Severe maternal morbidity – we need more action to prevent harm

Reviewing severe maternal morbidity (SMM) is considered a marker of the quality of maternity care, as in high income countries (HIC) maternal mortality is thankfully now rare.¹ SMM disrupts maternal (and wider family) wellbeing, causing considerable personal and public cost. SMM preventability review has the potential to reduce this and the associated harm. To do this, we must identify its occurrence, review these cases, and analyse findings to develop appropriate system improvements.

As Joanne Frost and her colleagues in this current Australian and New Zealand Journal of Obstetrics and Gynaecology state, there is currently no national consensus or agreement in Australia on terms to use, definitions to follow and therefore no ability to compare inter-state data on the rates and causes of SMM. There is also no defined process to assess preventability in Australia and without this at the outset it is difficult to see how change would be effected. While in Aotearoa (New Zealand), our Health Research Council has previously funded research to enable national SMM preventability reviews, across both countries there appears to be no will by our respective governments to provide ongoing funding to enable routine SMM preventability reviews to take place.² No funding is currently available at regional, state, or national levels, and there is no apparent plan for these reviews to become ‘business as usual’. This is regrettable, as opportunities are being missed to improve poor maternal and baby outcomes.

There is no global agreement on how to define and implement SMM or maternal near-miss (MNM) reviews. There is not even agreement on what to call it. Professor Marion Knight stated four years ago in an editorial for another equally high-quality journal, – ‘As we publish yet more studies (re)defining severe maternal morbidity, should we be questioning whether it is time to draw a line on this research waste and instead initiate a truly international consensus process?’³

And ‘ay, there is the rub’.⁴ How do we initiate a ‘truly international consensus process’? A systematic review of global practices in monitoring of MNM/SMM showed inconsistencies in monitoring with low /middle income countries (LIC/MIC) using predominantly the World Health Organization (WHO) definition of MNM and tools, and high-income countries (HIC) using the SMM definition tools such as the Geller tool for reviewing preventability. The authors concluded that global standardising was ‘not feasible at this time’.⁵ Even a good news recent systemic review and meta-analysis of the WHO MNM criteria uptake in LIC showed that despite good uptake in these countries enabling some intercountry comparisons, there was still the need in individual countries for contextual adaptations.⁶

Surely the conversation needs to change. A search for peer-reviewed research on SMM and MNM reviews revealed 100s of articles on defining, re-defining, counting, rates, associated factors, preventability, and opportunities for improvements. While these are all important, we could find few articles which described the follow-up on those opportunities, and the completion of what the WHO have framed as the cycle of surveillance and response.^7-11 That is to ‘identify, report, review, respond’- to be able to show improvement in maternal outcomes and a decrease in preventable harm. We need to close the audit loop and act on the documented recommendations and opportunities to change practice and systems.^{9, 11}

What do we already know about SMM in HIC? The review of cases of SMM is recognised globally as a quality measure to evaluate maternity care standards as these cases are 50–100 times more common than maternal mortality in HIC.^{12, 13} The causes of the majority of SMM globally are sepsis, haemorrhage (usually postpartum haemorrhage), hypertensive disorders, mainly pre-eclampsia and eclampsia, and pre-existing co-morbidities such as cardiovascular disease and the management of these disease processes.¹⁴ Different jurisdictions have shown that between 30 and 60% of SMM is preventable and that the commonest factors are provider (clinician) or system-related rather than being related to the pregnant person or their family.^{2, 14, 15}

Related to SMM, within-country inequities must be highlighted to show how maternity care systems might be privileging whiteness.¹⁶ Non-Hispanic Black American women suffer much higher rates of SMM than non-Hispanic Whites in the USA.^{17, 18} In Australia, Indigenous First Nations women probably suffer more SMM than White Australians – they have three times the maternal mortality rate.^{14, 19} In Aotearoa, Indigenous wāhine Māori (Māori women) suffer higher rates of maternal death and perinatal loss than white New Zealand Europeans, and Pacific women suffer the highest rates of preventable SMM.² Non-white minority ethnic groups in the Netherlands and UK experience similar disparities which are not explained by known risk factors for severe maternal morbidity.^{20, 21}

With a clear link between SMM and poor infant outcomes, there is a move in some jurisdictions to expand preventability review to the perinatal continuum as a whole – from pregnancy, through birth to neonatal outcomes. Rates of stillbirth, preterm birth, low birth weight, and admission to neonatal intensive care units (NICU) are all higher in SMM cases than non-SMM cases.^22-25

Let the paper by Frost et al and this editorial be an urgent call to action – one specific to Australasia. We – clinicians, researchers, and policy makers – know that multidisciplinary, non-punitive preventability reviews of SMM are possible, wanted, and can lead to recommendations to change policy, implement clinical guidelines, and improve clinical education and health systems.²⁶ So, let's do it.

Start at a facility, regional or state level. Choose a definition, establish a process with a multidisciplinary team, use a validated tool and just get started reviewing SMM cases. There are several tools and guides described in the literature about how to set up preventability reviews of SMM.^27-29 Of course, we won't capture all cases, but we must start somewhere.

Let's also be sure it is done with an appropriate lens. Our SMM study cases in Aotearoa were deidentified for ethnicity to minimise unconscious bias in the case reviews – the first national study on SMM to address racism in this process.²⁹ Importantly, results were presented with an Indigenous non-deficit focus, highlighting the opportunities for system improvement to improve care, reduce SMM and reduce inequitable outcomes. Incorporating these approaches to SMM reviews (such as deidentifying ethnicity), is a necessary step to addressing inequities.¹⁶

From our experience of SMM preventability review in Aotearoa, (across the then 20 health districts), there were multiple positive ripple effects from gathering together maternity, anaesthetic, intensivist and other clinicians from across the country: there was enhanced collegial respect; professional relationships were forged; and clinicians took learnings and recommendations gleaned from being involved in the reviews back to their own departments and professional groups to disseminate.

So, what if funding is not forthcoming from the government? Consider research funding opportunities to explore aspects of preventability reviews for SMM and/or expand further to look at the perinatal continuum. Join international alliances such as The Alliance for Perinatal and Reproductive Justice (www.perinataljustice.org) lobbying for culturally safe and responsive maternity care pathways that work for all to eliminate preventable harm and death. And of course, as researchers and clinicians we must lobby our respective policy funders at every level and at every opportunity to give this quality measure to improve maternal outcomes its due recognition and funding.