A Comprehensive Strategy to Mitigate Institutional Maternal Mortality: Lessons From a Quality Improvement Initiative...

Area of Science:

• Public Health
• Obstetrics and Gynecology
• Healthcare Quality Improvement

Background:

• Many pregnancy-related deaths are preventable with timely, evidence-based obstetric care.
• A quality improvement (QI) initiative was implemented in Brazilian public hospitals to address primary causes of maternal mortality.

Purpose of the Study:

• To evaluate the impact of a QI initiative on the institutional maternal mortality ratio (iMMR) in public Brazilian maternity hospitals.
• To assess the effectiveness of the '4Rs' approach (Recognize, Rescue, Reassess, Refer) and the Modified Early Obstetric Warning Score (MEOWS) in improving obstetric care.

Main Methods:

• Quasi-experimental time-series design in 19 Brazilian maternity hospitals.
• Implementation of the '4Rs' sequential approach and MEOWS tool to identify and manage postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy (HDPs).
• Structured learning system with tailored training and support for clinical staff.

Main Results:

• Overall maternal deaths reduced by 34.2% during the implementation period.
• Maternal mortality ratio (iMMR) due to postpartum hemorrhage decreased by 72.9% and sepsis by 100%.
• Despite a rise in overall iMMR (due to COVID-19) post-implementation, deaths from key obstetric emergencies remained stable or decreased.

Conclusions:

• QI initiatives, including structured care sequences and care bundles, are effective in reducing maternal mortality.
• The '4Rs' approach and MEOWS tool are feasible and promising for improving obstetric care and reducing iMMR.
• Optimizing care processes and reliable implementation of evidence-based interventions are critical for maternal health.