Call for action is premature



“Troubling news: Maternal mortality is on the rise,” by Robert L. Barbieri, MD (Editorial, October)

I think the statement leading off the October instant poll question, which was based on Dr. Barbieri’s editorial, is misleading. It says, “We need action to stem a rise in maternal mortality.”

We haven’t defined the problem adequately, so prescribing a course of action would be putting the cart before the horse.

Dr. Barbieri correctly states that “the cause of the turnaround (increased maternal mortality) isn’t clearcut.” We need better definitions and an understanding of cause and effect rather than a random call for action. Saying better care will result in better outcomes implies a causal relationship between the quality and amount of care and improved clinical outcomes. I’m not sure that relationship will be confirmed by any of the interventions suggested as “needed actions.”

Scott Thiele, MD
Midland, Mich

Dr. Barbieri responds:
We need both information and action

I appreciate Dr. Thiele’s excellent letter. I agree that more study is needed to understand the cause, or causes, of the increase in maternal mortality reported in the United States. One possibility is that improved reporting is the root cause of the rise in maternal mortality. Dr. Thiele supports the logical sequence of further study of the problem followed by analysis and action. An alternative is to simultaneously study the problem in greater depth while using the knowledge we possess to propose immediate clinical actions that might reduce maternal mortality.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, now known as “The Joint Commission”) has recommended that all maternity units undertake regular simulation exercises in labor and delivery, including exercises focused on the response to severe postpartum hemorrhage, a major cause of maternal mortality.1 This recommendation is based on adverse events that have been reported to the Joint Commission. The Commission believes that simulation exercises will provide a reliable means of assessing and improving the performance of the hospital system.

Rather than withhold all action until more research is completed, I believe the Joint Commission recommendation is wise. In a poll conducted by OBG Management, a minority of respondents indicated that their maternity unit had completed a simulation exercise as recommended in the recent past by the Joint Commission. I worry that, during “our watch,” we have permitted the maternal mortality rate to rise. We need to refocus on this serious adverse outcome.

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