In combating the risk of maternal hemorrhage, it is critical to closely examine the presence of health disparities as contributing factors. The CDC (2023) reports that 80% of all pregnancy deaths are preventable, along with the significant risk that Black women face in being three times more likely to die from a pregnancy-related cause than White women. With these statistics, it is imperative for healthcare organizations to focus on the healthcare disparities that are closely connected to maternal hemorrhage to ensure awareness for staff and patients with robust strategies to mitigate the risks.

Healthcare organizations can enact a plan to address maternal hemorrhage in the following ways:

• Implement Leadership Support and Prioritization. Leadership support and prioritization of initiatives are essential in all areas to effectively decrease the risk of maternal hemorrhage for all patients. Healthcare disparities exist that adversely affect patient care. When executing your healthcare equity plan, look closely at sociodemographic characteristics and for biases that can affect the delivery of patient care. What are the health-related social needs of your patient population? How can health-related social needs be incorporated into patient assessments so that this vital information is available from the start of patient care delivery so that staff are aware of any issues for prompt action and discharge planning? For example, are housing and food insecurity challenges impacting patient self-care and the provision of patient care? Do your patients have fair and equal access to care? As organizational leaders, how can you work within the surrounding community to help patients continue to recover through well-informed post-discharge resources? Maintaining emphasis and collaboration can help mitigate well-known risks to patients.
• Create a Prevention Plan Informed by Research and Evidence-Based Practices. Use research and literature to inform your healthcare equity plan. For maternal hemorrhage, what are the factors, such as racial and ethnic disparities, that increase risk? What can be done differently or, in addition, based on what research reveals? How can you anticipate/assume that harm will likely occur so that proactive actions are urgently and consistently taken? To prevent maternal hemorrhage, focus areas can include disparities related to race and standardization of clinical care like hypertension management.
• Provide Staff Training and Education on health-related social needs, sociodemographic considerations, standardized care, and the healthcare equity plan. Orient staff upon hire, annually, and as the program evolves so that staff are fully engaged and informed.
• Provide Patient and Family Education and Support. With patient-centered care, providing education and support to patients, families, and support systems helps to engage all involved in being proactive with care. Consider patient-centered programs such as the CDC’s Hear Her ™ Campaign to foster communication in women sharing concerns and being heard so patients know warning signs and how to access urgent medical attention. When collaborating with patients, pay close attention to health-related social needs, such as access to transportation that may affect their ability to attend medical appointments. Ask – what else is an obstacle to full access to care? What community and organizational supports can be accessed to prevent harm and improve outcomes? Assessing the patient’s knowledge of maternal care is important in addressing issues like a lack of awareness of risks that can happen even when patients feel healthy or have not encountered previous problems.
• Use Quality and Safety Metrics. Examine quality and safety metrics with sociodemographic data such as race and ethnicity, age, and gender. How does this data help identify elements of care that need special consideration and attention to prevent harm? Does the healthcare equity plan need to be revised based on ongoing data results? Analyze research statistics to compare organizational results against national and industry standards.
• Trace Patient Care to Assess Gaps and Effectiveness. Trace an episode of maternal care to look for gaps that need to be addressed through process changes, training, and increased monitoring. In reflecting the high-reliability principle of preoccupation with failure, assume issues exist to maintain openness and awareness of issues. Were all the health-related social needs identified during the admission process? How were these needs, along with sociodemographic considerations, addressed during hospitalization and discharge planning?
• Keep Leaders and Key Stakeholders Informed of initiatives and progress. Request support and resources to foster continuous improvement, transparency, and patient-caregiver collaborations. Use quality, safety, and healthcare disparity-related data continuously so that updates are data-driven and initiatives are measurable and well-designed.

As far as regulatory agency involvement, The Joint Commission issued an accreditation requirement at PC.06.01.01 in July 2020 that focuses on organizations reviewing, developing, or refining their processes to reduce maternal harm, specifically maternal hemorrhage, and to:

• Select, adopt, and implement evidence-based protocols for maternal hemorrhage
  • Implement an assessment of hemorrhage risks
  • Educate staff and patients regarding the risk of maternal hemorrhage and treatment
  • Provide drills for the implementation of your maternal hemorrhage protocols

The National Partnership for Maternal Safety developed by official representatives from the American Association of Blood Banks, the American Academy of Family Physicians, the American College of Nurse‐Midwives, the American College of Obstetricians and Gynecologists (the College/ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the Society for Maternal‐Fetal Medicine, and the Society for Obstetric Anesthesia and Perinatology created an Obstetric Hemorrhage Safety Bundle. The Safety Bundle focuses on four key domains to reduce the national maternal mortality and morbidity rate. These domains include:

Readiness

1. Stocked hemorrhage cart with emergency supplies
   a. Checklist and instruction cards for intrauterine balloons and compression sutures
   b. Immediate access to hemorrhage medications
   c. Rapid response team
   d. Mass blood transfusion protocols
   e. Unit education and drills on protocols

Recognition and Prevention

1. Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times) for every patient
   a. Measurement of cumulative blood loss (formal, as quantitative as possible)
   b. Active management of the 3rd stage of labor (department-wide protocol)

Response

1. Unit-standard, stage-based obstetric hemorrhage emergency management plan with checklists for every patient
   a. Support program for patients, families, and staff for all significant hemorrhages

Reporting and Systems Learning

1. Culture of huddles for high-risk patients
   a. Post-event debriefs to identify successes and opportunities
2. Multidisciplinary review of serious hemorrhages for systems issues
   a. Outcomes and process metrics in the perinatal quality improvement committee

ACOG and AWHONN emphasize the importance of the development of a Massive Transfusion Protocol and a Hemorrhage Ready Cart with the following items:

• IV supplies and fluids
  • Urinary catheter supplies
  • Rapid access to medications (oxytocin /uterotonics)
  • Lab supplies for type & crossmatch, CBC, coagulation, fibrinogen
  • Systems to place OR on alert
  • Having two units Red Blood Cells (RBCs) ready to hang
  • Preparation for Intrauterine Balloon Placement and Compression Sutures
  • Continued monitoring for signs of bleeding

In addition, evidence-based options to assess risk before, during, and after delivery are available through ACOG as part of its Safe Motherhood Initiative. Visit our Accreditation Resource Companion (ARC) for our Maternal Hemorrhage Checklist.

With a few critical strategies, we can improve the management of maternal hemorrhage by recognizing early opportunities to assess risk, anticipate, and plan for an obstetric hemorrhage. Interdisciplinary coordination and preparation, particularly with the ongoing readiness of the blood bank with rapid access to emergency supplies, are critical in providing safe obstetrical care. Implementing a standardized approach to obstetric hemorrhage includes a clearly defined, practiced approach to ensure appropriate actions are taken throughout pregnancy to assess risks before, during, and after delivery to manage emergencies and improve patient outcomes. A steadfast focus on healthcare disparities is also instrumental in providing consistently safe, quality care for all patients.

References

• CDC (2023, April 3). Working Together to Reduce Black Maternal Mortality.
• The Joint Commission (2023) National Patient Safety Goal on Health Care Equity.
• The Joint Commission Comprehensive Accreditation Manual for Hospitals, 2023.
• The joint Commission, Quick Safety Issue 51: Proactive Prevention of Maternal Death from Maternal Hemorrhage, 10/29/2019.
• The American College of Obstetricians and Gynecologists.
• The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
• Safe Healthcare For Every Woman website.

To learn more about Maternal Hemorrhage and Disparity contact the Courtemanche and Associates Team at 704-573-4535 or email us at info@courtmanche-assocs.com.