Eliminating Preventable, Hemorrhage-Related Maternal Mortality and Morbidity


  • The author reports no conflict of interest or relevant financial relationships.


Debra Bingham, DrPH, RN, Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), 2000 L Street, NW, Suite 740, Washington, DC 20036. dbingham@awhonn.org

An assumption exists that any woman who gives birth in any hospital in the United States will have access to blood products and other, basic, life-saving therapies and that these hospitals will have an adequate number of highly skilled clinicians (nurses, doctors, midwifes) who can reliably recognize, respond, and manage an obstetric hemorrhage. However, these assumptions have been called into question by multiple researchers who studied the preventability of obstetric hemorrhage-related deaths. In these studies, researchers reported that 54% (Della Torre et al., 2011), 70% (California Department of Public Health, 2011), or even 93% (Berg et al., 2005) of the obstetric hemorrhage-related mortality cases reviewed were judged to be preventable. These researchers found that clinician error was the major factor contributing to maternal deaths. Another very troubling statistic is the overall 3-fold to 4fold racial disparity in maternal mortality. Researchers from the Centers for Disease Control and Prevention (CDC) showed that Black women were equally as likely as White women to have an obstetric hemorrhage, but in women experiencing an obstetric hemorrhage, Black women were 2 to 3 times more likely to die than White women (Tucker, Berg, Callaghan, & Hsia, 2007).

Furthermore, the U.S. maternal mortality rate does not compare favorably with other countries. In 2010 the World Health Organization (WHO; 2010) ranked the United States 50th for maternal mortality, lower than almost all European countries. Out of concern over the high rates of maternal mortality, Amnesty International (2010), a human rights advocacy organization, compared the United States unfavorably to other developed countries. These reports are unsettling and serve as a call to action for every maternity nurse to scrutinize how he or she can work individually and collectively with others to improve maternal outcomes in their hospitals, cities, states, and country.

Hospital administrators, maternity nurses, and providers who work at the approximately 3,265 U.S. hospitals where women give birth (Simpson, 2011) realize that women die and suffer injury from preventable, obstetric hemorrhage-related causes. These leaders often want to take action but are not sure what to do to prevent the most harm. The purpose of the In Focus series on obstetric hemorrhage is to begin to answer these practical implementation questions. The articles included in this series were also selected to expand the national conversation through an in-depth discussion of specific strategies and tactics nurses can use and are using to lead effective efforts to eliminate preventable hemorrhage-related maternal morbidity and morbidity at hospital and multihospital system levels. The series contains five articles: two overview articles and three articles on the current state of the science and the experiences of direct care nurses who are working to improve processes in an effort to improve outcomes.

In the first article, Reneé Jones and I provide an overview of obstetric hemorrhage mortality and morbidity prevalence, etiology, and prevention and describe the need for enhanced sources of data to support nurses’ ability to lead effective quality improvement initiatives. In the second article, I explore the application of the generic error modeling system (GEMS) research-based conceptual framework to commonly occurring clinician errors related to obstetric hemorrhage. In the third article, Gabel and Weeber describe the integration of objective methods of measuring blood loss into clinical practice as a means of improving recognition of blood loss. In the fourth article, Hansen and Arafeh describe how to set up and run in situ or on-unit drills to ensure that the readiness plans of individual clinicians, teams, units, and hospitals are adequate and that any gaps in preparations are identified prior to an actual emergency situation. In the final article, Corbett et al. detail how leaders who work in a system of multiple hospitals and leaders from individual hospitals have been scrutinizing and reflecting on their emergency response practices. Under the leadership of nurses, these clinicians hold postemergency team debriefing discussions, record debriefing findings, share findings, and follow up on what they learned from their response during an actual obstetric hemorrhage. These debriefings are uncovering what went well (human and nonhuman factors) and common types of errors (active and latent) that are being made even if no harm occurred.

The first step toward eliminating preventable maternal mortality and morbidity is to realize that improvements are needed and are possible. Complacency or the willingness to continue to do things the way we always have done things must be overcome. Unless changes are made we will continue to get the same results. The next steps are to decide to take action, learn what others have done that was successful, thoroughly assess the situation using data from multiple sources including mortality reviews, make a plan, try out the plan, adjust the plan as needed, track progress using data, and work until all preventable deaths and injuries are eliminated in the United States.

Nurses can and are taking active leadership roles in these implementation efforts. Nurse leadership is critical because nurses are most often responsible for day-to-day operations and system-level decisions in the hospitals where most women give birth. Nurses are also trusted members of their communities to whom legislators will listen. As advocates for women and children, nurses need to ensure that each mother who dies from obstetric hemorrhage is honored by a careful review of her death. Careful review, reflection, and action are worth the effort because no one wants to be in the position of wondering “if only.”


  • Debra Bingham, DrPH, RN, is the Vice President of Research, Education, and Publications for the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), Washington, DC.