A number of different approaches can be used to address delays in recognition and escalation of obstetric emergencies. Several approaches that have demonstrated benefit in other aspects of perinatal care are described below.
Implementing Hospitalwide Safety Bundles
Maternal safety bundles21 are “a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices —generally three to five —that, when performed collectively and reliably, have been proven to improve patient outcomes.”22 Although bundles may vary in exact composition, they include a selection of existing guidelines and evidence-based recommendations in formats that promote adoption for consistency of practice.
For example, the National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage includes 13 key elements spanning the types of equipment, checklists, personnel, and processes associated with improved assessment, diagnosis, and response to maternal hemorrhage.23 Participation in a quality improvement collaborative with adoption of this safety bundle23 led to a 21 percent reduction in severe maternal hemorrhage morbidity.24
Bundles can be customized to fit each institution’s needs and culture, which requires local resources and revision of existing protocols, aiding organizations toward their journey to high reliability.25 Designation of bundle implementation as a key quality/safety priority is essential, with commensurate resources and incorporation of frontline input.26,27 Successful implementation requires commitment and investment from leadership and stakeholders, including education and training to implement these practices.
Addressing Implicit Bias, Structural Barriers, and Social Determinants of Health
Severe maternal morbidity and mortality disproportionately affect birthing people of color, especially Black women, with Black women twice as likely to experience a severe complication28 and three to four times more likely to die than non-Hispanic White women.5 How implicit bias affects diagnosis and adequate treatment needs to be better recognized. For example, although missing early signs of hypovolemia has been identified as a contributing factor to delayed recognition, understanding how implicit bias plays a role when underrecognition occurs is needed to inform targeted approaches to address this important diagnostic error.
Potential interventions to reduce disparate outcomes include training providers on cultural humility and implicit bias, identifying and dismantling structural barriers to accessing care, providing additional support in navigating healthcare systems, and incorporating community-based education and support for families.29,30 Many of these remain to be evaluated, suggesting much work still remains to ensure that the individuals caring for birthing people and the structures in which they are cared for are promoting racial and social equity for all.
Healthcare Simulation To Characterize, Design, and Change Processes
Healthcare simulation, a technique that creates a situation to allow people to experience a representation of a real event,31 has been applied to improve the outcome of a variety of obstetric emergencies, including shoulder dystocia,32 maternal cardiac arrest,33 and maternal hemorrhage.23 Simulation has also been used as a tool for health professional education and training.34 It is ideal for use in clinical settings, giving the multidisciplinary teams needed to respond to obstetric emergencies an opportunity to practice teamwork, communication, and skills to address obstetric process issues.35–37
Simulation can also be used to identify, understand, and address diagnostic error.38–41 Additional research could explore how simulation can also serve as a means of mitigating both cognitive factors such as bias and misdiagnosis/misinterpretation, as well as system errors (latent safety threats), to support reduction in diagnostic error,19,39,42 specifically in maternal care.
For example, in the Maternal Hemorrhage Case above, simulation could explore the causes of systemic issues (e.g., latent safety threats such as having the proper tubing for blood transfusion available in all rooms) and cognitive errors19 (e.g., related to implementing additional treatment options when those tried were ineffective). Simulation can be a useful modality for addressing diagnostic error in maternal health by facilitating implementation of new equipment or processes,43 including safety bundle components such as standardized stage-based treatment for hemorrhage or implementation of a massive transfusion protocol.
Some barriers exist to using simulation to improve quality, including the cultural shift needed to effectively use simulation as an improvement strategy, cost of equipment and staff time, recruitment and training of skilled facilitators/debriefers, and challenge of measuring its direct impact on improvement.43 Balancing the potential benefits and drawbacks of simulation is key for maximizing the potential of this technique.