Maternal hemorrhage is one of the most common causes of maternal death worldwide. Approximately one woman dies of maternal hemorrhage worldwide every four minutes or approximately 140,000 women annually.1
In 1998, The Los Angeles County Maternal Mortality Review Report was jointly produced by the California Department of Health Services, Maternal Child Health Branch, and the Los Angeles. County Department of Health Services through a Federal Title V block grant. The purpose of the review was to identify causes and contributing factors as well as strategies to reduce the number of preventable maternal deaths. Three main causes of death identified in the report were hemorrhage, embolism, and hypertension. African- American women were identified as being at higher risk. Accordingly 75% of the deaths had some chance of being prevented. In this review, provider factors contributed most commonly, patient factors contributed some and facility and community factors contributed less. Recommendations of the review panel to decrease maternal mortality addressed many types of contributing factors and dealt with all stages of pregnancy from improved women’s health care and preconception counseling to postpartum education and follow-up. 2
A review of data from 1999 to 2003 indicate that African-American women in Los Angeles County are three times more likely to die from a pregnancy related cause than all other women (Figure.1). The accuracy of data collected during this same time period regarding the leading causes of maternal mortality is hindered by the fact that 68% of the “other” category was chosen as the cause of death.
Figure 1. Los Angeles County Maternal Mortality Rates by Ethnicity
With 2.5 million women of childbearing age residing in Los Angeles County and one in twenty U.S. births occurring here, successful implementation of the Los Angeles Quality Improvement Project will result in significant reduction of hemorrhage-related morbidity and mortality, the most common cause of maternal death worldwide. In 2005, 22 maternal deaths (the total number of hemorrhage-related deaths is undetermined due to coding inconsistencies) occurred in the county. The strategies described have the potential not only to reduce the overall mortality rate, but can also prevent approximately 220 near misses and 2,200 serious morbidities.
The goal of the Los Angeles County Maternal Care Quality Improvement Project is to reduce the overall incidence of maternal morbidity and mortality by focusing on prevention, early recognition, and response to obstetrical hemorrhage (OBH).The project targets obstetrical providers, hospitals, and pregnant women in Los Angeles County at the top 10 delivery hospitals. We have assembled representatives from the American College of Obstetricians and Gynecologists (ACOG), Regional Perinatal Programs of California (RPPC), managed care health plans, community based organizations, local public health departments, key hospitals, and obstetrical providers. Additional partners include the Black Infant Health (BIH) Program, American College of Nurse Midwives, March of Dimes, and other key organizations.
A three-tired approach targeting obstetrical providers, hospitals, and pregnant women will be implemented. A Core Advisory Group comprised of key stakeholders from provider, hospital and patient organizations will be the body that will work with use to implement the desired state. Based on an identified knowledge gap, the ACOG Practice Bulletin on postpartum hemorrhage, and other evidence-based recommendations and algorithms, will be used as the basis for educating providers, through grand rounds, direct mailing, as well as other methods.
To inform and educate pregnant women, educational materials related to reducing postpartum hemorrhage risk will be developed in English and Spanish to be distributed to Black Infant Health Programs, health plans, Comprehensive Perinatal Services Providers, and case management programs working with the top 10 delivery hospitals.
Improving maternal hemorrhage in Los Angeles County will clearly impact the maternal mortality statistics in California as a whole, since over one third of the births in California occur in Los Angeles County, and one-third of ob/gyn providers in California practice in Los Angeles County. Our proposal will successfully close the gap in Los Angeles County and will provide significant leverage to close the gap in California as a whole. We propose a three tiered approach:
The ACOG Practice Bulletin on postpartum hemorrhage, and other evidence-based recommendations and algorithms, will be used as the basis for educating providers, through Grand Rounds, e-mail, public health publications, and direct mailings from health plans. Pre and post assessments will be implemented as part of the learning, retention and implementation of the information disseminated.
Figure 2. Strategies for Provider Implementation:
Collaboration with delivery hospitals will be accomplished through risk management teams, health plans, and RPPC to refine existing hemorrhage protocols, disseminate protocols, and urge implementation of hemorrhage drills. This will enable implementation of a validated emergency response. Incorporation of these recommendations will be done in a rapid cycle-change approach to quality improvement (Figure 3). These initial hospitals will be the early adaptors and facilitators for adoption of the hemorrhage protocol/drill by other hospitals. Through reminders and reinforcement of JACCHO requirements, we hope hospitals will incorporate the drill into their routine practice and review. Follow up meeting/evaluation with hospital representatives will track the implementation and perpetuity of the trainings and drill exercises.
Efforts to improve the accuracy and usefulness of postpartum hemorrhage coding will also be championed by these hospital partners. The hope is that the refined coding system would eventually incorporate and replace the current method of coding maternal morbidity and mortality. Follow-up and tracking of L.A. County vital statistics will be one way of monitoring the impact of the data coding modification.
An early alert system for hospitalized patients at risk for obstetrical hemorrhage is the final hospital component. Similar to an allergy band that is placed on a patient while hospitalized, a woman at risk for obstetrical hemorrhage would have a “high risk” band place on her hand. This will assure immediate identification of the patient’s risk by any one caring for her, whether it is a nurse coming to cover for another nurse or a new provider coming on shift, the early identification band will be an immediate signal that the patient is at risk for maternal hemorrhage. For patients without the ability to communicate in English, the maternal risk band will be a quick non-verbal way of indicating the patient’s risk to anyone caring for her. This identification band will be placed on high risk for obstetrical hemorrhage patients admitted to one of the initial 10 pilot delivering hospitals. Through improved coding, direct feedback from healthcare providers and hospital administrators, the effectiveness and usefulness of the early identification band will be assessed. In the future, our aim is to expand this early alert system to all the hospitals in Los Angeles County and eventually implement it into the prenatal care period.
Figure 3. Rapid-Cycle Change Approach to Quality Improvement: MAP IT: Mobilize Groups, Assess Data, Plan Standards & Changes, Implement Changes, Track Progress
Finally, to inform and educate women of reproductive age, focus group tested educational materials related to reducing postpartum hemorrhage maternal morbidity and mortality will be developed in English and Spanish and distributed through health plans, CPSP providers, and case management programs. An indirect way of tracking the efficacy of the educational and communication efforts will be to incorporate questions related to obstetrical hemorrhage risks in currently ongoing surveys in Los Angeles County such as the LAMB (Los Angeles Mommy and Baby Survey) and the L.A. HOPE (Health Assessment of a Pregnancy Event). With a response rate of over 50%, these surveys are sent out to over 20,000 women, and are providing a representative sample of all racial and geographic areas of Los Angeles County. African American women are over-sampled in these surveys because of the high negative perinatal outcomes. The surveys returned from the selected top 10 delivering hospitals will be reviewed to assess the efficacy of the teaching materials as well as the communication patients had with their obstetrical provider regarding obstetrical hemorrhage maternal morbidity and mortality.
1.Abouzher C. Antepartum and postpartum hemorrhage. In: Murray CJ, Lopez AD eds. Health dimensions of sex and reproduction: the global burden of sexually transmitted disease, HIV, maternal conditions, perinatal disorders , and congenital anomalies. Boston: Harvard University press, 1998:172-4.
2. Maternal Mortality in Los Angeles County 1994-1996, County of Los Angeles Department of health Services Family Health Programs. Available at: http://lapublichealth.org/mch/fimr/report.pdf. Retrieved April 1, 2008.
Resource and Link
California Maternal Quality Care
Obstetric Hemorrhage - Designed to promote a systemized and a standard response
Safe Motherhood Project Update
Obstetric Hemorrhage - Improvements in Health Care
Maternal Hemorrhage - Prevention of Maternal Deaths
Catastrophic Obstetric Hemorrhage
Maternal Mortality - Obstetric Hemorrhage
Patient Brochure on Heavy Bleeding (English) (revised)
Patient Brochure on Heavy Bleeding (Spanish)
LACMQCC Intranet (log in required) - Coming Soon!
For more information, please contact
the Los Angeles County Maternal Care Quality Improvement Project
staff, Diana Ramos, MD, MPH at
or Giannina Donatoni, PhD at