Public Release: 

Reduction of the most common cause of maternal death worldwide

Study looks at ways to prevent obstetric hemorrhage

Society for Maternal-Fetal Medicine

In a study to be presented Friday, Jan. 27, in the oral concurrent session at 1:15 p.m. PST, at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting™, researchers with the California Maternal Quality Care Collaborative, based at Stanford University, Palo Alto, Ca., will present Reduction of Severe Maternal Morbidity from Hemorrhage (SMM-HEM) Using a State-Wide Perinatal Collaborative.

The California Maternal Quality Care Collaborative is comprised of multi stakeholder professional organizations (obstetricians, nurses, midwives and family practitioners), hospitals, public health department and public representatives working together to end preventable mortality and morbidity in maternity care. The CMQCC drives improvement in maternal and infant outcomes through rapid-cycle data analytics and collaborative action.

The organization has developed a series of maternal safety toolkits aimed at responding to the leading causes of maternal morbidity and mortality including reducing complications from obstetric hemorrhage, severe hypertension and early elective delivery. The California Partnership for Maternal Safety project focused on scaling up safety initiatives to engage 126 California hospitals (with over 250,000 annual births) to improve outcomes from obstetric hemorrhage. While small studies have demonstrated the value of safety toolkits and quality improvement projects to reduce complications, this is the first project to scale to a population level showing the generalizability of this approach.

Obstetric hemorrhage is the most common cause of maternal death worldwide and the leading cause of severe maternal morbidity and preventable maternal mortality in the U.S. Among U.S. women, postpartum hemorrhage is diagnosed between 2-5% of all births with 0.5 to 1.5% considered severe (requiring transfusion or other intensive treatments.)

In this project, researchers focused on 99 hospitals that participated in the California Maternal Data Center, using rapid-cycle data that enabled access to immediate results. These hospitals had a reduction of severe hemorrhage by 21 percent after the first year of participation. Twenty-five hospitals that participated in an earlier quality collaborative and were in their second year did even better with a 28 percent reduction, illustrating that quality improvement is a continuous process.

Elliott Main, M.D. who is the medical director of the CMQCC and the presenter of the study at the SMFM annual meeting, explained, "The keys for success were (1) multi-partner engagement, (2) rapid cycle data and (3) use of a novel quality improvement model involving pairing physician and nurse mentors working with five to eight hospitals at a time, all within the construct of a large statewide project."

Improvement was seen in all sizes and types of hospitals. Small hospitals showed the greatest improvement underscoring the quality improvement opportunities represented by their more limited resources.

State perinatal quality collaboratives are now being established in most states with the support of state departments of health, the Centers for Disease Control and Prevention, and the Maternal Child Health Bureau. California had a head start with the Perinatal/Neonatal Collaborative established in 1996 and the related Maternal Collaborative in 2006.

Main added, "The rapid-cycle California Maternal Data Center can serve as a model for using current state collected data such as birth certificates to help drive quality improvement projects and minimize data collection burden on the hospitals."


A copy of the abstract is available at and below. For interviews please contact Vicki Bendure at 202-374-9259 (cell).

About the Society for Maternal-Fetal Medicine

The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed. For more information visit

Abstract #50 Reduction of severe maternal morbidity from hemorrhage (SMM-HEM) using a state-wide perinatal collaborative
Elliott Main1 , Valerie Cape1 , Anisha Abreo1 , Julie Vasher1 , Andrew Carpenter2 1 California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA, 2 Critical Juncture, San Francisco, CA

OBJECTIVE: To test a method for state-wide implementation of the national Obstetric Hemorrhage Safety Bundle* with a focus on reducing (SMM-HEM).

STUDY DESIGN: California hospitals were invited to participate in a staggered 18-month learning/implementation collaborative (Jan- 2015-Jun-2016). 20 trained nurse/physician mentor pairs were matched with groups of 6-8 hospital teams. The mentors and CMQCC staff held monthly conference calls with their teams providing education, implementation support and progress updates. The safety bundle was used as the template for QI action. In 99 hospitals, the project was supported by a rapid-cycle data system combining ICD codes with clinical data including timing of implementation of 17 bundle elements. The primary outcome measure was SMM (using CDC specifications) among women who had pregnancy bleeding complications. A 4-year baseline period was compared to the last 6 months of the collaborative.

RESULTS: 126 hospitals with 288,210 annual births participated in the CMQCC collaborative. 54% of hospitals completed 14 of 17 bundle elements; 76% reported regular unit based drills; 65% reported post hemorrhage event debriefs. SMM-HEM results for the 99 hospitals using the data system are shown in the Table. A comparison group included 48 hospitals using the data system but without current or prior participation in CMQCC hemorrhage collaboratives. While the rate of hemorrhage remained the same over time, severe complications related to hemorrhage (SMM-HEM) fell significantly only in the collaborative groups (p <.001).

CONCLUSION: We used an innovative collaborative QI approach (Mentor model) to scale up implementation of the national hemorrhage bundle focused on early treatment to prevent SMM-HEM. Participation in the collaborative was strongly associated with reductions in SMM-HEM. Hospitals now in their second collaborative had a greater reduction in SMM-HEM (28.6%) than those who were approaching the bundle for the first time (15.4%), This reinforces the need for longer time engagements to fully implement a complex change bundle.

This project was supported by Merck For Mothers

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