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Centers of Excellence for Anesthesia Care of Obstetric Patients

Carvalho, Brendan MBBCh, FRCA*; Mhyre, Jill M. MD

doi: 10.1213/ANE.0000000000004027
Editorials: Editorial
Free

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California

University of Arkansas for Medical Sciences.

Published ahead of print 10 December 2018.

Accepted for publication December 10, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Brendan Carvalho, MBBCh, FRCA, Department of Anesthesiology, Perioperative and Pain Medicine, H3580 Stanford University School of Medicine, Stanford, CA 94305. Address e-mail to bcarvalho@stanford.edu.

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Maternal mortality is the sixth most common cause of death among women age 20–34 years old in the United States.1 Maternal mortality has increased over the past decade in the United States, with 1 analysis showing estimated maternal mortality rate increasing by 27% from 18.8 (per 100,000 live births) in 2000 to 23.8 in 2014.2 The reason for rising maternal mortality in the United States is likely multifactorial. Advancing maternal age with growing prevalence of comorbidities and chronic conditions, increasing prevalence of obesity, greater numbers of women with cardiac disease surviving to reproductive age, increasing cesarean deliveries (with associated higher complications than vaginal delivery), racial, ethnic, and social disparities, inadequate federal family-planning budgets, fragmented health care, and lack of access to antenatal and postpartum care likely all contribute to maternal mortality, and may account for why the maternal mortality in the United States is significantly higher than in other developed countries.

The provision of optimal hospital care during labor and delivery is essential to reduce maternal morbidity and mortality. Many pregnancy-related deaths have been determined to be preventable. The Centers for Disease Control and Prevention reports that 60% of deaths during childbirth are preventable, and the California Maternal Quality Care Collaborative determined that facility factors contributed to 75% of fatal outcomes when analyzing preventable maternal deaths.3 There is unfortunately significant heterogeneity in risk-adjusted maternal and neonatal outcomes among hospitals providing care for pregnant women,4,5 driven in part by hospital-level variables such as delivery volume and case-mix. In a striking example from New York City, the hospital where mothers delivered their babies appeared to explain as much as half of the observed disparity in severe maternal morbidity between African American and Caucasian women.6

Data are limited to elucidate the extent to which high-quality anesthetic care contributes to differences in maternal and neonatal outcomes. Adverse anesthesia-specific events differ between institutions but make a relatively small contribution to overall maternal morbidity.7 However, anesthesiologists play an essential role in the interdisciplinary care team and management of the critically ill pregnant women. In this edition of Anesthesia & Analgesia, Pryde’s8 article “Contemplating our maternity care crisis in the United States: reflections of an obstetrician anesthesiologist” outlines the important role of the obstetric anesthesiologist in improving maternal care especially during critical rescue events. He suggests that obstetric anesthesiologists are ideally suited as leaders in this setting with their expertise in obstetric physiology and complications of pregnancy, and training for early recognition of evolving maternal crises, appropriate escalation of monitoring when necessary, and orchestration of team-supported life-saving and morbidity-limiting treatments. The important role of the obstetric anesthesiologist in optimizing maternal care and reducing maternal morbidity and mortality has been highlighted in several excellent articles.9,10

To ensure that the highest-risk patients are delivered at institutions with comprehensive services, including high-quality and dedicated obstetric anesthesia care, “risk-appropriate care” has been proposed by American College of Obstetricians and Gynecologists in their document on the levels of maternal care.11 Their proposed classification system for levels of maternal care include basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). To fulfill requirements for subspecialty care (level III) and regional perinatal health care centers (level IV), anesthesia services must be available at all times. In addition, a “board-certified anesthesiologist with special training or experience in obstetrics is in charge of obstetric anesthesia services.” Nevertheless, the document is silent on more specific characteristics that may impact the quality of anesthetic services delivered.

To address this gap, the Society of Obstetric Anesthesia and Perinatology has recently proposed a process to designate Centers of Excellence for obstetric anesthesia care. The aim of the Society of Obstetric Anesthesia and Perinatology Centers of Excellence designation is to recognize institutions and programs that demonstrate excellence in obstetric anesthesia care, to set a benchmark level of expected care to improve the standards nationally, and to provide a broad surrogate quality metric of institutions providing obstetric anesthesia care. The criteria for Centers of Excellence designation cover various domains including personnel and staffing; equipment, protocols, and policies; simulation and team training; obstetric emergency management; cesarean delivery and labor analgesia care; recommendations and guidelines implementation; and quality assurance and patient follow-up systems. The criteria for Centers of Excellence designation, which cover all aspects of obstetric anesthesia care, were generated by expert consensus and incorporate evidence-based recommendations. Key recommendations that are required for Centers of Excellence designation are outlined in the Table. The full list of Society of Obstetric Anesthesia and Perinatology Centers of Excellence designation criteria are listed at https://soap.org/grants/center-of-excellence/.

Table.

Table.

In conclusion, there are many aspects contributing to the higher than desired maternal mortality and morbidity in the United States. Improvements in the quality of care that hospitals provide pregnant women undergoing labor and delivery will help reduce maternal and neonatal harm. The training and expertise of obstetric anesthesiologists make them ideally suited to make significant contributions toward reducing maternal mortality. The overall quality of obstetric anesthesia care provided is important to benchmark. The Society of Obstetric Anesthesia and Perinatology proposed “Centers of Excellence for Anesthesia Care of Obstetric Patients’ Designation” aims to recognize institutions that provide optimal care, improve the standards nationally, and provide a broad surrogate quality metric for institutions providing obstetric anesthesia care. This Society of Obstetric Anesthesia and Perinatology Centers of Excellence designation combined with American College of Obstetricians and Gynecologists levels of maternal care will hopefully ensure that proportional level care is provided for pregnant women especially those at high risk for maternal morbidity and mortality.

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DISCLOSURES

Name: Brendan Carvalho, MBBCh, FRCA.

Contribution: This author helped write the manuscript and approved the final version of the manuscript.

Name: Jill M. Mhyre, MD.

Contribution: This author helped write the manuscript and approved the final version of the manuscript.

This manuscript was handled by: Jean-Francois Pittet, MD.

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REFERENCES

1. Heron MDeaths: leading causes for 2014. Natl Vital Stat Rep. 2016;65:1–96.
2. MacDorman MF, Declercq E, Cabral H, Morton CRecent increases in the US maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol. 2016;128:447–455.
3. The California Pregnancy-Associated Mortality Review Report from 2002 and 2003 Maternal Death Reviews. Available at: https://www.cmqcc.org/resource/2520/download. Accessed October 1, 2018.
4. Howell EA, Egorova N, Balbierz A, Zeitlin J, Hebert PLBlack-white differences in severe maternal morbidity and site of care. Am J Obstet Gynecol. 2016;214:122.e1–122.e7.
5. Glance LG, Dick AW, Glantz JC, et al.Rates of major obstetrical complications vary almost fivefold among US hospitals. Health Aff (Millwood). 2014;33:1330–1336.
6. Howell EA, Egorova NN, Balbierz A, Zeitlin J, Hebert PLSite of delivery contribution to black-white severe maternal morbidity disparity. Am J Obstet Gynecol. 2016;215:143–152.
7. Guglielminotti J, Landau R, Wong CA, Li GPatient-, hospital-, and neighborhood-level factors associated with severe maternal morbidity during childbirth: a cross-sectional study in New York State 2013–2014. Matern Child Health J. 2018 July 16 [Epub ahead of print].
8. Pryde PGContemplating our maternity care crisis in the United States: reflections of an obstetrician anesthesiologist. Anesth Analg. 2019;128:1036–1041.
9. Abir G, Mhyre JMaternal mortality and the role of the obstetric anesthesiologist. Best Pract Res Clin Anaesthesiol. 2017;31:91–105.
10. McQuaid E, Leffert LR, Bateman BTThe role of the anesthesiologist in preventing severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61:372–386.
11. American College of Obstetricians and Gynecologists. Levels of maternal care. Obstetric Care Consensus No. 2. Obstet Gynecol. 2015;125:502–515.
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