“The observation … that anesthesia-related complications are declining while nonanesthetic perioperative complications are increasing suggests [that we need] to look beyond the delivery of safe anesthesia and to embrace the role of … peridelivery physician.”

Image: ©Thinkstock.

Image: ©Thinkstock.

Anesthesia and analgesia for childbirth have become remarkably safe and together account for fewer than one maternal death per million deliveries, representing a 75% decline from the corresponding rate in 1980.1,2  Although maternal deaths from anesthesia are rare, anesthesia-related complications persist. Based on data from 30 North American institutions over a 5-yr period, approximately 1 in 3,000 anesthetics for delivery results in a serious complication of anesthesia, most commonly high neuraxial blockade or difficult intubation.3  Dural puncture, considered separately, complicated 0.7% of all neuraxial anesthetics.

As with many adverse maternal outcomes, the event rates of anesthesia complications are both sufficiently rare that they are difficult to study at the clinical level and unacceptably high from a societal perspective. While important, few population-level data are available to identify temporal trends in the complication frequency of anesthesia administered specifically for cesarean delivery. The study in this month’s Anesthesiology by Guglielminotti et al.4  attempts to fill this gap. The investigators used administrative data from the State of New York between 2003 and 2012 to analyze adverse outcomes over time. Overall, anesthesia-related complications declined 25% over the duration of the study. Secondary analyses investigated trends stratified by anesthetic technique and suggest a 25% decrease in risk of anesthesia-related adverse events among women receiving neuraxial anesthesia without a general anesthetic and a 21% decrease in the use of general anesthesia.

Administrative data collected primarily for the reimbursement for healthcare services facilitates analysis of rare but important events because this kind of data includes diagnosis and procedure codes from the International Classification of Diseases. Administrative data have been an important tool in studies of the epidemiology of pregnancy-related complications and are used by the U.S. Centers for Disease Control and Prevention as the primary national surveillance tool for maternal morbidity.5,6  Anesthesia complications identified in administrative data have been proposed as a quality measure, and outlier hospitals have been identified.7,8  However, studying anesthesia complications with administrative data presents particular challenges. Diagnosis codes for anesthesia complications do not align directly with clinically meaningful complications. Close to 40% of analyzed events in the current study received an International Classification of Diseases, Ninth Revision, Clinical Modification code for “other and unspecified systemic adverse events,” which could indicate a wide range of complication types, from the trivial to the catastrophic. Validation studies suggest that the coding of anesthesia-related complications in administrative data can be inaccurate.9,10  Nevertheless, the magnitude of the observed reduction in anesthesia-related complications by Guglielminotti et al. likely reflects real gains in the safety of anesthetic management and should be welcome news for anesthesiologists.

Yet complacency must be avoided because during the same time period, serious nonanesthetic perioperative complications increased 47% to a frequency of 1,130 per 100,000 deliveries in 2012. Complications included myocardial ischemia, venous thromboembolism, coagulopathy, sepsis, stroke, and heart, respiratory, and renal failure. Similar trends in maternal morbidity and mortality have been observed at the national level. In the United States between 1998 and 2009, severe maternal morbidity (i.e., end-organ injury) during the hospitalization for delivery increased by 75%.5  Likewise, the U.S. maternal mortality ratio increased an estimated 50% between 1990 and 2015, over a time when the global maternal mortality declined 25%, and only five countries in the world experienced an increase.11  These trends have garnered the attention of public health officials and have prompted a national call to action to improve population health and health outcomes for maternal patients.12,13 

What can be done to stem this tide of obstetric morbidity and mortality? Several approaches show promise. New data support the effectiveness of universal thromboembolism prophylaxis protocols for women undergoing cesarean delivery, rapid antihypertensive administration protocols for women with preeclampsia, and comprehensive, intraprofessional hemorrhage protocols to reduce severe maternal morbidity.14–16  Based on mortality surveillance for 1.25 million deliveries between 2000 and 2006, all hospitals affiliated with the Hospital Corporation of America implemented system-wide universal pneumatic compression devices for all women undergoing cesarean delivery and protocols for rapid antihypertensive therapy for inpatients with preeclampsia. Among the next 1.5 million births, postoperative pulmonary embolism deaths decreased seven-fold, and deaths from in-hospital intracranial hemorrhage were eliminated.14  Similarly, 29 Dignity Health System maternity units implemented comprehensive maternal hemorrhage protocols in 2011. Based on analysis of more than 20,000 deliveries before and after implementation, the total number of units of blood consumed per 1,000 deliveries decreased by 26%.14–16 

Efforts in California have shown that implementation of these approaches can even result in a substantial reduction in maternal death. Mortality trends in California increased annually and paralleled those of the United States between 1999 and 2008.17  In 2006, the California Maternity Quality Care Collaborative (CMQCC) was founded in response to findings from the California Pregnancy-Associated Mortality Review Committee.18  The CMQCC has since developed resources and toolkits for delivery units to implement comprehensive systems to reduce the likelihood of maternal morbidity and mortality, focusing first on hemorrhage and preeclampsia.18  A state-wide Maternal Data Center offers rapid-cycle performance metrics to support local quality improvement activities.18  Surveillance data now suggest the maternal mortality trend in California began to diverge from that of the United States in 2009. By 2013, the California maternal mortality rate had declined 50% to 7 per 100,000 live births,17  presumably as a consequence of the efforts of the CMQCC.

There is a movement to translate the California results nationwide. The Council for Patient Safety in Women’s Health Care19  is a consortium of professional organizations, whose members provide care for parturients, including the American Society of Anesthesiologists and the Society of Obstetric Anesthesia and Perinatology. The Council is sponsoring development of a series of maternal patient safety bundles focused on hemorrhage, venous thromboembolism, and hypertensive disorders. Each bundle includes a list of protocols and tools that should be implemented in every delivery unit in the United States.

In addition to these protocols, facility-based review of severe maternal morbidity has recently been recommended by the Centers for Disease Control and Prevention and leaders in obstetrics.20,21  In February 2015, the Joint Commission added intrapartum severe maternal morbidity to the list of sentinel events that indicate root cause analysis.22  A simplified review process proposed by the Council recommends that facilities screen all pregnant and recently delivered women for intensive care unit admission or transfusion of four or more units of erythrocytes.20,21  For each woman who meets either criterion, her case should be reviewed by a multidisciplinary facility-based committee to first determine whether the case was complicated by any preventable harm, and if so, to identify opportunities for systems-based improvement. Structured review forms are available to guide case abstraction and committee discussion.19 

Finally, designated levels of maternal care have been proposed, modeled on traditional levels of neonatal care, to promote the integration of regional maternal health networks to target risk-appropriate care across a spectrum of maternal health conditions.23  Although serious complications of birth can develop in any parturient, risk for severe maternal morbidity is concentrated in women with significant antenatal medical comorbidities and obstetric complications.24,25  The newly proposed levels of maternal care include five categories that range from birth centers (with no anesthesia services) all the way to comprehensive services for the most critically ill women at level IV Regional Perinatal Health Centers. Each level is characterized by increasingly comprehensive anesthesia, perioperative, and critical care services.

In a new era of value-based payments, health systems will encounter mounting financial pressure to improve patient-centered perioperative and peridelivery outcomes. The observation by Giagliomotti et al. that anesthesia-related complications are declining while nonanesthetic perioperative complications are increasing suggests the need for members of our specialty to look beyond the delivery of safe anesthesia and to embrace the role of the “perioperative and peridelivery physician.”26,27  Although optimal perioperative medicine by the individual physician anesthesiologist may improve birth outcomes for individual patients, experience from the Hospital Corporation of America and from the State of California indicates that intraprofessional collaboration and systems optimization will be necessary to ensure high quality and safe delivery experiences for all childbearing women. Perioperative and peridelivery physicians who engage with intraprofessional teams to implement the new maternal safety bundles, severe maternal morbidity reviews and levels of maternal care will maximize both individual and institutional capacity to optimize birth-related outcomes for the sickest mothers, to improve the experience of care for the childbearing population, and to ensure that the care delivered is efficient, effective, and equitable.28 

Acknowledgments

Dr. Bateman is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (grant No. K08HD075831).

Competing Interests

The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with the topic of this article.

References

References
1.
Creanga
AA
,
Berg
CJ
,
Syverson
C
,
Seed
K
,
Bruce
FC
,
Callaghan
WM
:
Pregnancy-related mortality in the United States, 2006–2010.
Obstet Gynecol
2015
;
125
:
5
12
2.
Hawkins
JL
,
Chang
J
,
Palmer
SK
,
Gibbs
CP
,
Callaghan
WM
:
Anesthesia-related maternal mortality in the United States: 1979–2002.
Obstet Gynecol
2011
;
117
:
69
74
3.
D’Angelo
R
,
Smiley
RM
,
Riley
ET
,
Segal
S
:
Serious complications related to obstetric anesthesia: The serious complication repository project of the Society for Obstetric Anesthesia and Perinatology.
Anesthesiology
2014
;
120
:
1505
12
4.
Guglielminotti
J
,
Wong
C
,
Landau
R
,
Li
G
:
Temporal trends in anesthesia-related adverse events in cesarean deliveries, New York State, 2003–2012.
Anesthesiology
2015
;
123
:
1013
24
5.
Callaghan
WM
,
Creanga
AA
,
Kuklina
EV
:
Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.
Obstet Gynecol
2012
;
120
:
1029
36
6.
Kuklina
EV
,
Meikle
SF
,
Jamieson
DJ
,
Whiteman
MK
,
Barfield
WD
,
Hillis
SD
,
Posner
SF
:
Severe obstetric morbidity in the United States: 1998–2005.
Obstet Gynecol
2009
;
113
:
293
9
7.
El Haj Ibrahim
S
,
Fridman
M
,
Korst
LM
,
Gregory
KD
:
Anesthesia complications as a childbirth patient safety indicator.
Anesth Analg
2014
;
119
:
911
7
8.
Guglielminotti
J
,
Li
G
:
Monitoring obstetric anesthesia safety across hospitals through multilevel modeling.
Anesthesiology
2015
;
122
:
1268
79
9.
Romano
PS
,
Yasmeen
S
,
Schembri
ME
,
Keyzer
JM
,
Gilbert
WM
:
Coding of perineal lacerations and other complications of obstetric care in hospital discharge data.
Obstet Gynecol
2005
;
106
:
717
25
10.
Jones
A
,
Monagle
JP
,
Peel
S
,
Coghlan
MW
,
Malkoutzis
V
,
Groom
A
:
Validity of anaesthetic complication coding data as a clinical indicator.
Aust Health Rev
2012
;
36
:
229
32
11.
Kassebaum
NJ
,
Bertozzi-Villa
A
,
Coggeshall
MS
,
Shackelford
KA
,
Steiner
C
,
Heuton
KR
,
Gonzalez-Medina
D
,
Barber
R
,
Huynh
C
,
Dicker
D
,
Templin
T
,
Wolock
TM
,
Ozgoren
AA
,
Abd-Allah
F
,
Abera
SF
,
Abubakar
I
,
Achoki
T
,
Adelekan
A
,
Ademi
Z
,
Adou
AK
,
Adsuar
JC
,
Agardh
EE
,
Akena
D
,
Alasfoor
D
,
Alemu
ZA
,
Alfonso-Cristancho
R
,
Alhabib
S
,
Ali
R
,
Al Kahbouri
MJ
,
Alla
F
,
Allen
PJ
,
AlMazroa
MA
,
Alsharif
U
,
Alvarez
E
,
Alvis-Guzmán
N
,
Amankwaa
AA
,
Amare
AT
,
Amini
H
,
Ammar
W
,
Antonio
CA
,
Anwari
P
,
Arnlöv
J
,
Arsenijevic
VS
,
Artaman
A
,
Asad
MM
,
Asghar
RJ
,
Assadi
R
,
Atkins
LS
,
Badawi
A
,
Balakrishnan
K
,
Basu
A
,
Basu
S
,
Beardsley
J
,
Bedi
N
,
Bekele
T
,
Bell
ML
,
Bernabe
E
,
Beyene
TJ
,
Bhutta
Z
,
Bin Abdulhak
A
,
Blore
JD
,
Basara
BB
,
Bose
D
,
Breitborde
N
,
Cárdenas
R
,
Castañeda-Orjuela
CA
,
Castro
RE
,
Catalá-López
F
,
Cavlin
A
,
Chang
JC
,
Che
X
,
Christophi
CA
,
Chugh
SS
,
Cirillo
M
,
Colquhoun
SM
,
Cooper
LT
,
Cooper
C
,
da Costa Leite
I
,
Dandona
L
,
Dandona
R
,
Davis
A
,
Dayama
A
,
Degenhardt
L
,
De Leo
D
,
del Pozo-Cruz
B
,
Deribe
K
,
Dessalegn
M
,
deVeber
GA
,
Dharmaratne
SD
,
Dilmen
U
,
Ding
EL
,
Dorrington
RE
,
Driscoll
TR
,
Ermakov
SP
,
Esteghamati
A
,
Faraon
EJ
,
Farzadfar
F
,
Felicio
MM
,
Fereshtehnejad
SM
,
de Lima
GM
,
Forouzanfar
MH
,
França
EB
,
Gaffikin
L
,
Gambashidze
K
,
Gankpé
FG
,
Garcia
AC
,
Geleijnse
JM
,
Gibney
KB
,
Giroud
M
,
Glaser
EL
,
Goginashvili
K
,
Gona
P
,
González-Castell
D
,
Goto
A
,
Gouda
HN
,
Gugnani
HC
,
Gupta
R
,
Gupta
R
,
Hafezi-Nejad
N
,
Hamadeh
RR
,
Hammami
M
,
Hankey
GJ
,
Harb
HL
,
Havmoeller
R
,
Hay
SI
,
Pi
IB
,
Hoek
HW
,
Hosgood
HD
,
Hoy
DG
,
Husseini
A
,
Idrisov
BT
,
Innos
K
,
Inoue
M
,
Jacobsen
KH
,
Jahangir
E
,
Jee
SH
,
Jensen
PN
,
Jha
V
,
Jiang
G
,
Jonas
JB
,
Juel
K
,
Kabagambe
EK
,
Kan
H
,
Karam
NE
,
Karch
A
,
Karema
CK
,
Kaul
A
,
Kawakami
N
,
Kazanjan
K
,
Kazi
DS
,
Kemp
AH
,
Kengne
AP
,
Kereselidze
M
,
Khader
YS
,
Khalifa
SE
,
Khan
EA
,
Khang
YH
,
Knibbs
L
,
Kokubo
Y
,
Kosen
S
,
Defo
BK
,
Kulkarni
C
,
Kulkarni
VS
,
Kumar
GA
,
Kumar
K
,
Kumar
RB
,
Kwan
G
,
Lai
T
,
Lalloo
R
,
Lam
H
,
Lansingh
VC
,
Larsson
A
,
Lee
JT
,
Leigh
J
,
Leinsalu
M
,
Leung
R
,
Li
X
,
Li
Y
,
Li
Y
,
Liang
J
,
Liang
X
,
Lim
SS
,
Lin
HH
,
Lipshultz
SE
,
Liu
S
,
Liu
Y
,
Lloyd
BK
,
London
SJ
,
Lotufo
PA
,
Ma
J
,
Ma
S
,
Machado
VM
,
Mainoo
NK
,
Majdan
M
,
Mapoma
CC
,
Marcenes
W
,
Marzan
MB
,
Mason-Jones
AJ
,
Mehndiratta
MM
,
Mejia-Rodriguez
F
,
Memish
ZA
,
Mendoza
W
,
Miller
TR
,
Mills
EJ
,
Mokdad
AH
,
Mola
GL
,
Monasta
L
,
de la Cruz Monis
J
,
Hernandez
JC
,
Moore
AR
,
Moradi-Lakeh
M
,
Mori
R
,
Mueller
UO
,
Mukaigawara
M
,
Naheed
A
,
Naidoo
KS
,
Nand
D
,
Nangia
V
,
Nash
D
,
Nejjari
C
,
Nelson
RG
,
Neupane
SP
,
Newton
CR
,
Ng
M
,
Nieuwenhuijsen
MJ
,
Nisar
MI
,
Nolte
S
,
Norheim
OF
,
Nyakarahuka
L
,
Oh
IH
,
Ohkubo
T
,
Olusanya
BO
,
Omer
SB
,
Opio
JN
,
Orisakwe
OE
,
Pandian
JD
,
Papachristou
C
,
Park
JH
,
Caicedo
AJ
,
Patten
SB
,
Paul
VK
,
Pavlin
BI
,
Pearce
N
,
Pereira
DM
,
Pesudovs
K
,
Petzold
M
,
Poenaru
D
,
Polanczyk
GV
,
Polinder
S
,
Pope
D
,
Pourmalek
F
,
Qato
D
,
Quistberg
DA
,
Rafay
A
,
Rahimi
K
,
Rahimi-Movaghar
V
,
ur Rahman
S
,
Raju
M
,
Rana
SM
,
Refaat
A
,
Ronfani
L
,
Roy
N
,
Pimienta
TG
,
Sahraian
MA
,
Salomon
JA
,
Sampson
U
,
Santos
IS
,
Sawhney
M
,
Sayinzoga
F
,
Schneider
IJ
,
Schumacher
A
,
Schwebel
DC
,
Seedat
S
,
Sepanlou
SG
,
Servan-Mori
EE
,
Shakh-Nazarova
M
,
Sheikhbahaei
S
,
Shibuya
K
,
Shin
HH
,
Shiue
I
,
Sigfusdottir
ID
,
Silberberg
DH
,
Silva
AP
,
Singh
JA
,
Skirbekk
V
,
Sliwa
K
,
Soshnikov
SS
,
Sposato
LA
,
Sreeramareddy
CT
,
Stroumpoulis
K
,
Sturua
L
,
Sykes
BL
,
Tabb
KM
,
Talongwa
RT
,
Tan
F
,
Teixeira
CM
,
Tenkorang
EY
,
Terkawi
AS
,
Thorne-Lyman
AL
,
Tirschwell
DL
,
Towbin
JA
,
Tran
BX
,
Tsilimbaris
M
,
Uchendu
US
,
Ukwaja
KN
,
Undurraga
EA
,
Uzun
SB
,
Vallely
AJ
,
van Gool
CH
,
Vasankari
TJ
,
Vavilala
MS
,
Venketasubramanian
N
,
Villalpando
S
,
Violante
FS
,
Vlassov
VV
,
Vos
T
,
Waller
S
,
Wang
H
,
Wang
L
,
Wang
X
,
Wang
Y
,
Weichenthal
S
,
Weiderpass
E
,
Weintraub
RG
,
Westerman
R
,
Wilkinson
JD
,
Woldeyohannes
SM
,
Wong
JQ
,
Wordofa
MA
,
Xu
G
,
Yang
YC
,
Yano
Y
,
Yentur
GK
,
Yip
P
,
Yonemoto
N
,
Yoon
SJ
,
Younis
MZ
,
Yu
C
,
Jin
KY
,
El Sayed Zaki
M
,
Zhao
Y
,
Zheng
Y
,
Zhou
M
,
Zhu
J
,
Zou
XN
,
Lopez
AD
,
Naghavi
M
,
Murray
CJ
,
Lozano
R
:
Global, regional, and national levels and causes of maternal mortality during 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013.
Lancet
2014
;
384
:
980
1004
12.
D’Alton
ME
,
Main
EK
,
Menard
MK
,
Levy
BS
:
The national partnership for maternal safety.
Obstet Gynecol
2014
;
123
:
973
7
13.
Main
EK
,
Menard
MK
:
Maternal mortality: Time for national action.
Obstet Gynecol
2013
;
122
:
735
6
14.
Clark
SL
,
Christmas
JT
,
Frye
DR
,
Meyers
JA
,
Perlin
JB
:
Maternal mortality in the United States: Predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.
Am J Obstet Gynecol
2014
;
211
:
32.e1
9
15.
Shields
LE
,
Smalarz
K
,
Reffigee
L
,
Mugg
S
,
Burdumy
TJ
,
Propst
M
:
Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products.
Am J Obstet Gynecol
2011
;
205
:
368.e1
8
16.
Shields
LE
,
Wiesner
S
,
Fulton
J
,
Pelletreau
B
:
Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety.
Am J Obstet Gynecol
2015
;
212
:
272
80
17.
The California Pregnancy-Associated Mortality Review. Maternal Mortality: Definitions, Trends, and Race and Age Stratifications, 1999–2013.
2015
18.
California Maternal Quality Care Collaborative.
2015
Available at: https://www.cmqcc.org/. Accessed June 29, 2015
19.
The Council on Patient Safety in Women’s Healthcare.
2015
20.
Callaghan
WM
,
Grobman
WA
,
Kilpatrick
SJ
,
Main
EK
,
D’Alton
M
:
Facility-based identification of women with severe maternal morbidity: It is time to start.
Obstet Gynecol
2014
;
123
:
978
81
21.
Kilpatrick
SJ
,
Berg
C
,
Bernstein
P
,
Bingham
D
,
Delgado
A
,
Callaghan
WM
,
Harris
K
,
Lanni
S
,
Mahoney
J
,
Main
E
,
Nacht
A
,
Schellpfeffer
M
,
Westover
T
,
Harper
M
:
Standardized severe maternal morbidity review: Rationale and process.
Obstet Gynecol
2014
;
124
:
361
6
22.
Sentinel Events. The Comprehensive Accreditation Manual for Hospitals.
2015
23.
Menard
MK
,
Kilpatrick
S
,
Saade
G
,
Hollier
LM
,
Joseph
GF
Jr
,
Barfield
W
,
Callaghan
W
,
Jennings
J
,
Conry
J
:
Levels of maternal care.
Am J Obstet Gynecol
2015
;
212
:
259
71
24.
Bateman
BT
,
Mhyre
JM
,
Hernandez-Diaz
S
,
Huybrechts
KF
,
Fischer
MA
,
Creanga
AA
,
Callaghan
WM
,
Gagne
JJ
:
Development of a comorbidity index for use in obstetric patients.
Obstet Gynecol
2013
;
122
:
957
65
25.
Mhyre
JM
,
Bateman
BT
,
Leffert
LR
:
Influence of patient comorbidities on the risk of near-miss maternal morbidity or mortality.
Anesthesiology
2011
;
115
:
963
72
26.
Bateman
BT
,
Tsen
LC
:
Anesthesiologist as epidemiologist: Insights from registry studies of obstetric anesthesia-related complications.
Anesthesiology
2014
;
120
:
1311
2
27.
Kain
ZN
,
Fitch
JC
,
Kirsch
JR
,
Mets
B
,
Pearl
RG
:
Future of anesthesiology is perioperative medicine: A call for action.
Anesthesiology
2015
;
122
:
1192
5
28.
Berwick
DM
,
Nolan
TW
,
Whittington
J
:
The triple aim: Care, health, and cost.
Health Aff (Millwood)
2008
;
27
:
759
69