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rate in the United States, according to a new perspective from leading obstetricians published in the New England Journal of Medicine.
The authors, including Kimberlee McKay, MD, president of the American College of Obstetricians and Gynecologists (ACOG), also call for collaboration with family physicians to increase access to obstetric care in rural areas.
The president of the American Academy of Family Physicians (AAFP), John S. Cullen, MD, in a separate statement, welcomed the opportunity for collaboration in addressing the maternal mortality crisis. However, some distance still lies between the finer points of how the two organizations see family physicians helping curb the crisis.
“Women in the United States are more likely to die from childbirth- or pregnancy-related causes than women in any other high-income country, and black women die at a rate three to four times that of white women,” noted Susan Mann, MD, along with her coauthors of the obstetric perspective, calling increasing maternal mortality a “tragedy.”
In an interview, Dr. Cullen concurred, calling the current situation “unconscionable.” One of the primary reasons he sought AAFP leadership, he said, was to bring experiences learned during his 25 years of obstetric practice in rural Alaska to bear on the current crisis.
A set of maternal care bundles created by the Alliance for Innovation on Maternal Health (AIM) provides the framework for the first action recommended by Dr. Mann and her coauthors. The AIM bundles focus on protocols that improve readiness, recognition, response, and reporting in maternal care. The protocols are institution specific. For example, the authors noted, antihypertensive medications should be readily available around the clock, because not all facilities will have a pharmacist in-house at all times, and hypertensive emergencies are among the gravest obstetric complications.
“Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7,” said Dr. Mann, a physician in private practice in Boston, and her coauthors.
The second recommended action revolves around multidisciplinary staff meetings to perform individual assessments for each woman’s obstetric risk factors. These huddles should include assessing hemorrhage risk by using the California Maternal Quality Care Collaborative guidelines, and briefings with the full care team to “develop shared understandings of the patient and the procedure” before elective or nonurgent cesarean deliveries, said Dr. Mann and her colleagues. Patients should be informed of any safety concerns, and caregivers should use shared decision-making moving forward.
“Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services,” Dr. Mann and her coauthors noted.
Third, simulation of obstetric emergencies lets all members of the team understand the speed at which decisions must be made and actions taken when minutes, or even seconds, count. Dr. Mann and her coauthors pointed out that logistics problems come out during a well-run simulation, giving such examples as a lag in receiving blood products or a poorly placed hemorrhage cart.
Drawing an analogy to the extensive time pilots spend in flight simulators, Dr. Mann and her coauthors noted that “because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events.”
Using the Maternal Health Compact will help ensure that lower-resource hospitals have a relationship in place with a facility that can provide a higher level of maternal care when needed, they said.
This fourth action means that there’s a connection that “can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources,” said Dr. Mann and her coauthors. When transport is necessary, it too can be facilitated if a compact is already in place.
The final, broader, recommendation from the obstetricians is that ACOG and AAFP collaborate “on an additional year of comprehensive training for family medicine physicians who are considering practicing obstetrics in rural areas.” The fourth year of training for these family physicians could help address widespread shortages of obstetricians and midwives in rural communities, Dr. Mann and her coauthors wrote. They observed that “pregnant women who live in rural areas may need to travel hundreds of miles to obtain routine prenatal care or consultation with an obstetrical specialist.”
Dr. Cullen, whose practice is in Valdez, Alaska, said he happily reciprocates the desire for collaboration. In his inaugural blog post after assuming the AAFP presidency in October, 2018, he extended warm thanks to his obstetrician and perinatologist colleagues. “The relationship between family physicians and obstetricians is vital in rural communities like mine. The training I received has saved lives and prevented catastrophe,” he wrote.
At the same time, Dr. Cullen said that he believes family physicians are the best hope for quality obstetrical care in rural communities. Dr. Cullen’s own training, he said, was structured to involve significant obstetric experience with obstetrician mentorship. “A 3-year residency left me very comfortable with fairly sophisticated obstetric management at graduation,” he added.
In his practice, Dr. Cullen said, a family physician hired a decade ago after a 3-year residency came with excellent obstetric skills, which have been further honed during the succeeding years of rural practice. During a 3-year residency, “family physicians receive training and demonstrate the skills and competencies required to deliver high-quality maternity care in any community, including those in rural settings,” he said in his statement.
“The bigger issue is really the closure of obstetric units in rural hospitals,” said Dr. Cullen. He pointed out that although obstetric services may have left a community, that rural hospital will still have miscarrying patients with hemorrhage, patients in preterm labor, and other obstetric emergencies arriving at the doorstep. These and other instances often “represent true emergencies without possibility of transfer, requiring immediate and effective response,” he wrote.
“We would encourage the authors to ensure an equal focus on improving care at all levels and in all hospitals, as well as relying on transfer as appropriate,” Dr. Cullen said in his statement.
Such mutual support can be bolstered by new technology, wrote Dr. Mann and her coauthors, because “telehealth and collaborations and consultation with clinics and regional hospitals can help increase the availability of maternity care in the United States.”
For Dr. Cullen also, the way forward is together. In his blog, he wrote: “As family physicians, we can only deliver obstetrical care to our patients with the cooperation of obstetricians and perinatologists. Conversely, obstetricians can only improve maternal and infant mortality rates, especially in rural areas, with the help of family physicians.”
SOURCE: Mann S et al. N Engl J Med 2018;379:1689-91.
rate in the United States, according to a new perspective from leading obstetricians published in the New England Journal of Medicine.
The authors, including Kimberlee McKay, MD, president of the American College of Obstetricians and Gynecologists (ACOG), also call for collaboration with family physicians to increase access to obstetric care in rural areas.
The president of the American Academy of Family Physicians (AAFP), John S. Cullen, MD, in a separate statement, welcomed the opportunity for collaboration in addressing the maternal mortality crisis. However, some distance still lies between the finer points of how the two organizations see family physicians helping curb the crisis.
“Women in the United States are more likely to die from childbirth- or pregnancy-related causes than women in any other high-income country, and black women die at a rate three to four times that of white women,” noted Susan Mann, MD, along with her coauthors of the obstetric perspective, calling increasing maternal mortality a “tragedy.”
In an interview, Dr. Cullen concurred, calling the current situation “unconscionable.” One of the primary reasons he sought AAFP leadership, he said, was to bring experiences learned during his 25 years of obstetric practice in rural Alaska to bear on the current crisis.
A set of maternal care bundles created by the Alliance for Innovation on Maternal Health (AIM) provides the framework for the first action recommended by Dr. Mann and her coauthors. The AIM bundles focus on protocols that improve readiness, recognition, response, and reporting in maternal care. The protocols are institution specific. For example, the authors noted, antihypertensive medications should be readily available around the clock, because not all facilities will have a pharmacist in-house at all times, and hypertensive emergencies are among the gravest obstetric complications.
“Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7,” said Dr. Mann, a physician in private practice in Boston, and her coauthors.
The second recommended action revolves around multidisciplinary staff meetings to perform individual assessments for each woman’s obstetric risk factors. These huddles should include assessing hemorrhage risk by using the California Maternal Quality Care Collaborative guidelines, and briefings with the full care team to “develop shared understandings of the patient and the procedure” before elective or nonurgent cesarean deliveries, said Dr. Mann and her colleagues. Patients should be informed of any safety concerns, and caregivers should use shared decision-making moving forward.
“Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services,” Dr. Mann and her coauthors noted.
Third, simulation of obstetric emergencies lets all members of the team understand the speed at which decisions must be made and actions taken when minutes, or even seconds, count. Dr. Mann and her coauthors pointed out that logistics problems come out during a well-run simulation, giving such examples as a lag in receiving blood products or a poorly placed hemorrhage cart.
Drawing an analogy to the extensive time pilots spend in flight simulators, Dr. Mann and her coauthors noted that “because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events.”
Using the Maternal Health Compact will help ensure that lower-resource hospitals have a relationship in place with a facility that can provide a higher level of maternal care when needed, they said.
This fourth action means that there’s a connection that “can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources,” said Dr. Mann and her coauthors. When transport is necessary, it too can be facilitated if a compact is already in place.
The final, broader, recommendation from the obstetricians is that ACOG and AAFP collaborate “on an additional year of comprehensive training for family medicine physicians who are considering practicing obstetrics in rural areas.” The fourth year of training for these family physicians could help address widespread shortages of obstetricians and midwives in rural communities, Dr. Mann and her coauthors wrote. They observed that “pregnant women who live in rural areas may need to travel hundreds of miles to obtain routine prenatal care or consultation with an obstetrical specialist.”
Dr. Cullen, whose practice is in Valdez, Alaska, said he happily reciprocates the desire for collaboration. In his inaugural blog post after assuming the AAFP presidency in October, 2018, he extended warm thanks to his obstetrician and perinatologist colleagues. “The relationship between family physicians and obstetricians is vital in rural communities like mine. The training I received has saved lives and prevented catastrophe,” he wrote.
At the same time, Dr. Cullen said that he believes family physicians are the best hope for quality obstetrical care in rural communities. Dr. Cullen’s own training, he said, was structured to involve significant obstetric experience with obstetrician mentorship. “A 3-year residency left me very comfortable with fairly sophisticated obstetric management at graduation,” he added.
In his practice, Dr. Cullen said, a family physician hired a decade ago after a 3-year residency came with excellent obstetric skills, which have been further honed during the succeeding years of rural practice. During a 3-year residency, “family physicians receive training and demonstrate the skills and competencies required to deliver high-quality maternity care in any community, including those in rural settings,” he said in his statement.
“The bigger issue is really the closure of obstetric units in rural hospitals,” said Dr. Cullen. He pointed out that although obstetric services may have left a community, that rural hospital will still have miscarrying patients with hemorrhage, patients in preterm labor, and other obstetric emergencies arriving at the doorstep. These and other instances often “represent true emergencies without possibility of transfer, requiring immediate and effective response,” he wrote.
“We would encourage the authors to ensure an equal focus on improving care at all levels and in all hospitals, as well as relying on transfer as appropriate,” Dr. Cullen said in his statement.
Such mutual support can be bolstered by new technology, wrote Dr. Mann and her coauthors, because “telehealth and collaborations and consultation with clinics and regional hospitals can help increase the availability of maternity care in the United States.”
For Dr. Cullen also, the way forward is together. In his blog, he wrote: “As family physicians, we can only deliver obstetrical care to our patients with the cooperation of obstetricians and perinatologists. Conversely, obstetricians can only improve maternal and infant mortality rates, especially in rural areas, with the help of family physicians.”
SOURCE: Mann S et al. N Engl J Med 2018;379:1689-91.
rate in the United States, according to a new perspective from leading obstetricians published in the New England Journal of Medicine.
The authors, including Kimberlee McKay, MD, president of the American College of Obstetricians and Gynecologists (ACOG), also call for collaboration with family physicians to increase access to obstetric care in rural areas.
The president of the American Academy of Family Physicians (AAFP), John S. Cullen, MD, in a separate statement, welcomed the opportunity for collaboration in addressing the maternal mortality crisis. However, some distance still lies between the finer points of how the two organizations see family physicians helping curb the crisis.
“Women in the United States are more likely to die from childbirth- or pregnancy-related causes than women in any other high-income country, and black women die at a rate three to four times that of white women,” noted Susan Mann, MD, along with her coauthors of the obstetric perspective, calling increasing maternal mortality a “tragedy.”
In an interview, Dr. Cullen concurred, calling the current situation “unconscionable.” One of the primary reasons he sought AAFP leadership, he said, was to bring experiences learned during his 25 years of obstetric practice in rural Alaska to bear on the current crisis.
A set of maternal care bundles created by the Alliance for Innovation on Maternal Health (AIM) provides the framework for the first action recommended by Dr. Mann and her coauthors. The AIM bundles focus on protocols that improve readiness, recognition, response, and reporting in maternal care. The protocols are institution specific. For example, the authors noted, antihypertensive medications should be readily available around the clock, because not all facilities will have a pharmacist in-house at all times, and hypertensive emergencies are among the gravest obstetric complications.
“Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7,” said Dr. Mann, a physician in private practice in Boston, and her coauthors.
The second recommended action revolves around multidisciplinary staff meetings to perform individual assessments for each woman’s obstetric risk factors. These huddles should include assessing hemorrhage risk by using the California Maternal Quality Care Collaborative guidelines, and briefings with the full care team to “develop shared understandings of the patient and the procedure” before elective or nonurgent cesarean deliveries, said Dr. Mann and her colleagues. Patients should be informed of any safety concerns, and caregivers should use shared decision-making moving forward.
“Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services,” Dr. Mann and her coauthors noted.
Third, simulation of obstetric emergencies lets all members of the team understand the speed at which decisions must be made and actions taken when minutes, or even seconds, count. Dr. Mann and her coauthors pointed out that logistics problems come out during a well-run simulation, giving such examples as a lag in receiving blood products or a poorly placed hemorrhage cart.
Drawing an analogy to the extensive time pilots spend in flight simulators, Dr. Mann and her coauthors noted that “because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events.”
Using the Maternal Health Compact will help ensure that lower-resource hospitals have a relationship in place with a facility that can provide a higher level of maternal care when needed, they said.
This fourth action means that there’s a connection that “can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources,” said Dr. Mann and her coauthors. When transport is necessary, it too can be facilitated if a compact is already in place.
The final, broader, recommendation from the obstetricians is that ACOG and AAFP collaborate “on an additional year of comprehensive training for family medicine physicians who are considering practicing obstetrics in rural areas.” The fourth year of training for these family physicians could help address widespread shortages of obstetricians and midwives in rural communities, Dr. Mann and her coauthors wrote. They observed that “pregnant women who live in rural areas may need to travel hundreds of miles to obtain routine prenatal care or consultation with an obstetrical specialist.”
Dr. Cullen, whose practice is in Valdez, Alaska, said he happily reciprocates the desire for collaboration. In his inaugural blog post after assuming the AAFP presidency in October, 2018, he extended warm thanks to his obstetrician and perinatologist colleagues. “The relationship between family physicians and obstetricians is vital in rural communities like mine. The training I received has saved lives and prevented catastrophe,” he wrote.
At the same time, Dr. Cullen said that he believes family physicians are the best hope for quality obstetrical care in rural communities. Dr. Cullen’s own training, he said, was structured to involve significant obstetric experience with obstetrician mentorship. “A 3-year residency left me very comfortable with fairly sophisticated obstetric management at graduation,” he added.
In his practice, Dr. Cullen said, a family physician hired a decade ago after a 3-year residency came with excellent obstetric skills, which have been further honed during the succeeding years of rural practice. During a 3-year residency, “family physicians receive training and demonstrate the skills and competencies required to deliver high-quality maternity care in any community, including those in rural settings,” he said in his statement.
“The bigger issue is really the closure of obstetric units in rural hospitals,” said Dr. Cullen. He pointed out that although obstetric services may have left a community, that rural hospital will still have miscarrying patients with hemorrhage, patients in preterm labor, and other obstetric emergencies arriving at the doorstep. These and other instances often “represent true emergencies without possibility of transfer, requiring immediate and effective response,” he wrote.
“We would encourage the authors to ensure an equal focus on improving care at all levels and in all hospitals, as well as relying on transfer as appropriate,” Dr. Cullen said in his statement.
Such mutual support can be bolstered by new technology, wrote Dr. Mann and her coauthors, because “telehealth and collaborations and consultation with clinics and regional hospitals can help increase the availability of maternity care in the United States.”
For Dr. Cullen also, the way forward is together. In his blog, he wrote: “As family physicians, we can only deliver obstetrical care to our patients with the cooperation of obstetricians and perinatologists. Conversely, obstetricians can only improve maternal and infant mortality rates, especially in rural areas, with the help of family physicians.”
SOURCE: Mann S et al. N Engl J Med 2018;379:1689-91.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE