Commentary: Improving Important Pregnancy Outcomes
Robert Goldenberg, MD, Drexel University College of Medicine, 245 N. 15th Street, Philadelphia, PA 19102, USA.
Two of the major killers of women, fetuses, and newborns are eclampsia and severe obstetric hemorrhage. Osman, Campbell, and Nassar, in their investigation of the use of emergency obstetric drills to improve pregnancy outcomes, have tested a strategy aimed at improving the facility management of those conditions, and especially the speed at which that management is implemented (1). They have rightly concluded that increasing staff knowledge regarding the appropriate management of these conditions alone may not be sufficient to improve outcomes, and that practice, with the goal of identifying problems and improving speed, was necessary if timely and appropriate treatment was to be achieved. Using a preevaluation and postevaluation strategy, they demonstrated that the use of obstetric drills can improve facility management of eclampsia and severe obstetric hemorrhage.
Although not proved by this study or by others published to date (2,3), it seems likely that with the regular use of emergency obstetric drills, some improvement in pregnancy outcomes will occur. The American College of Obstetricians and Gynecologists (ACOG) concurs, and in a Committee Opinion states that using emergency obstetric drills can answer several important questions, including whether the necessary drugs are readily available, whether the staff can easily obtain blood products, and the time it takes to move a women with an obstetric emergency to the delivery room (4). Perhaps more important, ACOG also believes that emergency drills allow physicians and hospital staff to practice principles of effective communication in a crisis.
However, the importance of this paper on emergency obstetric drills can only be placed into perspective with an understanding of the background of adverse pregnancy outcomes around the world.
Differences in Outcomes Among Countries
The most important pregnancy outcomes include maternal mortality, stillbirth, and neonatal mortality. Discrepancies in their frequency between high-income and low- and middle-income countries are often huge, but even within high-income countries, surprising differences in important pregnancy outcomes are found among various hospitals and geographic areas. In low-income countries, maternal mortality rates may be greater than 100 times or more than those seen in high-income countries (1,000-1,500 vs 5-10 deaths per 100,000 live-born infants), whereas low-income country stillbirth and neonatal mortality rates may be tenfold higher (5 vs 50 deaths per 1,000 births or live-born infants, respectively) (5). The differences among hospitals or geographic areas within high- and middle-income countries are less striking, but twofold differences in adverse pregnancy outcomes are not uncommon (6,7).
Some differences in the adverse outcomes among geographic areas are associated with characteristics the mother brings to the pregnancy herself, such as her weight, height, and overall nutritional status; medical history including exposure to and appropriate treatment of various infectious diseases; illicit drug, alcohol, and tobacco use; and perhaps even her genetic makeup (8). Nevertheless, it is clear that most of these observed differences relate to the availability of appropriate obstetric and newborn care and the quality of that care.
The major killers of pregnant women worldwide include hemorrhage, preeclampsia/eclampsia, and infection (9). Stillbirths are most frequently attributed to obstructed labor, asphyxia, abruption/hemorrhage, preeclampsia/eclampsia, and infection. Most neonatal deaths are related to asphyxia, often preceded by maternal hemorrhage/abruption, preeclampsia/eclampsia and obstructed labor, infection, and various complications of preterm birth (10). Whereas few, if any, of these conditions are preventable, and most are first identified in labor, each can be treated so that the maternal, fetal, and neonatal deaths can be substantially reduced.
Strategies to Reduce Maternal Risk Factors
Although all types of maternal risk assessment tools have been proposed—and some have been useful in identifying women at risk for one or more of the adverse outcomes just described—most have not proved of value in reducing maternal, fetal, or neonatal mortality. Their failure likely stems from several factors, including the relatively low sensitivity and specificity for the outcome of interest. Most women identified as being at risk for these adverse outcomes have uneventful pregnancies, whereas most of the adverse outcomes are found in low-risk women. Considering the antenatal and intrapartum periods, it is clear that most adverse outcomes have their origins, or at least become clinically apparent, just before or within the intrapartum period (11). Thus, although preeclampsia may be discovered days or weeks before delivery, most of the other killers, including hemorrhage/abruption, obstructed labor, chorioamnionitis/sepsis, preterm labor with or without membrane rupture, and even many cases of preeclampsia/eclampsia, first become apparent in the intrapartum period (12).
Appropriate treatment—whether it be cesarean section, blood transfusion, the administration of antibiotics or magnesium sulfate, or newborn resuscitation—is often time dependent. Delays of hours or even minutes in instituting appropriate treatment for one or more of these conditions are often responsible for many deaths in low- and middle-income countries that in other geographic areas would simply not occur.
Emergency obstetric and neonatal care services (EmONC), defined by the World Health Organization and other agencies, includes parenteral administration of antibiotics, oxytocics, and anticonvulsants; manual removal of the placenta; manual vacuum aspiration; vacuum extraction; and neonatal resuscitation in addition to blood transfusion and the ability to perform a cesarean delivery (13). It seems apparent that these interventions, delivered in a timely manner, would prevent many, or most, of the adverse outcomes described above.
Therefore, preventing most maternal, fetal, and neonatal deaths is feasible with currently known interventions. With their use, throughout the high-income countries, and within many middle- and some low-income countries, the maternal, fetal, and neonatal mortality rates have fallen to very low levels. The major question in other low- and middle-income countries is why these interventions are not more universally available, and in higher income countries why, even with intervention availability, can they not be delivered in a timely manner?
In many low-income countries, most women give birth at home, in the home of a traditional birth attendant, or at a community facility that provides few if any of the EmONC interventions. Community or traditional birth attendants are often not trained to recognize or manage maternal obstructed labor, preeclampsia, hemorrhage and infection, or fetal or newborn distress, infection, and asphyxia. Antibiotics for infection, magnesium sulfate for eclamptic seizure prevention, blood for transfusions, facilities for cesarean sections, and newborn resuscitation equipment are often simply not available. Practitioners with the skills to initiate these interventions are rarely present in the community. Even if a hospital facility with the staff, skills, and equipment necessary to save maternal, fetal, and newborn lives is reasonably close at hand, transportation to the facility either is often not available or has not been prearranged so as to be available in a timely manner. Finally, at the facility, large delays often occur because the staff does not react to emergencies sufficiently quickly. Although the preceding discussion has mostly focused on low-income countries, similar delays are reported in higher income countries and account for some of the discrepancies in rates of adverse pregnancy outcomes reported by hospitals.
Thus, it is clear that in most locations, no single intervention will have a major impact on reducing adverse pregnancy outcomes. Instead, comprehensive strategies that address early identification of pregnancy complications, patient stabilization, transportation, and facility improvement will be necessary to achieve substantial improvements in pregnancy outcomes (14).
Evaluation and Targeted Interventions Are Needed
Despite the focus on emergency obstetric drills in this commentary, we believe that a more comprehensive intervention will likely achieve greater improvements in outcomes. A decision about which strategies, interventions, and improvements to choose among the many available should be made only after a thorough evaluation of the facility itself and after an audit to determine why specific maternal, fetal, and neonatal deaths occur in that facility, and which deaths might be preventable using various interventions. It should then be clearer whether more staff, additional staff training in fundamentals, staff practice in achieving timely interventions, or better or more drugs or equipment would be necessary at the facility level to reduce pregnancy-related mortality. These mortality audits, especially if they include investigation of the community factors involved in each case, would also identify the proportion of deaths resulting from delays due to problem recognition or transportation, and suggest potentially beneficial interventions in care before the mother’s arrival at the facility (13). Although pregnancy-related maternal, fetal, and neonatal mortality has been substantially reduced in many geographic areas, the tools exist to achieve similar results in all places in the world.