Applying Human Factors Engineering to Reduce Severe Maternal Morbidity and Mortality
TimeFriday, April 162:00pm - 3:00pm EDT
DescriptionChildbirth is the most common indication for hospitalization in the United States; with an estimated 3.8 million births in 2018 (Hamilton, Martin, Osterman, & Rossen, 2019). Despite having the most expensive maternity care in the world, the maternal mortality rate ( deaths occurring within 42 days of pregnancy per 100,000 live births) in the US has increased from 7.2 deaths in 1987 to 17.3 deaths in 2017, with estimates as high as 26.4 in 2015 (Building U.S. Capacity to Review and Prevent Maternal Deaths., 2018; Callaghan, Creanga, & Kuklina, 2012; Creanga, Syverson, Seed, & Callaghan, 2017; Deadly Delivery: The Maternal Health Crisis in the USA, 2010). This is the highest of any developed country. The leading medical causes of maternal mortality include cardiovascular conditions, infections, hemorrhage, cardiomyopathy, hypertensive disorders of pregnancy, and embolisms, with each condition contributing up to 9 -15% of deaths (Creanga et al., 2015; Creanga et al., 2017). Black women are 3 to 4 times more likely to die from pregnancy-related causes than white women and pregnancy-related deaths are also elevated among Native Americans/Alaskans, Asians/Pacific Islanders, and for certain subgroups of Latina women, including Puerto Ricans (Centers for Disease & Prevention, 2001; Gray, Wallace, Nelson, Reed, & Schiff, 2012; Hopkins et al., 1999; Howell, 2018). For every maternal death, there are 100 cases of severe maternal morbidity (SMM) - such as peripartum hysterectomy, hemorrhage, pulmonary embolism, and septic shock (Howell, Egorova, Balbierz, Zeitlin, & Hebert, 2016; Kilpatrick, 2015). The SMM rate in the US has also increased sharply – rising 120 - 200% since 2000 (Centers for Disease & Prevention, 2019). Women of color experience higher rates of SMM, which result in significant short or long-term health consequences, and case fatality (Deadly Delivery: The Maternal Health Crisis in the USA, 2010; Howell, 2018; Howell & Zeitlin, 2017; Lawton, Jane MacDonald, Stanley, Daniells, & Geller, 2018; MacDorman & Mathews, 2010; "Severe Maternal Morbidity in the United States," 2017). There are also additional intensive-acute psychiatric events not reflected in MMR and SMM rates, including suicide, which is the second leading cause of maternal death (Lindahl, Pearson, & Colpe, 2005; Metz et al., 2016). Although these issues are a serious concern for all birthing people, they are particularly severe among underserved populations, including African-Americans, Latinas, (Creanga et al., 2015) and individuals with limited English-language proficiency (Hayes, Enohumah, & McCaul, 2011; Pope, 2005).
The majority of deaths, and increasing incident of SMM, occur during the postpartum phase (Spelke & Werner, 2018). However, 40 – 60% of all maternal deaths and SMM are preventable with timely and appropriate care (Berg et al., 2005; Building U.S. Capacity to Review and Prevent Maternal Deaths., 2018; Kilpatrick, 2015; Main, McCain, Morton, Holtby, & Lawton, 2015). Mortality and SMM from several specific conditions, such as hemorrhage and preeclampsia, have much higher rates of preventability; in some cases as high as 93%.(Berg et al., 2005; Kilpatrick, 2015; Main et al., 2015) These figures suggests opportunities to intervene within the maternal clinic care environment to reduce mortality, SMM, and disparities in care (Abeysekera, Bergman, Kluger, & Short, 2005; Berg et al., 2005; Kilpatrick, 2015). Despite at least 20 years of human factors and systems research in healthcare, few studies have examined how clinical systems contribute to adverse outcomes and disparities in maternal care nor applied human factors to develop interventions. Previous literature on disparities in maternal care suggested the need to investigate the clinical system and define methods to identify and analyze disparities in quality of care (Building U.S. Capacity to Review and Prevent Maternal Deaths., 2018; Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006; Main et al., 2015). Maternal mortality review committees (MMRCs), which review pregnancy-related deaths and assess their preventability, also noted that while surveillance (such as vital statistics) and population level data highlight trends and disparities, smaller scale, complementary efforts are needed to identify specific opportunities to improve care and reduce disparities within clinical systems (2001; Building U.S. Capacity to Review and Prevent Maternal Deaths., 2018; Medicine, 2003; Wyatt, Laderman, Botwinick, Mate, & Whittington, 2016).
In order to design systems where women survive pregnancy and childbirth and report positive experiences with their care, we must learn what makes the systems work well or perform poorly, examining the care provided in the prenatal period, during childbirth, and in the postpartum period. This includes systems and data analysis as well as listening to the patients, care providers, and family members themselves, identifying and resolving quality of care issues within clinical environments, and ensuring women are sufficiently supported as they transition to lower levels of care. In this panel we discuss our efforts to apply human factors and systems engineering methods – including work systems analysis and human-centered design - to analyze in-patient maternal care, redesign systems of care to improve transitions, and develop dynamic tools to help postpartum mothers determine when to seek treatment. These multifaceted approaches target different stages of the pregnancy timeline and will support safe, comprehensive and equitable maternal care.