“Where is it safe to practice obstetrics?” is a broader question

I totally agree with the concern that we cannot rely on historic data to determine the safest and most cost-effective route for hysterectomy. I encourage all of us to track and publically report our outcomes and monitor the complication rates of gynecologic surgical procedures. Our ongoing commitment to delivering the best care for our patients requires nothing less.

“REDUCING MATERNAL MORTALITY IN THE UNITED STATES—LET’S GET ORGANIZED!”
ROBERT L. BARBIERI, MD (EDITORIAL; SEPTEMBER 2015)

Structured business methods will improve outcomesDr. Barbieri’s call for getting organized and breaking down health care silos while establishing multidisciplinary teams is of great importance. Most providers have not witnessed a maternal mortality in their careers and many are not aware of the near misses. Incorporating foundations of established business methods has been advocated to reduce waste, improve collaboration, decrease variance, and improve patient safety.

If we view the adverse outcomes through this lens, then the increase in maternal mortality and morbidity are lagging indicators in the structured analysis methods (such as Six Sigma and Lean Six Sigma). These methods lead us to focus and measure the leading indicators of input and process (prenatal care and pregnancy management). Our reliance on lagging indicators often comes too late to make any change effective.

Around 1973, several important processes were introduced into obstetric practice: fetal heart-rate monitoring; ultrasonography; and a reduction of the use of forceps with an increase in the use of vacuum extraction. Safety rates improved, but we witnessed the 8% cesarean delivery rate in 1973 rise to 32% in 2013.^1,2 The maternal mortality rate reported in 2013 is now the same as it was in 1973. A corresponding increase in the cesarean delivery rate over this time frame could be inferred.

By focusing on analysis and management of variables in pregnancy and implementing standardization of care based on good evidence from all disciplines involved in patient safety, we can improve maternal mortality. Simulations and debriefings are critical instruments to enhance management of all aspects of prenatal management, particularly emergent care.

As leaders in improving maternal quality, ObGyns must implement structured business methods (input and process analysis) to improve outcomes. A culture also can be positively altered if the mission and vision are clearly elucidated. Transparent, dynamic, granular, accurate, and reliable data will facilitate “buy-in” of the caregivers and provide more successful solutions. Decreased variance is critical. Expect resistance due to provider autonomy. The alteration in culture of the multidisciplinary team takes time, but a reduction in cesarean delivery rates should be number one on the list to reduce maternal mortality. The unintended consequences of all interventions and monitoring methods also should be pursued.

Robert A. Knuppel, MD, MPH, MBA
Naples, Florida
Judith Withers, RN, MN, MBA
San Diego, California

References
1. Blanchette E. The rising cesarean delivery rate in America. Obstet Gynecol. 2011;118(3):687–690.
2. Knuppel RA. Personal review of Centers for Disease Control and Prevention, National Vital Statistics Reports, 1973–2015.

Dr. Barbieri respondsI wholeheartedly agree with Dr. Knuppel and Ms. Withers: increasing the use of high reliability clinical processes is critically important in our quest to reduce maternal mortality. In addition to decreasing the cesarean delivery rate, I would prioritize ensuring the use of highly effective contraceptives by women with serious medical comorbidities that increase their risk of maternal mortality.

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.