Maternal Safety Comes in Threes

Illustration depicting the silhouettes of a family, where the silhouette of the mother is a dotted line, as if showing she has disappeared.

Keeping moms healthy with new safety bundles

Subject Matter Experts: Dr. Scott Sullivan and Dr. Judith Burgis

By Katharine Hendrix

On completion of this article, readers should be able to:

  • Describe current maternal mortality and morbidity trends in the U.S. and SC.
  • Describe populations that are most likely to experience pregnancy-related death or morbidity.
  • List the most common complications that lead to pregnancy-related deaths, many of which are preventable.
  • Identify proven-effective treatment protocols that can be adopted in SC to reduce the upward trend in maternal mortality and morbidity.
  • Describe why improved maternal morbidity data reporting is needed in SC.

Maternal mortality

Approximately 700 women across the United States die each year as a result of pregnancy or pregnancy-related complications.1 The U.S. maternal mortality rate is 14 deaths per 100,000 live births and is substantially higher than in peer nations like Canada which has 7 maternal deaths per 100,00 live births and the United Kingdom which has 9 maternal deaths per 100,000 live births.2 High income countries typically have low annual maternal death rates (3–12 deaths per 100,000), and rates have consistently declined over the last 25 years. Unfortunately, the U.S. has seen an opposite trend with a 16.7 percent increase in the maternal mortality rate from 1990 to 2015.

The South Carolina maternal mortality rate is approximately 24 per 100,000 live births and is significantly higher among black women than white women (41.9 vs. 14.9 per 100,000).3 This disparity is also observed nationally, with U.S. in-hospital maternal mortality being three times higher for black women than for white women in 2015 (11 vs. 4 per 100,000 deliveries).4

Maternal morbidity

For each woman who dies as the direct or indirect result of pregnancy, exponentially more women experience life-threatening complications. Severe maternal morbidity (SMM) refers to unexpected outcomes of labor and delivery that have significant short- or long-term consequences for a woman’s health. Nationwide, SMM is about 100 times more common than pregnancy-related death, affecting approximately 52,000 American women annually.5 In other words, for each maternal death in the U.S., an estimated 50–100 women experience SMM. Sometimes referred to as “near-misses,” instances of SMM include potentially fatal events such as acute myocardial infarction, pulmonary embolism and sepsis.

Like maternal mortality, the U.S. SMM rate (as defined by 21 conditions and procedures) has also increased sharply – rising 45%, from 101.3 to 146.6 per 10,000 delivery hospitalizations between 2006 and 2015.4 In addition, SMM also disproportionately affects minority and low-income women, especially non-Hispanic black women and those with Medicaid coverage. The U.S. SMM rate is 112–115 percent higher for black women than for white women, and this inequity has not changed in over a decade – with black vs. white SMM rates of 164 vs. 76 in 2006 and 241 vs. 114 in 2015 (per 10,000 delivery hospitalizations).4

Contributing factors

Delay and a lack of urgency in addressing our rising rates of maternal mortality and morbidity can be largely attributed to two environmental factors. First, many physicians do not personally experience a maternal death at their own facilities in any given year. Second, SMM events may occur before or after the actual delivery and may be treated by another physician or facility. Thus, documentation and medical records may not correctly associate an SMM event with a woman’s pregnancy or delivery.

While maternal mortality is regularly and consistently reported, SMM is inconsistently defined and reported, making the task of assessing these data and identifying priorities difficult at both state and national levels. Nonetheless, it is clear that meeting the Healthy People 2020 target of reducing the U.S. maternal death rate to 11.4 per 100,000 live births and complications during hospitalized labor and delivery to 28 percent (from 31.1 percent) will require a concerted, state-level effort.

From 2011–2013, 15.1 percent of U.S. pregnancy-related deaths were caused by cardiovascular disease, 14.5 percent by non-cardiovascular diseases, 12.7 percent by infection and sepsis and 11.4 percent by hemorrhage.6 A legislative brief from the SC Maternal Mortality and Morbidity Review Committee finds that the most common causes of maternal death in SC are cardiovascular and coronary conditions, hemorrhage, infection and embolism.7

The SC Maternal Mortality and Morbidity Review Committee also recently collaborated with the Centers for Disease Control and Prevention on a report combining data from nine states.1 Nearly half of all pregnancy-related deaths in participating states were caused by hemorrhage, cardiovascular and coronary conditions, cardiomyopathy or infection. Importantly, the authors estimated that over 60 percent of pregnancy-related deaths reviewed were preventable.

The report cited three common contributing factors to maternal death: patient/family factors (e.g., not recognizing warning signs and the need to seek care); provider factors (e.g., misdiagnoses and ineffective treatments) and care systems factors (e.g., lack of coordination between providers). It concluded by recommending broad steps that birthing facilities can take to reduce maternal mortality and morbidity, which included: adopting levels of maternal care, improving prevention policies and initiatives, enforcing policies and procedures related to hemorrhage and improving patient management policies.

Effective tools for prevention

A set of proven-effective safety protocols called Maternal Safety Bundles have been developed by the Alliance for Innovation on Maternal Health (AIM) in association with the American College of Obstetricians and Gynecologists (ACOG) to help birthing centers reduce maternal mortality and morbidity.

These condition-specific treatment protocols are readily available and represent best practices in maternity care.8 The three core Safety Bundles focus on: OB Hemorrhage, Severe Hypertension in Pregnancy and Venous Thromboembolism Prevention in Pregnancy. Three supplemental Safety Bundles address: Maternal Early Warning Criteria, Facility Review and Family and Staff Support.9 After implementing these protocols, maternal death rates in California fell from 16.9 per 100,000 live births to 7.3.10

A 2015 ACOG opinion further supports statewide implementation of Maternal Safety Bundles, stating: “Protocols and checklists are shown to reduce patient harm through improved standardization and communication. The use of checklists and protocols has been clearly demonstrated to improve outcomes…Variation in processes of care is problematic because it may lead to increased errors… Performing critical tasks the same way every time can reduce human error, especially when fatigue is a factor, and the environment is stressful.”11

Finally, it is essential to improve statewide data collection and reporting of SMM cases in order to determine how to best focus efforts and resources for reducing maternal morbidity in SC. It is recommended that birthing facilities across the state put screening processes in place to detect and review SMM cases. ACOG and the Society for Maternal-Fetal Medicine recommend two SMM screening criteria: (1) transfusion of four or more units of blood, and (2) admission of a pregnant or postpartum woman to an ICU. Individual institutions may also incorporate additional screening criteria to identify SMM cases.9


1. Brantley MD, et al. Building U.S. Capacity to Review and Prevent Maternal Deaths: Report from Nine Maternal Mortality Review Committees. Atlanta, GA: CDC Division of Reproductive Health; February 2018.

2. WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015. Geneva, Switzerland: WHO; 2015.

3. SC DHEC. South Carolina Vital and Morbidity Statistics, 2016. Columbia, SC: SC DHEC; October 2017.

4. Fingar KR, et al. Healthcare Cost and Utilization Project. Statistical Brief #243: Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity 2006-2015. Rockville, MD: AHRQ; September 2018.

5. Callaghan WM, et al. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029-1036.

6. CDC. Pregnancy Mortality Surveillance System. Accessed November 2017.

7. SC DHEC. SC Maternal Mortality and Morbidity Review Committee: Legislative Review, 2017. Columbia, SC: SC DHEC; 2017.

8. ACOG. Alliance for Innovation on Maternal Health (AIM).

9. Sullivan S, et al. Deployment of maternal safety bundles in your hospital. Presentation to the South Carolina Hospital Association.

10. California Department of Public Health, Maternal, Child, and Adolescent Health Division. Maternal Mortality Rate, California and the United States: 1999-2013. Sacramento, CA: CDPH; May 2015.

11. ACOG. Committee Opinion Number 629: Clinical Guidelines and Standardization of Practice to Improve Outcomes. Washington, DC: American College of Obstetricians and Gynecologists; April 2015