The United States spends significantly more money on the delivery of health care yet experiences inferior results. Maternal and infant mortality rates are elevated in the United States as compared to other high-income nations. In an effort to improve outcomes and increase the value of services, healthcare organizations throughout the country have developed and monitor quality measures. Such measures exist in the obstetric space, but are largely considered insufficient, particularly in relation to high-risk pregnancies.
To address these gaps and attempt to hasten the adoption of impactful quality measures, the Society for Maternal-Fetal Medicine (SMFM) convened a workshop with other national leaders in obstetric care, including the National Institute of Child Health and Human Development (NICHD) and the American College of Obstetricians and Gynecologists (ACOG). Entitled, "The Quality Measures in High-Risk Pregnancies Workshop," the event took place on February 3-4, 2016 in conjunction with SMFM's 36th Annual Pregnancy Meeting™ and an executive summary of the workshop was published in the October 2017 issue of the American Journal of Obstetrics and Gynecology (AJOG).
The expert participants of the workshop suggested that the following topics merit quality measures.
- Preterm birth is the leading cause of neonatal death and disability affecting almost 400,000 women annually in the U.S. Recommended measures are related to the optimal administration of antenatal corticosteroids and the delivery of very low birth weight infants at the appropriate neonatal intensive care until (NICU) level of care.
- Preeclampsia is one of the leading causes maternal and neonatal morbidity and death worldwide. Recommended measures to address hypertension and preeclampsia include the timely treatment of serve hypertension in pregnancy to reduce maternal death, low-dose aspirin for the prevention of preeclampsia, the use of magnesium sulfate for seizure prophylaxis, and follow-up evaluation and education for women with gestational hypertension or preeclampsia who are at risk for future cardiovascular disease.
- Cesarean birth is the most common inpatient operation in the U.S. and is associated with an increased risk of hemorrhage, hysterectomy, infection, and other complications for the woman and infant. Recommendations include measuring the rate of cesarean birth for nulliparous, term, singleton, vertex pregnancies; and the appropriate administration of antibiotics to women with cesarean births to prevent operation related infection.
- Hospital emergencies, such as venous thromboembolism (VTE) hemorrhage, and sepsis are several of the leading causes of pregnancy-related death. Recommendations include the measurement of women who receive a VTE risk assessment in pregnancy and the postpartum period, the total number of units of red blood cells used for transfusion in the immediate postpartum period, and the presence of a protocol for sepsis identification, evaluation, and treatment that includes pregnant patients.
- Outpatient care, such as ultrasonography and genetic testing, makes up the majority of patient-provider interactions for women with high-risk pregnancies. Medical decisions and procedures performed in the outpatient setting have tremendous effects on the cost of care and eventual patient outcomes. Recommended measures include obstetric ultrasound accreditation, monitoring detection of significant congenital heart defects by prenatal ultrasound, and the proportion of women who receive advanced microarray analysis in the setting of fetal structural abnormality and the performance of a diagnostic invasive procedure.
"The SMFM-led workshop provided an incredible opportunity to convene a multidisciplinary group of the nation's leading scientists and clinicians in high-risk pregnancy care," said lead author of the AJOG executive summary and Secretary-Treasurer of SMFM, Brian K. Iriye, MD. "The commitment of the participants and the national organizations that they represented, demonstrates the resolve our organizations possess towards the realization of meaningful quality measures for high-risk obstetric conditions to optimize the care of women and their infants."
Consensus among workshop participants included the need for enhanced electronic health records and the formation of a national birth certificate system in order to implement and further refine the recommended quality measures.