How to Reduce Risk in Maternity Care Deserts

Their 2023 report, Where You Live Matters: Maternity Care Deserts and the Crisis of Access and Equity, shows access to maternity care worsening with a 4% drop in birthing hospitals. Nationwide, more than 400 maternity services closed between 2006 and 2020.

Malpractice risk and maternity care deserts

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In a review of our malpractice claims, diagnostic error is the #1 most frequent allegation and #1 most costly in emergency department (ED) claims; obstetrical (OB) claims are third in total cost despite representing only 4% of claims.

A 30-year-old woman presented to the ED of her local hospital four days postpartum with complaints of severe pain in her vagina, fever and a swollen perineum. She had a history of a 3rd-degree perineal laceration during delivery. She was examined by a nurse practitioner (NP) who noted a high white blood count (WBC) and low platelet count. The NP ordered an ultrasound that showed no products of conception were present, and the radiologist suggested a diagnosis of endometriosis. The NP discharged the woman with a diagnosis of endometriosis after prescribing IM Rocephin, an oral antibiotic and lidocaine for her perineum pain. The NP instructed the woman to follow up with her regular physician the next day.

The next day, the patient presented to the same ED with complaints of fainting, pain, nausea, dizziness, fever and swelling of her abdomen and legs. She was transferred to a tertiary hospital and was admitted to the ICU with a diagnosis of sepsis. Despite IV antibiotics and IV fluids, her condition deteriorated. A surgical consult was ordered, and she was taken to the operating room for a hysterectomy. She did poorly following surgery and died the next day. Her family filed a malpractice claim against the NP and the hospital for failing to timely diagnose and treat sepsis, resulting in death. The experts who reviewed the care were critical of the NP for failing to note the low platelet count, failing to refer the woman to a physician and for failing to timely diagnose and treat sepsis. The case was closed with a payment to the patient’s husband.

Many smaller and rural hospitals have stopped providing OB services due to low birth volumes, low reimbursement, staffing challenges and rising costs. However, just because a hospital has stopped offering OB services doesn’t mean there will be no deliveries or OB care, such as treating pregnant women in hypertensive crisis with postpartum hemorrhage or sepsis in the ED.

“It’s not just the process of having skilled clinicians and equipment to deliver a baby that makes it risky, but also before and after delivery. When a community lacks experienced clinicians and care teams with the appropriate education, training and monitoring equipment, the risk of failing to timely diagnose conditions (such as sepsis, as the case study illustrates) is much higher.”

Brandi Seys, Senior Risk Consultant at Curi and ERC Risk Solutions

How to reduce risk in maternity care deserts

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1. Implement education, training and simulation drills for emergency deliveries and maternal emergencies, such as hypertension, sepsis and hemorrhage.
2. Have precipitous delivery kits and infant resuscitation equipment available in the ED. Consider the creation of emergency medication kits for postpartum hemorrhage and suspected pre-eclampsia.
3. Use algorithms, early recognition tools, maternal early warning systems and best practice guidelines for sepsis, hypertension/pre-eclampsia, postpartum hemorrhage, and infant resuscitation. The California Maternal Quality Care Collaborative has many algorithms and examples to utilize.
4. In the ED, ask and document if the patient is pregnant or has been pregnant in the past six weeks. Post signage to help remind patients to inform healthcare providers if they have been pregnant.
5. Implement training for your EMS teams on performing an emergency delivery and rapid assessment for other potential OB emergencies like postpartum hemorrhage or hypertensive crisis.
6. Partner with tertiary medical centers and OB groups for education, training, consultation and transfer agreements. Consider the use of telehealth to obtain rapid consultation with an obstetrician.
7. Debrief after every OB delivery (if the hospital does not have OB services) or harm event. Utilize event reporting to track and trend OB events for your institution.

Risk reports

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Our risk reports analyze malpractice claim data on various topics and specialties, including family medicine, emergency medicine and obstetrics. Each risk report shares insights to help reduce harm events and malpractice claims.

Are you a client? Sign in to MyAccount to access exclusive client versions of our risk reports. The expanded risk reports share actionable insights and strategies you can utilize to help reduce harm events and malpractice claims. After you sign in to MyAccount, follow Risk Resources > Tools & Resources > Publications > Risk Reports. You also have access to a host of Bundled Solutions (in Risk Resources) that cover a wide variety of topics, such as obstetrics and preventing diagnostic error, to assist you in your risk mitigation efforts.

Resources

• AIM Patient Safety Bundles
• California Maternal Quality Care Collaborative
• American Academy of Pediatrics and American Heart Association Neonatal Resuscitation Wall Chart
• Maternity Care Desert Dashboard

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.

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