Maternal Mobility and Morbidity in the United States

Posted on: 11th May 2023

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”

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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

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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