Author: Jennifer Banayan, M.D.
ASA Monitor 03 2017, Vol.81, 10-11.
Jennifer Banayan, M.D., is Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago.
Adverse maternal outcomes are a concern not just worldwide but in the United States as well. Compared to other developed countries, the maternal mortality rate in the U.S. has risen over the past 25 years.1 Parturients are three times more likely to die from pregnancy-related complications in this country than women in any other developed nation.1,2 Not only has maternal mortality in the U.S. increased, but severe maternal morbidity (e.g., sepsis, acute renal failure, pulmonary edema) has more than doubled in the 21st century, affecting 50,000 women every year.3 These statistics are surprising considering this country’s advances in medical care such as improvement in aseptic technique, development and utilization of medications to control hemorrhage and blood pressure, and the percentage of births being attended by those trained in obstetrical care.2 The increase in severe maternal morbidity in the U.S. has resulted in mortality increasing from different etiologies than are seen worldwide.Cardiovascular disease is now the number-onecontributor to maternal mortality in the U.S.; non-cardiac co-existing disease and sepsis play an increasingly large role also.4
Fortunately, anesthetic complications leading to maternal mortality have continued to decline, currently estimated to be 1.2 per 1 million live births.5 As leaders in patient safety and experts in managing critical illness, we as anesthesiologists need to apply our clinical and administrative skills in helping establish systems aimed at reducing maternal mortality. Many of the most common causes of maternal death and near-miss complications, such as hemorrhage, hypertensive disorders and thromboembolic events,4,6 have been found to be preventable with educational programs and systematic changes.5 Anesthesiologists can and should play vital roles in helping implement these interventions.
Historically, the framework of regionalization of care focused completely on neonatal needs. The March of Dimes created a system of levels of neonatal care in 1970s. These interventions improved outcomes for babies but created a system with nearly 40 percent of hospital births in this country taking place in centers that have fewer than 500 deliveries a year.7 Obstetric complications are observed to occur more frequently in hospitals with low delivery volume.8 For example, studies have shown that maternal medical conditions such as placenta previa or placenta accreta are best managed in high-volume hospitals.9,10 Additionally, high-volume centers may be better equipped to manage severe maternal morbidity, with greater availability of subspecialty care.
Considering the maternal safety climate, the need to emphasize maternal health is essential in improving outcomes. Recognizing this concern, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine published their consensus statement, Levels of Maternal Care, in the February 2015 issue of Obstetrics & Gynecology.11
One of the objectives of this statement is to introduce “uniform designations for centers of maternal care” that are distinct (yet still complementary) from the levels of neonatal care already in place. Currently, various states have implemented levels of maternal care, but the variability between different states’ nomenclature can contribute to confusion. The statement describes a uniform classification system for facilities: Birth Center, Level I (Basic Care), Level II (Special Care), Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers) to overcome this problem. The goal is to ensure that appropriate personnel, space, equipment and technology are available based on these designations to provide consistent levels of care and develop a geographically distributed network that promotes an integrated approach for the peripartum care of the parturient. By specifically outlining each facility’s capabilities, the type of health care providers present in each, and examples of patients who would be appropriately cared for in each type of facility, the statement establishes well-defined thresholds for transferring women to facilities tooptimize their care. The transfer many occur prenatally, intrapartum or during the postpartum period. A high-risk patient with severe maternal morbidity (e.g., history of peripartum cardiomyopathy) can be transferred to a Level IV Regional Perinatal Health Care Center while, conversely; a low-risk woman such as a parturient with an uncomplicated singleton term pregnancy with vertex presentation can be delivered at a freestanding birthing center by a midwife. In this way, the levels of maternal care centers address different care requirements based on co-morbidities and risk.
This statement is an excellent initiative that provides governing bodies and health care institutions a framework that allows parturients to receive care in facilities prepared to provide the level of specialized care when needed. Accordingly, it has been endorsed by both ASA and the Society for Obstetric Anesthesia and Perinatology. However, the implementation of this framework needs to address several questions. For example, the availability of anesthesia services is an important factor described in ACOG’s maternal levels of care statement. For a Level I facility, it says, “anesthesia services must be available at all times.” What is meant by available? Does that mean on site or available by phone? In Level II facilities, physician anesthesiologists need to be available for consultation. Again, the term available should be better described. For Level III and IV facilities, a board-certified anesthesiologist with subspecialty training or experience in obstetric anesthesia should lead the obstetric anesthesia services. For any level, defining who can provide the anesthesia services and what is meant by “available” is debatable.
Availability of anesthesia services is just one reason why anesthesiologists need to be involved in the implementation of a coordinated system incorporating the suggested levels of care. Other requirements listed also have significant limitations that anesthesiologists can help address. For example, a Level IV center requires “adult medical and surgical specialty and subspecialty consultants available on-site at all times to collaborate with MFM care team.” Even at some of the largest and busiest tertiary/quaternary care centers, attending cardiologists, pulmonologists and intensivists are not available on-site around the clock. Conversely, most tertiary/ quaternary centers will have anesthesia services on site 24 hoursa day. Therefore, given our expertise in managing critically ill patients and our availability, we could manage most acute situations in a Level III or IV facility until another subspecialist arrives (e.g., cardiologist). This emphasizes the potential role we can play in helping design these systems where the ultimate goal is to reduce maternal/perinatal morbidity and mortality.
Additionally, many other barriers exist when implementing levels of maternal care. Concerns include the availability of appropriate personnel for hiring, financial strains, maintenance and accreditations to name just a few.
Maternal mortality and morbidity is a legitimate concern for all clinicians managing the parturient. Recognizing that risk-stratification and early intervention can make meaningful outcome differences was the inspiration behind the maternal levels of care consensus statement. Future work should be directed at assessing whether the resource allocation required in implementing these levels results in improved outcomes. As members of the peripartum care team, anesthesiologists are well positioned to help implement the suggested levels of care and study their efficacy.
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