Featured Point of View

Martin T. November, MD, MBA, FACOG
Chief Medical Officer
Advanced Practice Strategies

In my role as Chief Medical Officer at APS, and as a practicing OB, I spend a lot of time thinking about patient safety in obstetrics. Recently, I found an AJOG-published study very interesting and wanted to share it to hear your thoughts and reactions. The study examines maternal deaths at the largest hospital system in the United States with the aim of identifying systemic changes for prevention. Whether these results reflect the general experience at hospitals across the country is open for debate, but the consistency of their reported causes for maternal mortality with previous studies certainly suggests their results are pertinent.

The authors examined the mode of delivery for a causal relationship with maternal death and found a higher risk with cesarean versus vaginal delivery. The overall magnitude of this difference though, was not overwhelming—roughly translating to 20 deaths per year in the U.S. caused by the cesarean delivery procedure. To address this, the authors recommend prophylaxis against pulmonary thromboembolism with all cesarean deliveries. Since epidural anesthesia is common, pneumatic compression devices rather than anti-coagulants were recommended to avoid bleeding complications.

Another interesting finding was that maternal mortality was more common in “low risk” women lacking any significant co-morbidity. This stresses the need for vigilance with all patients. The authors chose not to focus on psychosocial causes (alcohol abuse, suicide, poor compliance, etc.) which they felt were due to lack of action by non-health personnel. But it certainly does suggest instituting systemic methods to identify and address these issues would be valuable.

I have included additional details about the study below and encourage you to review it in its entirety:

Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008 Jul;199(1):36.e1-5; discussion 91-2. e7-11. Epub 2008 May 2.

Summary: Study to determine the cause of maternal death, preventability, and causal relationship to mode of delivery from a retrospective review of nearly 1.5 million deliveries at 124 Hospital Corporation of America hospitals between the years 2000 to 2006. Of the ninety-five maternal deaths identified (6.5 deaths per 100,000 births), the leading causes were complications associated with preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth vs. 2.2 per 100,000 for cesarean delivery. This difference, which was significantly different in the HCA experience, would translate into 20 deaths caused by cesarean delivery annually in the U.S.

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