Maternal Mobility and Morbidity in the United States
Question
Instructions: Research Sentinel Events in nursing, including but not limited to The Joint Commission Websites: The Joint Commission (Links to an external site.) Select a specific sentinel event that has taken place and is documented on The Joint Commission site. Your account of the event should be as realistic as possible, as if it actually happened in your hospital or health care setting – OR - choose one from your own experience and describe the event as it happened or likely happened. As the department leader, you will be responsible for creating a fishbone diagram & a plan of corrective action to satisfy The Joint Commission, and to prevent future sentinel events. Write a page paper that explores the sentinel event, analysis of causes, develops a plan of corrective action, and proposes future evaluation of the plan. Conduct a literature review that informs a plan for corrective action. Citations are required for all information that is “not common knowledge”


Solution
Maternal
Mobility and Morbidity in the United States
Maternal mortality rates among women
population in America have reached an alarming rate. The United States is
ranked 57th worldwide in maternal rates (The Joint Commission).
Maternal mortality rates provide key indicators for the well-being and health
of a society. However, the indicator seldom captures the key factors that form
the well-being of society. Therefore, such measures must capture the near-miss
factors resulting in death during pregnancy. According to the United States
Centers for Disease Control and Prevention (CDC), the concept pertains to the
unexpected problems in delivery and labor, which lead to notable long and
short-term health issues for the mother. The term also refers to serious
diseases when carrying the pregnancy, including ectopic pregnancy and those
after delivery, such as cardiomyopathy. The current study examines the concept
of maternal mortality as one of the sentinel events that The Joint Commission
has identified. The reason is that the United States has reported rates that
seem to be steadily adjusting upwards. Although the women population in America
enjoys better healthcare compared to others, SMM is still increasing at an
alarming rate. Therefore, this study examines the present steady increase in
SMM rates and the required approaches and strategies to combat it.
Sentimental
Events
Although numerous advances have been
made in maternal fatal care and obstetrics, more still needs to be done
regarding standardization, improvement, and implementation of regionalized care
systems. Consequently, the Joint Commission developed a verification for the level
of care women require in 2022 January to formulate solutions and contribute
towards improving care outcomes. The verification was developed in close
association with the American College of Obstetricians and Gynecologists
(ACOG). Besides, ACOG has also developed a document called Maternal Care
Obstetric Care Consensus (OCC), which defines the maternal fertility personnel
and capabilities, including the framework for the integrated systems defining
the maternal care requirements. The program’s main aim is to enhance the
reduction of maternal morbidity and mortality by supporting the evolution and
growth of systems aiming to develop perinatal reorganization and maternal care
that address risks related to maternal well-being and health.
Based on the program, several states
have formulated laws that create standards for maternal care that pertain to
all care facilities that deal with maternal care. More states are also expected
to pass similar legislation and attain milestones in achieving the necessary
levels of care for mothers based on verification. The Joint Commission professionals
have also established effective systems to assess the capability of facilities
to deal with maternal care. The commission also verifies that facilities offer
treatment to patients based on their equipment, resources, and expertise. As a
result, the program ensures safety, better maternal outcomes, and successful
births. With such verifications, a facility instills confidence within the
community in the safety and quality of its services and treatment of patients.
To better understand events related
to maternal mortality, organizations such as the CDC conduct surveillance meant
to reveal the causes and risk factors. The standard employed includes Pregnancy
Mortality Surveillance System (PMSS). The system defines morbidity as occurring
as the mother carries the pregnancy or within one year after giving birth from the
causes related to pregnancy complications. Medical epidemiologists analyze and
record death records to reveal maternal mortality rates. Additionally, they
also analyze feta death records and linked birth records. Other relevant data
from over 50 states in America are analyzed using PMSS to provide the mortality
ratio (CDC). The result estimates the total death occurrences in relation to
pregnancy for every 100,000 live births. The trend in maternal mortality rates
suggests a constant increase in rates from 1987 to 2017 (CDC). The rate in 1987
was 7.2 deaths for every 100,000, while in 2017, it was 17.3 deaths per 100,000
live births (CDC). The rate is high considering the objectives set by CDC and
other organizations.
Noteworthy, the reasons behind this
sharp increase remain unclear. Due to computerized data, the identification of mortality
as a result of carrying pregnancy has seen improvements with time. As a result,
there have been changes in how such deaths are recorded. In recent years,
maternal mortality rates have been relatively stable. The maternal mortality
rate is higher among non-Hispanic blacks than Latinos or Hispanics and
non-Hispanic whites by ethnicity. Maternal rate variability can be attributed
to several reasons such as care access, implicit biases, structural racism, the
constant prevailing chronic diseases, and care quality. The most common causes
of death among pregnant women are cerebrovascular and cardiovascular diseases.
In the United States, such circumstances are likewise on the rise. Chronic
disorders, such as hypertension, chronic heart disease, and diabetes, are
becoming more prevalent as the number of pregnant women rises. The woman is at
a high risk of experiencing pregnancy-related problems during pregnancy or
within a year of giving birth due to the circumstances.
As aforementioned, an in-depth
understanding of events during, prior to, and post-delivery provides the framework
for more effective maternal care approaches. The maternal rate in the United
States stands at between 650 and 750 per year, while severe maternal morbidity
affects approximately 50,000 and 60,000 women annually (The Joint Commission).
The rate still continues to persist, and as a result, addressing issues pertaining
to maternal morbidity i8s critical in advancing maternal health. Nonetheless,
measuring maternal mobility is still challenging today. The reason is that the
measure stretches simply determining the impacts of maternal deaths in terms of
whether a given cause of death emanates from a given event. Maternal death
encompasses the impacts of discrimination, racism, and access to care. Reliable
means of capturing data about maternal death must be established by researchers
and other professionals. So far, three different levels have been developed to
categorize occurrences. The categories include near-miss morbidity, severe
maternal morbidity (SMM), and maternal morbidity.
Sentimental
Event Case
Maternal mortality among American
others still continues to be of great importance due to the persistent trends.
Many more still experience the same complications for women who continue to die
due to pregnancy-related complications. Nonetheless, the exact burden of severe
maternal mortality cannot be established. According to the World Bank, the
burden continues to increase each day. The severe maternal mortality rate is
higher in low and middle-income countries compared to developed countries.
According to Geller
et al. (2018), the World Health Organization recommended that high-income
countries with high severe maternal mortality ratios examine the SMM. The
recommendation came from identifying system failures and establishing prevention
measures. As a result, most researchers operating in high-income countries have
decided to turn their attention to matters relating to SMM. In cases where
surveillance has been successful, the most common manifestation of SMM has been
hypertensive disorders and severe obstetric hemorrhage. In addition, among
high-income countries that have successfully performed surveillance,
provider-related factors have been established to cause high rates of SMM.
Delays in treatment and diagnosis and the failure to identify the high risks
are other factors identified to lead to high rates of SMM.
Countries within Sub-Saharan Africa bear the greatest burden
due to SMM. Geller et al. (2018) indicate that the SMM rate among the
sub-Saharan African countries is at 198 per 100,000 live births. Noteworthy,
across all regions of the world, it has been established that hypertensive
disorders and hemorrhage are the leading conditions that cause high maternal
mortality rates. However, limited case reviews have revealed conditions of inadequate
application of evidence-based approaches and substandard maternal healthcare
towards SMM treatment. Although severe maternal mortality is known to place the
pregnant mother’s life at risk, her fetus may also be faced with severe impacts
of SMM. Adverse outcomes upon delivery are often commonly experienced among
women who suffer from SMM. The efforts put into reducing SMM also result in the
reduction of mortality cases, thereby enhancing the health and life of the newborn.
Maternal mortality refers to a sentinel event that is often applied
in measuring women’s reproductive health globally and reveals the steps
different countries have made to reduce such cases. Generally, the worldwide
maternal mortality rate dropped from 385 per 100,000 live births in 1990 to 216
in 2015 (Geller et al., 2018). The figure represents a 44% reduction in SMM
over the period. Most high-income countries record low maternal mortality
rates, which fall between 3 and 12 per 100,000 live births (Geller et al., 2018).
The rates have also decreased constantly over the past 25 years.
Nevertheless, America has become an exception, with a high
SMM of 14 per 100,000 live births representing a 16.7% increase since 1990 (Agrawal, 2015). “Maternal
mortality” affects 99 percent of low- and middle-income nations, with the
majority of deaths occurring in “Sub-Saharan Africa.” The 2030 Sustainable
Development Goals aim at reducing the rates to 70 per 100,000 live births (CDC).
Further, no country is expected to exceed “140 per 100,000 live births.” Between
the year 2003 and 2009, hemorrhage, sepsis, and hypertension-related diseases
accounted for more than half of all maternal deaths. Moreover, there is a
remarkable variation in maternal mortality rates across all regions. 36.9% of
all deaths in North Africa resulted from hemorrhage compared to 16.3% in
high-income countries.
The sentinel event presented in this study pertains to an
occurrence that was reported in the emergency department in one of the care
facilities in the state. The patient reported complications right after birth
with conditions similar to hypertensive disorders. Luckily, the doctors
successfully diagnosed the patient and offered medical treatment. Nonetheless,
as suggested by the Joint Commission, such events are preventable and only
require better reporting and analysis to combat. As aforementioned, the rate of
“maternal mortality” is still increasing in the US. As a result, better
approaches ought to be taken to ensure better health and well-being of all
women. The Sustainable Development Goals of 2030 cab be achieved through a
collaborative approach by ensuring better access to healthcare for women.
Therefore, all stakeholders must ensure that maternal mortality issues are well
documented so that better solutions can be established to avoid the increase in
such cases.
Root
Cause Analysis (RCA)
To understand the possible reasons
why maternal mortality rates are on the rise, a root cause analysis was
conducted. A correlation between the causes and effects of maternal mortality
was carried out to achieve this. Although the women population in the states
enjoy better healthcare services than their colleagues in less “developed and
developing countries,” maternal mortality is alarmingly high. CDC’s Division of
Reproductive Health (DRH) forms a focal point from which issues related to
maternal mortality can be found (Creanga et al., 2014). The DRS plays host to the
National Pregnancy Surveillance System, besides being involved in public health
activities and research about maternal morbidity and mortality, mental health
issues, and abuse of substances during pregnancy. The factors that cause the
events in America are regularly published on the CDC website and updated. The
most notable factors have been established to include hemorrhage, infections,
hypertensive disorders, thrombotic pulmonary embolism, amniotic fluid embolism,
cardiovascular conditions, anesthesia, cerebrovascular accidents,
cardiomyopathy, and other medical conditions.
The
Fish-borne Diagram
The root cause of the increased SMM
rates has been established to be poor quality care which impedes the capacity
of hospitals to take care of women whose health deteriorates. Poor
implementation of standard operating procedures emanates from inadequate
skills, unavailability of primary services, ineffective communication, and lack
of forwarding planning (See Appendix A). Some of the root causes identified in
primary care include referral to facilities that lack the required services, inadequate
risk management skills, and inadequate collaboration between hospitals and
primary care. As a result, there is an urgent requirement to drastically
enhance the quality of care through support for consistent application of
procedures, skills, and knowledge (Mahmood et al., 2018). Essential services should also
be made available as hospitals also implement effective risk management and
assessment and facilitate effective referral services to facilities with better
equipment.
Hemorrhage is the major factor
leading to morbidity in expectant mothers in the United States. One of the main
reasons it has become difficult to manage hemorrhage is the delay in operation
due to the absence of senior obstetricians. Other reasons include inadequate
assessment of blood and delayed blood transfusion. In other cases, women have
been transfused with inadequate blood leading to loss. Besides, some patients perish
as a result of missing clot screening or renal function assessment. Hemorrhages
emanate from the rapture of the uterine wall that obstructs labor due to the unborn
baby’s weight (Mahmood et al., 2018). On numerous occasions, babies born with a
weight of 4kg and above cause such complications. The condition is also often
aggravated by delays in accessing healthcare. The delays in accessing
healthcare are attributed to midwives’ delays in facilitating referrals and
transfer to hospitals. Further, poor referral communication also causes women
to arrive at facilities that lack proper services.
Some people who provide midwife
services also fail to advise pregnant women to deliver in hospitals despite
notable complications such as huge babies or a history of stillbirth. Besides,
such advice is lacking despite a facility nearby that can take care of such
complications. Poor organization management is also often experienced in
tertiary and primary care facilities (Say et al., 2014). Inadequate staffing, a
lack of guidelines, protocols, and regulations, a shortage of senior staff,
failure or delay in emergency response, a delay in receiving test findings, and
a delay in processes are some of the other fundamental reasons of increasing
maternal mortality rates. Inadequate communication, failure to seek
supervision, lack of recognition of the seriousness of the situation, poor
communication, and geography are other factors leading to high SMM. Therefore,
several factors deal with the problem of maternal mortality, including but not
limited to better communication.
Plan
for Corrective Action
The main objective
of the current study was to examine the root causes of maternal health issues and provide the necessary recommendation
that can reduce such events. According to the CDC, it is better to avoid
unwanted pregnancies to avoid maternal mortality. As such, women of all ages
should be assured of access to contraception, safe abortion following the law,
and quality care after performing an abortion. The plan for the corrective
measure included for the sentinel event is based mainly on prevention measures
(see Appendix B). Noteworthy, it is also crucial to avoid infections after
delivery by observing good hygiene. If such infections are established, they
ought to be treated promptly. Severe bleeding experienced after the birth of a
child is capable of killing a woman within hours.
Nonetheless, most factors responsible for SMM are
preventable (Say et al., 2014). High-quality care should be availed during
pregnancy, delivery, and after birth. Maternal health and the health of the
newborn are closely related. Therefore, all births must be attended to by
skilled personnel to save the lives of both the woman and the child. However,
several factors impede efforts by women to access the type of care they need.
Some of these factors include poverty, lack of information, and access to facilities.
Countries
have united behind the new set target to eliminate maternal mortality based on
the Millennium Development Goals. The MDG 3 clearly states the need to reduce
maternal mortality to 70 per 100,000 by 2030. Besides, it also states that no
country should target a maternal mortality rate of more than twice this target
(World Health Organization, 2019). The WHO also aims at improving maternal
mortality rates through evidence from research. The organization also aims at
improving programmatic guidance and providing global standards to be followed
by hospitals and primary care facilities. The corrective action that WHO and
other organizations aim at adopting will include collaboration with partners to
address the inequality in accessing healthcare, providing universal healthcare
coverage, and addressing all the causes of maternal mortality. Additionally, strategies
have been formulated to strengthen care and ensure accountability. More
importantly, the timeline provided by the concerned organizations is 2030, when
all countries worldwide are expected to achieve the set results.
Lewin’s
Change Theory
According to Lewin’s
Change Theory, individuals or a team of individuals are often affected by
limiting forces restraining the driving forces. The driving forces support
change, while the limiting factors aim to maintain the status quo (Wojciechowski et al., 2016). The
tension between the two opposing factors leads to an equilibrium. However, for
an organization to realize change, it must implement the three stages model.
The first step is to unfreeze awareness creation to enable people to abandon
the old norms. The second step is to impact change whereby alternative ways of
doing things are sought. Finally, the organization should move to a refreezing
phase where it integrates the change process and ensures that it is stable. The
model should be used to eliminate the vice of SMM.
Timeline
The proposed
timeline for change is set to begin immediately after established policies and
guidelines. The subsequent activities will be carried out in stages, with each
stage having a set of objectives to be achieved. The first activity will be to
train healthcare professionals on the best practices that are aimed at reducing
the incidents of SMM. The sensitization process will then follow, including
using different media to reach the masses. The next level will bring all
stakeholders together and forge a way forward. Finally, the best alternative
will be implemented.
Evaluation
of Plan
The evaluation
process of the change process will require the stakeholders to conduct several
internal and external processes. A series of meetings will be necessary to
discuss the progress of the change process. The plan will be considered
successful if all the activities included in the plan have been achieved, and
the outcomes are desirable. In other words, success will be measured in terms
of reduction in SMM rates.
Communication
of Results
All the
stakeholders must collaborate in ensuring that the planned action is successfully
implemented and the desired outcomes are achieved. Individuals holding
leadership positions are expected to ensure that the change process outcomes
are communicated to every concerned individual. Internally, communication will
be done through departmental meetings and memos. Internally and publicly,
social media will be used to converse the results.
Conclusion
To
conclude, the study aimed at identifying the root causes of SMM in the United
States. The reason is that the SMM rate is currently on the rise and is
expected to become high even further in the coming years. Women in the United
States have the upper hand in terms of getting access to quality care. However,
they still face the vice of maternal mortality. Hemorrhage and hypertensive
diseases are two of the primary causes of the rising maternal mortality rate.
The main cause of such sentinel events is women's lack of access to appropriate
treatment during and after pregnancy. As a result, through the Millennium
Development Goals, health organizations around the world have taken steps to
drastically reduce maternal death by 2030. In addition to ensuring that
pregnant women have better access to excellent treatment, WHO has emphasized
the importance of avoiding undesired births in order to reduce maternal
mortality. If such measures are taken alongside providing policies and
procedures to combat the vice, all nations of the world will contribute towards
achieving this crucial objective.
References
Agrawal,
P. (2015). Maternal mortality and morbidity in the United States of
America. Bulletin of the World
Health Organization, 93, 135-135.
CDC. (n.d). Pregnancy
Mortality Surveillance System. CDC. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality- surveillance-system.htm
Creanga,
A. A., Berg, C. J., Ko, J. Y., Farr, S. L., Tong, V. T., Bruce, F. C., &
Callaghan, W. M. (2014). Maternal
mortality and morbidity in the United States: where are we now?. Journal of women’s health, 23(1),
3-9.
Geller,
S. E., Koch, A. R., Garland, C. E., MacDonald, E. J., Storey, F., & Lawton,
B. (2018). A global view of severe
maternal morbidity: moving beyond maternal mortality. Reproductive
health, 15(1), 31-43.
Mahmood,
M. A., Mufidah, I., Scroggs, S., Siddiqui, A. R., Raheel, H., Wibdarminto, K.,
... & Wahabi, H. A. (2018).
Root-cause analysis of persistently high maternal mortality in a rural district of Indonesia: role of
clinical care quality and health services organizational factors. BioMed research international, 2018.
Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller,
A.B., Daniels, J.D. (2014). Global Causes of
Maternal Death: A WHO Systematic Analysis. Lancet Global Health;2(6): e323- e333.
The Joint Commission. (n.d). About Us. The Joint Commission. https://www.jointcommission.org/
The Joint Commission. (n.d). Delivering Confidence Across All Levels of Maternal Care. The Joint Commission.
https://www.jointcommission.org/accreditation-and- certification/verification/maternal-levels-of-care-verification/
Wojciechowski, E., Pearsall,
T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach
for change. Online journal of issues in nursing, 21(2).
World Health Organization. (2019). Maternal Mortality. World Health
Organization.
Appendices
Appendix
A
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Lack of knowledge
Maternal comorbidities
i.e. HTN Unequipped health
facilities
Delay seeking medical treatment inadequate staff i.e. midwives,
obstetricians
Lack of essential supplies
and equipment’s
|
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Uterine
atony
Macrosmia Uterine
rupture
|
|
Appendix B
Root Cause Types (Table A-1) |
Causal Factors/Root Cause Details (Table A-1) |
Corrective Actions |
Action Strength (Table A-2) |
Measure
of Success (Numerator / Denominator) (Table A-3) |
Sample
Size (Table
A-4) |
Communication Factors |
·
Staff
knowledge deficit or competency ·
Failure
to provide training ·
Appropriate
rules/policies/procedure or lack thereof ·
Availability
of information ·
Communication
breakdowns between and among teams, staff, and providers
|
Action Item #1: ·
Maternal
health safety committee formed ·
Educate
& train all staff on team approach ·
Hospital
administration convey clear quality expectations ·
Develop
new policies ·
Review
and update policies to include debriefing, security, & safety support |
Intermediate Actions
|
High maternal mortality
and morbidity rates related to lack of communication and support |
100% of the cases
|
Environmental Factors |
·
Space
restrictions ·
High
vol. of patient/placement issues ·
High-stress
environment ·
High
wait periods |
Action Item #2: ·
Redesign
ED spaces ·
Create
surge team ·
Designate
overflow spaces & AOD involvement ·
Designate
spaces for behavioral spaces |
Intermediate Actions
|
High maternal mortality
rates due to limited department space and high volume of patients
|
100% of the cases
|
Methods Factors |
·
Failure
to provide necessary information ·
Availability
of information for at-risk patients
|
Action Item #3: ·
Create
assessment guidelines ·
Plan
on how to care for patients in crisis ·
Tracking
process of patients with a past history of birth complications |
Intermediate Actions
|
High maternal mortality
rates related to the methodology of managing disruptive patients with
guidelines |
100% of the cases
|
Human Factor |
·
Organizational-level
failure to correct a known problem and/or provide resource support, including
staffing ·
Leadership
commitment to staff/patient safety |
Action Item #4: ·
Expedite
hiring & the hiring process ·
The
hiring of traveler nurses to decrease burn-out ·
Educate
and train all staff on the team approach ·
CNO
& Hospital administration convey clear quality expectations ·
Leadership
training |
Intermediate Actions
|
High maternal mortality
rates related to human factors |
100% of the cases
|




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