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).

Obstetric Hemorrhage

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

Hospitals are asked to spend 18 months implementing the recommended changes and 6 months institutionalizing them in their facilities.

Hospitals and providers participating in the OHI will be better prepared to assess for hemorrhage risks, prepare for and manage obstetrical hemorrhage in earlier stages, and measure their results. The FPQC helps 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.

Strategies are adaptable to all hospital settings and recognize that some facilities do not have the necessary equipment or trained professionals to utilize some of the higher technology or complex procedures and guidelines. There are 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 either adopts an existing set of protocols or guidelines and tools or develop/adapts protocols or guidelines and tools using the evidence based elements. Collaborative hospitals learn improvement strategies that include establishing goals and methods to develop, and test and implement changes to their systems.