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Developed By: Committee on Obstetric Anesthesia
Original Approval: October 26, 2022
Purpose
The purpose of this statement is to review the evidence on the role of anesthesiologists in reducing maternal mortality and severe maternal morbidity (SMM), and to provide recommendations for anesthesiologists to contribute to these efforts at the local, regional, and national levels.
Background
Maternal mortality consistently ranks among the top causes of death among women ages 20-44 years in the United States.1 Unlike other high-resourced countries where rates have remained the same or declined, in the United States the maternal mortality rate has steadily increased since the 1990s. According to the World Health Organization (WHO) maternal mortality is defined as the “death of a woman while pregnant or within 42 days of termination of pregnancy2”. The United States maternal mortality rate (MMR) for 2020 was calculated to be 23.8 deaths per 100,000 live births compared to 20.1 in 2019, nearly triple the rate reported in 1987 (7.2 per 100,000 live births).3,4 Notably, up to 60% of pregnancy related deaths are considered preventable.5 Reasons for the increase in maternal mortality in the United States are multifactorial and includes racial disparities, an increase in the age of childbearing women, increase in the comorbidities associated with an older population, and an increase in the cesarean section rate.
The Pregnancy Mortality Surveillance System (PMSS) stratified causes of maternal mortality from 2014-2017. Although the lowest cause of maternal mortality was 0.4% for anesthesia related complications, opportunities for anesthesiologists and acute care physicians to help reduce mortality have been identified. There were 15.5% of deaths due to cardiovascular events other than cardiomyopathy, 12.7% to infection/sepsis, and 12.5% to non-cardiovascular complex medical conditions.6 Prevention and early intervention of these non-anesthesia causes of maternal mortality, as well as those due to hemorrhage, embolism, cerebrovascular accidents, and hypertensive disorders, makes anesthesiologists’ knowledge imperative. The expertise of anesthesiologists has garnered attention from organizations committed to improving maternal health. Published recommendations, as well as individual institutions, have included anesthesiologists in efforts to review quality and safety measures, optimize care and identify the causes of severe maternal morbidity and mortality. As experts with experience in perioperative medicine, critical care medicine, systems engineering and safety, physician anesthesiologists are essential when addressing issues related to obstetric emergencies and underlying maternal disease.
Anesthesiologist Contributions to Reducing CMM and Mortality
Severe maternal morbidity (SMM) is defined as unintended (adverse) outcomes of labor and delivery that results in significant short term or long term consequences to a woman’s health.7 Evidence supports that anesthesiologists are instrumental in providing safe obstetric care through management of difficult airways, placement of vascular access, and massive blood product administration on the labor and delivery unit.8,9 Standard anesthesiology training consists of acute perioperative and critical care medicine, including postoperative care units, perioperative medicine, intensive care units, and acute and chronic pain management clinics. These universal training points make anesthesiologists ideal partners and leaders of teams, both within and outside of the operating room theater, that work together to reduce SMM and mortality.
Levels of Maternal Care
In 2015 and again in 2019, members of the American Society of Anesthesiologists (ASA) contributed to the American College of Obstetricians Gynecologists (ACOG) and the Society of Maternal and Fetal Medicine (SMFM) consensus statement on Levels of Maternal Care (LOMC). This statement defines a system of perinatal regionalization and risk-appropriate maternal care. The goal of LOMC is to reduce maternal morbidity and mortality, including health care disparities, by promoting a standardized regionalized system of care, that places pregnant people in the most appropriate care locations. Maternity services for the highest levels (Level 3 and 4) include 24/7 anesthesia services coverage, as well as a board-certified anesthesiologist with specialty training or experience in obstetrics who is in charge of the obstetric anesthesia service. These recommendations place physician anesthesiologists at the forefront of managing the most complex obstetric patients. The Levels of Maternal Care consensus statement was reaffirmed in 2019 and 2021,10 and emulates neonatal levels of care, the implementation of which led to improvements to neonatal morbidity and mortality.11,12
SOAP Centers of Excellence
The Society of Obstetric Anesthesiology and Perinatology (SOAP) has extended efforts to reduce maternal morbidity and mortality by developing a process to designate Centers of Excellence for Obstetric Care (COE). The goal of the COE program is, “to recognize institutions and programs that demonstrate excellence in obstetric anesthesia care and to set a benchmark of expected care to improve standards nationally and internationally”. Expert consensus and evidence-based recommendations are central to the COE criteria for designation. There are currently 83 hospitals with the prestigious SOAP COE designation.13
Alliance for Innovation on Maternal Health (AIM)
Both ASA and SOAP members have been involved in the Alliance for Innovation on Maternal Health (AIM) in order to drive improvement through quality measures. Safety bundles that include best practices, tool kits, and the Maternal Early Warning Sign (MEWS) are a few examples of processes with which anesthesiologists have been directly involved. Collaboration in quality improvement projects directed at reducing maternal morbidity and mortality highlights the importance of anesthesiologists in improving maternal care.14,15
State Maternal Mortality Review Committees (MMRCs)
After passage of the Preventing Maternal Death Act in 2018, states have been able to fund Maternal Mortality Review Committees (MMRC). Most states are moving to implement MMRCs.16 The goal of MMRCs is to review all maternal deaths; evaluate the potential causes of death; identify racial or socioeconomic disparities associated with mortality; and to provide strategies to improve maternal care and prevent maternal morbidity.17 Currently, committee membership varies by state, although many include obstetricians, social workers, coroners, and midwives. In a comprehensive survey of United States MMRC professional composition, it was noted that physician anesthesiologists were represented members on only 50% of state MMRCs.18 There is an important and unmet need to increase physician anesthesiologist representation in state MMRCs.
Obstetric or Perinatal Quality Committees (PQC, or Equivalent)
The Anesthesia Patient Safety Foundation (APSF) launched in 1985 was one of the first independent multidisciplinary organizations that addressed preventable outcomes, especially those related to the human factor. The exchange of ideas, communication of safety related issues, education, and directed projects has made this anesthesia led foundation a leader in quality improvement. In the report, “To Err is Human”, The Institute of Medicine (IOM) in 1999 called to action health care providers to improve patient safety and quality.19 The report specifically recognized anesthesiology as the only specialty for significantly improving patient safety and reducing anesthesia-related harms. Anesthesiologists have similarly addressed quality of maternal care and safety, and anesthesia-related maternal mortality is consistently the lowest frequency among all factors contributing to maternal-mortality. Currently, recommendations are for anesthesiologists to serve on Obstetric Quality Committees or equivalents at the institutional, state, and regional level thus assisting in review of poor maternal outcomes and pushing safety improvements consistent with best practices.8,9
Antenatal Anesthesiology Consultations
Maternal mortality has continued to increase in the United States, and specifically, the number of parturients with complex medical conditions who die during or within the first year of birth is rising.20 Anesthesiologists play a key role in the potential to improve outcomes in this population due to their perioperative knowledge and acute care skills, and should be involved in the development of plans for these high risk parturients. It is essential that institutions involve physician anesthesiologists in a formal antenatal anesthesiology consult system. The system should include a method, to contact the physician anesthesiologist, criteria for requesting a consult, and a timeframe for referral. (See: ASA Statement on Antenatal Anesthesiology Consultation).
Simulation
Historically, anesthesiologists were on the forefront in developing simulation-based methods, equipment, and technology, most notably the use of mannequins and computer training modules that provide data in real time.21 Currently, ASA requires that practicing anesthesiologists have simulation training as part of their Maintenance of Certification for Anesthesiology (MOCA). Anesthesia SimSTAT is available to all ASA members and includes a specific module for labor and delivery emergencies. Further, the ASA has endorsed numerous centers around the country as hubs for high fidelity in-person simulation. Anesthesiologists are optimal team leaders for obstetric simulation and should be present on OB simulation committees and task forces to assist in the development, implementation, and maintenance of such an important aspect of improving patient safety and quality.
Hypertension Management
Early identification and management of hypertension during pregnancy and into the postpartum period can lead to significant reductions in hypertension related complications.22 The National Partnership for Maternal Safety and the Council on Patient Safety in Women's Health Care have developed a safety bundle that provides guidance to health care providers.23 Anesthesiologists are listed as part of the multidisciplinary team to be consulted to assist, especially in cases of refractory hypertension. Consultation frequently includes discussion of neuraxial anesthesia and analgesia as a means of simultaneous labor pain and blood pressure management, as it decreases maternal circulating catecholamines, increases uteroplacental blood flow, avoids the unnecessary use of general anesthesia in cases of emergency, and improves overall maternal and neonatal outcomes. Anesthesiology consultation for appropriateness of invasive monitoring to provide beat to beat blood pressure monitoring and for advice on appropriate vasoactive infusions, are designated roles of the anesthesiologist in this important safety bundle.24
Hemorrhage Management
Recent articles and data affirm that hemorrhage remains one of the leading causes of preventable SMM.25 ACOG and SMFM have recommended two criteria in the screening process for SMM. One of those criteria is transfusion of 4 or more units of blood. Timely identification of hemorrhage and early involvement of the anesthesia team are listed in the PPH safety bundles.26 Anesthesiologists are well versed in the safe and effective management of massive transfusion and should help lead the team during these situations.27 These contributions can prevent consequences of severe PPH such as coagulation defects and multi-organ failure. It has been suggested that active management of anesthesiology teams with neuraxial labor analgesia may even potentially reduce the risk of SMM mediated through a decrease in risk for PPH.28 Resuscitation and pain management expertise enables anesthesiologists to contribute maximally to prevention of SMM related to PPH.
Recommendations
References
1 Centers for Disease Control and Prevention. Leading causes of death in females-United States 2017 {Internet}, Available from: https://www.cdc.gov/women/lcod/index.htm
2 World Health Organization. Maternal mortality ratio (per 100,000 live births).www.who.int/healthinfo/statistics/indmaternalmortality/en/ Accessed February 28, 2022
3 Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. 2022. DOI: https://dx.doi.org/10.15620/cdc:113967external icon
4 Centers for Disease Control and Prevention. Pregnancy mortality surveillance system [Internet]. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. 2020 [cited 2020 March 21]. Available from: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
5 Review to action, CDC Foundation. https://reviewtoaction.org/learn/definitions. Accessed April 1, 2022.
6 https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
7 ACOG Obstetric CareConsensus #5, Severe maternal morbidity: screening and review 2016, 2019 ACOG LOMC) (requoted SMM in Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41e55.
8 McQuaid E, Leffert LR, Bateman BT. The Role of the Anesthesiologist in Preventing Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018 Jun;61(2):372-386. doi: 10.1097/GRF.0000000000000350. PMID: 29319586.
9 Abir G, Mhyre J. Maternal mortality and the role of the obstetric anesthesiologist. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):91-105. doi: 10.1016/j.bpa.2017.01.005. Epub 2017 Feb 3. PMID: 28625309.
10 Levels of maternal care: Obstetric care consensus. Obstet Gynecol. 2019;134(2):e-41-55.
11 Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA. 2010;304(9):992–1000[PubMed]
12 https://publications.aap.org/pediatrics/article/130/3/587/30212/Levels-of-Neonatal-Care Accessed 04/20/2022
13 Carvalho B, Mhyre JM. Centers of Excellence for Anesthesia Care of Obstetric Patients. Anesth Analg. 2019 May;128(5):844-846. doi: 10.1213/ANE.0000000000004027. PMID: 30994544.
14 Council on Patient Safety in Women’s Health Care. Alliance for Innovation on Maternal Health Programm.https//safehealthcarefor everywoman.org/aim-program/. Accessed April 1, 2022
15 Mahoney, Jeanne RN The Alliance for Innovation in Maternal Health Care: A Way Forward, Clinical Obstetrics and Gynecology: June 2018 - Volume 61 - Issue 2 - p 400-410 doi: 10.1097/GRF.000000000000036
16 “H.R. 1318-115th Congress: Preventing Maternal Deaths Act of 2018”. www.GovTrack.us 2017. <https://www.govtrack.us/congress/bills/115/hr1318>. Accessed April 28, 2022.
17 Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews. 2019 Oct;20(10):e561-e574. doi: 10.1542/neo.20-10-e561. PMID: 31575778; PMCID: PMC7377107.=
18 Lozada, James & Peralta, Feyce & Pacheco, Luis. (2018). U.S. Maternal Mortality Review Committee Composition: An analysis of membership profession and committee reports. 10.13140/RG.2.2.21535.05285. This is an analysis of the level of professional diversity on all existing U.S. Maternal Mortality Review Committees.
19 Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
20 Gibson C, Rohan A, Gillespie K. Severe Maternal Morbidity During Delivery Hospitalizations. WMJ. 2017;116 (5):215-20.
21 John R. Boulet, David J. Murray, David S. Warner; Simulation-based Assessment in Anesthesiology: Requirements for Practical Implementation. Anesthesiology 2010; 112:1041–1052 doi: https://doi.org/10.1097/ALN.0b013e3181cea265
22 American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Available at: http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy. Accessed April 19, 2022.
23 Hypertension in pregnancy maternal safety bundle. Available at: www.safehealthcareforeverywoman.org. (http://safehealthcareforeverywoman.org). Accessed April 19, 2022.
24 Podovei, Mihaela MD*; Bateman, Brian T. MD, MSc*† The Consensus Bundle on Hypertension in Pregnancy and the Anesthesiologist: Doing All the Right Things for All the Patients All of the Time, Anesthesia & Analgesia: August 2017 - Volume 125 - Issue 2 - p 383-385
doi: 10.1213/ANE.0000000000002296
25 Bienstock JL, Eke AC, Hueppchen NA. Postpartum hemorrhage. N Engl J Med. 2021;384(17):1635-1645. doi:10.1056/NEJMra1513247.
26 Main, Elliott K. MD; Goffman, Dena MD; Scavone, Barbara M. MD; Low, Lisa Kane PhD, CNM; Bingham, Debra DrPH, RN; Fontaine, Patricia L. MD, MS; Gorlin, Jed B. MD; Lagrew, David C. MD; Levy, Barbara S. MD National Partnership for Maternal Safety, Anesthesia & Analgesia: July 2015 - Volume 121 - Issue 1 - p 142-148 doi: 10.1097/AOG.0000000000000869.
27 Ring L, Landau R. Postpartum hemorrhage: Anesthesia management. Semin Perinatol. 2019 Feb;43(1):35-43. doi: 10.1053/j.semperi.2018.11.007. Epub 2018 Nov 14. PMID: 30578145.
28 Guglielminotti J, Landau R, Daw J, Friedman AM, Chihuri S, Li G. Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity. JAMA Netw Open. 2022 Feb 1;5(2):e220137. doi: 10.1001/jamanetworkopen.2022.0137. PMID: 35191971; PMCID: PMC8864505.
Curated by: Governance
Last updated by: Governance
Date of last update: October 26, 2022
