Authors: Martin C et al.
Anesthesia Patient Safety Foundation Newsletter, volume 41, number 1, February 2026.
Summary
This article examines rising maternal mortality and severe maternal morbidity through the lens of two underrecognized contributors: wellness bias and physiologic masking in pregnancy. The author argues that these cognitive and systems-level factors delay recognition of critical illness in obstetric patients and disproportionately place anesthesia professionals in the position of intervening only after physiologic reserve has been exhausted.
“Wellness bias” is described as the subconscious assumption that pregnant patients are inherently healthy, resilient, and capable of compensating for illness. This bias persists even in medically complex or older obstetric patients and is compounded by the normalization of deviance, in which repeated exposure to abnormal findings without adverse outcomes gradually erodes adherence to safety standards. Together, these forces lower clinical suspicion, leading clinicians to dismiss concerning symptoms, vital signs, or laboratory abnormalities as “normal pregnancy,” thereby delaying escalation of care.
The article highlights how maternal physiology masks deterioration. Pregnancy-related changes in plasma volume, cardiac output, respiratory drive, renal function, and coagulation can obscure early signs of sepsis, hemorrhage, renal failure, respiratory compromise, and disseminated intravascular coagulation. Examples include tachycardia and hypotension being dismissed as physiologic, lack of fever in maternal sepsis, creatinine values that appear normal but represent acute kidney injury in pregnancy, and dilutional anemia or elevated fibrinogen levels masking bleeding and coagulopathy. The absence of pregnancy-adjusted thresholds in many electronic health record alert systems further compounds these risks.
A critical theme is the bias-driven withholding or delay of maternal diagnostics and therapy due to disproportionate concern for fetal risk. Imaging, antibiotics, vasopressors, surgery, and other evidence-based treatments are frequently deferred despite data showing that maternal stabilization is the strongest predictor of fetal survival. The author emphasizes that failing to treat maternal disease aggressively is itself a form of bias and a recurrent finding in maternal mortality reviews.
Systemic inequities further magnify risk. Advanced maternal age, obesity, race and ethnicity, and insurance status all correlate with higher maternal mortality. For anesthesia teams, these factors translate into increased airway difficulty, altered pharmacokinetics, limited physiologic reserve, and higher risk of catastrophic decompensation if recognition is delayed.
The article concludes with practical recommendations for anesthesia professionals and health systems. These include rejecting nonpregnant definitions of “normal,” advocating for early escalation and multidisciplinary involvement, encouraging early neuraxial analgesia when appropriate, maintaining postpartum vigilance, and actively challenging delays in diagnostics or therapy driven by fetal-focused bias. System-level solutions such as pregnancy-adjusted EHR alerts, simulation training targeting wellness bias, early anesthesia involvement in obstetric huddles, and standardized bundles with clear anesthesia triggers are emphasized as essential steps toward reducing preventable maternal harm.
Key Points
Wellness bias leads clinicians to underestimate illness severity in pregnant patients
Physiologic changes of pregnancy can mask early deterioration and delay recognition
Maternal sepsis, hemorrhage, and organ dysfunction are frequently identified too late
Nonpregnant vital sign and laboratory thresholds are unsafe in obstetric care
Delays in maternal diagnostics or therapy driven by fetal concern increase risk for both mother and fetus
Anesthesia teams are often consulted only after reserve is lost, increasing procedural risk
Pregnancy-adjusted EHR alerts, early escalation, and anesthesia involvement can reduce preventable harm
Thank you to the Anesthesia Patient Safety Foundation for allowing us to summarize and share this APSF Newsletter article addressing maternal safety, wellness bias, and anesthesiology’s critical role in early recognition and intervention.