Statewide bundle reduces risk for deliveries complicated by postpartum hemorrhage

Implementation of a statewide obstetric hemorrhage quality-improvement bundle in New York coincided with significant reductions in transfusion, severe maternal morbidity (SMM), and disseminated intravascular coagulation (DIC) among deliveries complicated by postpartum hemorrhage (PPH), according to a repeated ecologic cross-sectional analysis published in Obstetrics & Gynecology.

PPH affects an estimated 2% to 5% of pregnancies and is among the most preventable causes of pregnancy-related death, with hemorrhage and transfusions accounting for nearly 30% of SMM, according to the study authors.

A United States population-based study from 2000 to 2019 found that the rate of PPH increased from 2.7% to 4.3% over that period.

“Because the majority of women who experience PPH have no identifiable risk factors, timely identification and response are imperative, and safety reviews have found that delayed recognition and response to PPH are frequently avoidable causes of related adverse outcomes,” the authors noted.

In 2013, ACOG District II launched the Safe Motherhood Initiative obstetric hemorrhage bundle, a statewide hospital-based effort in New York designed to improve preparedness, identification, and treatment of PPH. Bundle completion occurred in May 2014, with dissemination to participating hospitals in July 2014. The current study sought to evaluate population-level trends in PPH diagnoses and outcomes before, during, and after bundle implementation.

15-year analysis of New York delivery hospitalizations

Researchers analyzed delivery hospitalizations in the 2007–2022 New York State Inpatient Database, encompassing 3,563,885 delivery hospitalizations. Joinpoint regression was used to determine average annual percent change (AAPC) in PPH diagnoses and 4 adverse outcomes: transfusion, nontransfusion SMM, DIC, and hysterectomy. Adjusted logistic regression models were additionally performed for each outcome.

PPH increased continuously throughout the study period, rising from 22 per 1,000 deliveries in 2007 to 59 per 1,000 in 2022 (AAPC 6.9%; 95% CI, 6.5–7.5%).

Among deliveries complicated by PPH, transfusion rates rose from 192 per 1,000 in 2007 to 212 per 1,000 in 2013 (AAPC 2.1%; 95% CI, 0.6–6.6%), before declining to 174 per 1,000 in 2016 (AAPC −6.8%; 95% CI, −9.5% to −2.1%) before rising again to 212 per 1,000 in 2022 (AAPC 2.8%; 95% CI, 1.2–8.1%).

How did severe maternal morbidity, DIC, and hysterectomy trend over time?

SMM rose from 88 per 1,000 in 2007 to 122 per 1,000 in 2014 (AAPC 2.8%; 95% CI, 0.7–7.6%), then declined to 76 per 1,000 in 2017 (AAPC −16.3%; 95% CI, −20.8% to −8.4%) before rising again to 88 per 1,000 in 2022 (AAPC 4.4%; 95% CI, 0.1–18.5%).

DIC followed a similar pattern, increasing from 54 per 1,000 in 2007 to 90 per 1,000 in 2014 (AAPC 4.5%; 95% CI, 1.3–12.6%), declining to 53 per 1,000 in 2017 (AAPC −19.3%; 95% CI, −25.3% to −8.9%), and then rising without a statistically significant association.

“Hysterectomy rates decreased significantly from 26 per 1,000 in 2013 to 9 per 1,000 in 2022 (AAPC −10.2%, 95% CI, −14.3% to −8.7%); there was a trend change point in 2013, and the decrease was statistically significant from 2013 to 2022 (AAPC −10.2%, 95% CI, −14.3% to −8.7%), whereas the decrease from 2007 to 2013 was not (AAPC −3.7, 95% CI, −6.5% to 3.1%),” the investigators found.

What explains the later upturn in morbidity?

Reductions in SMM, DIC, and transfusion persisted for approximately 3 to 4 years following bundle initiation before later trends reversed.

“In comparison,” the authors concluded, “hysterectomy decreased continuously until the end of the study period. Case mix and worsening comorbidity may have accounted for later study trends given that adjusted regression models for SMM demonstrated decreased odds of peripartum hysterectomy over the later portion of the study.”

Reference:

Goffman D, Winter E, Simpson L, et al. Maternal Outcomes Associated With a Statewide Obstetric Hemorrhage Quality-Improvement Initiative. Obstetrics & Gynecology. 148(2), 217–228. doi:10.1097/AOG.0000000000006320