre, et al, 2011). A 2011 study found that delay in treatment or diagnosis, ineffective management, and lack of proper preventive measures for hemorrhage led to preventable pregnancy-related deaths and extreme morbidity (Della Torre et al, 2011).
Although there is no clear trend, the pregnancy-related mortality ratio (PRMR) in Florida fluctuated from 13.3 in 2005 to 26.2 in 2009. Hemorrhage was one of the top three causes of maternal mortality, accounting for 15% of deaths during this time period. Most maternal deaths from hemorrhage were caused by ruptured ectopic pregnancy, uterine atony/postpartum bleeding, placenta accreta, percreta, or increta, and retained placenta (FL PAMR). Risk factors associated with deaths due to hemorrhage in Florida included lack of prenatal care, non-Hispanic Black race; having a cesarean delivery and advanced maternal age (FL PAMR).
In order to address Florida’s pregnancy-related mortality, the Florida Department of Health contracted with the Florida Perinatal Quality Collaborative (FPQC) to convene a group of maternal health, public health, and quality improvement leaders to work on a Maternal Mortality Prevention Initiative. The FPQC maternal mortality workgroup reached consensus that hemorrhage is one of the state’s most preventable maternal mortality issues and the highest priority because hemorrhage is one of the top causes of maternal mortality in Florida and because hospital and provider strategies to address the issue are highly feasible and effective.
Multi Hospital Collaborative
We plan to achieve improvements in maternal outcomes related to hemorrhage by implementing best practice guidelines as developed by the OHI Work Group. Hospitals and providers will be better prepared to assess for hemorrhage risks, prepare for and manage obstetrical hemorrhage in earlier stages, and measure their results. The FPQC will help Collaborative participants meet OHI goals by sharing the best available scientific knowledge, teaching and applying methods for organizational change, involving experienced hospital experts, and sharing participating hospital experiences, challenges, and successes.
OHI will be implemented in a multiple phased approach, with up to 25 to 30 facilities in an “alpha cohort” (or demonstration phase). Remaining facilities will be engaged over time by supporting additional cohorts or other dissemination approaches based on resources and interest. In 18 months, participating facilities would implement strategies in the order of hospital priority until all core components appropriate to a hospital are implemented, then spend at least 6 additional months institutionalizing the strategies.
Strategies will be adaptable to all hospital settings and recognize that some facilities will not have the necessary equipment or trained professionals to utilize some of the higher technology or complex procedures and guidelines. There will be core elements that are recommended in a priority order to be included in all locations, including participation in data collection for core metrics. Each facility can either adopt an existing set of protocols or guidelines and tools or develop/adapt protocols or guidelines and tools using the evidence based elements. A toolbox of materials to assist with implementation will be provided. Collaborative hospitals will learn improvement strategies that include establishing goals and methods to develop, and test and implement changes to their systems.
For more information on this initiative, please contact firstname.lastname@example.org