Author: Jillian Genereux

Respectful Care in the Neonatal Intensive Care Unit

Respectful Care continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care.

Elizabeth Rochin, PhD, RN, NE-BC | June 29, 2023

Posted under: Other, Quality of Care

In previous blogs, I have offered insight into the Alliance for Innovation on Maternal Health (AIM) patient care bundles, and their importance in maternal health.

It only makes sense to create newborn and NICU patient care bundles that are similar in nature to their maternal patient care bundle counterparts. After all, standardization and reducing variation are key to patient safety outcomes. The NICU is a natural next step in creating and cultivating patient safety bundles.

Patient safety bundles include the following domains:
  • Readiness
  • Recognition
  • Response
  • Reporting/Systems Learning
In 2021, a 5th bundle element was incorporated into the AIM patient care bundles, Respectful Care. This was the fifth element to be incorporated into all maternal patient care bundles. Respectful Maternity Care (RMC) is defined as the preservation of a birthing person’s dignity, choices, and preferences during birth and during the postpartum period. Understanding the value and importance of respectful care in the neonatal care setting is and will be an essential conversation to engage. Respectful Care has been and continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care. While the Respectful Care model typically focuses on the mother/birthing person, it is essential that these elements are applied to the supportive care of the mother/birthing person and newborn dyad in the Neonatal Intensive Care Unit. Several of these elements are described below:
  • Alleviation of Environmental Stressors: Providing support to the mother/birthing person to assure opportunities for bonding and care provision are essential. Transportation, food security, and the care of other dependent children as needed for frequent visitation to the NICU provides stability. Financial challenges compound these issues and further accelerate the disparities that are found within neonatal care. The promotion of dignity, autonomy and the ability to care for a sick newborn amid turmoil, such as an unexpected admission to the NICU, cannot be overstated.

  • Provision of a NICU Family Navigator/Support Structures: The ability for a mother/birthing person to achieve the highest levels of autonomy during a NICU stay relies on the ability to fully comprehend and understand the course of care. A NICU Family Navigator or NICU Family Support Program can facilitate communication and ensure that every newborn and family are assured the same level of care and discharge planning. Lake and colleagues described disparities in NICU outcomes related to race, and failure to offer the same level of discharge care to all families is antithetical to the Respectful Care model. Any differences in care, specifically racial and/or ethnic outcomes discovered during inpatient care or during the discharge process should be immediately evaluated. The inclusion of postpartum doulas to offer support for the woman/birthing person during the NICU stay should be encouraged. (If you have not thought about using Postpartum doulas in your NICU as a support for your parents, now is the time).

  • Trauma-Informed Care: Trauma-informed care is an essential principle of the Respectful Care model. Facets of trauma-informed care, such as previous experiences of trauma and subsequent response and reducing the impact of a current trauma (such as an unexpected admission to the NICU) provide a meaningful foundation to the care of mothers/birthing people during a stay in the NICU. Maternal/newborn separation can exacerbate trauma, and facilitation of visitation and information is key. Again, identification of environmental and social/structural determinants of health and their mitigation can ease the impact of further trauma to a family unit. These elements are cyclical, and all serve as conduits within a Respectful Care paradigm.





How much does it cost to park in your hospital parking garage? How much is a bottle of water or a small meal in your hospital cafeteria? And if a baby is in the NICU for weeks, what does that cost? Childcare for those children at home? Lost hours at work? The trauma of an unexpected NICU admission can be but the very start of a perpetual traumatic experience for a family.

The Black Mamas Matter Alliance describes best practices for holistic maternal and neonatal care:
  • Addresses gaps in care and ensures continuity of care
  • Affordable and accessible care
  • Ensures informed consent
  • Confidential, safe, and trauma-informed
  • Provides wraparound services and connections to social services
Achieving a care model that not only supports but promotes and sustains Respectful Care should be considered requisite for any facility caring for women/birthing people and their newborns. Strategic planning should include a focus on equity and include the voices of those populations most impacted by disparate outcomes. Continuous quality improvement through an equity lens and self-reflection performed by individuals, departments and organizations is fundamental to the continued evolution of a robust and holistic care program. Respectful Care in maternal and neonatal settings will be critical to elevating both short and long-term outcomes, and supporting a strong foundation for autonomy, dignity, and a well-defined transition to home and equitable access to community resources.

So, let’s start a checklist for Respectful Care in the NICU:
Centering the baby and family for all care and decisions
Dignity and autonomy
Informed consent
Shared decision-making
Equitable access to pain management
Access to Postpartum doulas
Access to Community Health Workers
Postpartum depression assessment of mother and partner with appropriate referrals
24-hour access to baby
Parental presence during resuscitation
Assessment of childcare needs
Assessment of transportation availability
Assessment of nutrition
Equity in access to lactation support and donor milk
A home transition plan that respects and incorporates the culture, values, and lived experience of the family
Ability to measure Respectful Care and its impact on patient outcomes

Building respectful care into any NICU patient safety bundle should be a first step. I hope to hear from you and let’s continue to grow a new and emerging model of Respectful Care in the NICU.

References
1. Moridi M, Pazandeh F, Hajian S, Potrata B. Midwives’ perspectives of respectful maternity care during childbirth: A qualitative study. PLOS ONE. 2020;15(3):e0229941. doi:10.1371/journal.pone.0229941

2. Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

3.Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018;61(2):387-399. doi:10.1097/GRF.0000000000000349

4.Harvey SA, Lim E, Gandhi KR, Miyamura J, Nakagawa K. Racial-ethnic Disparities in Postpartum Hemorrhage in Native Hawaiians, Pacific Islanders, and Asians. Hawaii J Med Public Health. 2017;76(5):128-132.

5.Km M, A K-D, R K, et al. Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care. Med Care. 2021;59(2):131-138. doi:10.1097/mlr.0000000000001461

6.Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

7.Glazer KB, Sofaer S, Balbierz A, Wang E, Howell EA. Perinatal care experiences among racially and ethnically diverse mothers whose infants required a NICU stay. Journal of Perinatology. Published online July 15, 2020:1-9. doi:10.1038/s41372-020-0721-2

8.Sigurdson K, Morton C, Mitchell B, Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology. 2018;38(5):600-607. doi:10.1038/s41372-018-0057-3

9.Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women’s Health. 2020;30(2):230-235. doi:10.1089/jwh.2020.8882

10.Barfield WD, Cox S, Henderson ZT. Disparities in Neonatal Intensive Care: Context Matters. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1688

11.Davidson JE, Aslakson RA, Long AC, et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Critical Care Medicine. 2017;45(1):103-128. doi:10.1097/CCM.0000000000002169

12.Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology. 2018;38(1):3-10. doi:10.1038/jp.2017.124

13. Black Mamas Matter Alliance. Setting the standard for holistic care of and for Black women. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf
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The Last Person You’d Expect to Die in Childbirth…Again…

The past few weeks have been very difficult for families within the United States. Communities are grappling with mothers who are dying on the day of childbirth, or within a day or two.

Elizabeth Rochin, PhD, RN, NE-BC | June 14, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

The past month has been very difficult for the maternal health community. Simply review the Go Fund Me accounts set up within the past month alone, and you will find the following posts of mothers who have died in childbirth, or before discharge home (not exhaustive):

32-year-old Justine Kostenbauder died of severe complications during childbirth (South Carolina).

Camylle Bowen died two days after childbirth (Texas).

28-year old Vanessa Dannecker died during childbirth (Long Island).

And social media erupted with disbelief this week upon hearing of Tori Bowie’s death during labor at her home, a track star and Olympic champion, the last person you’d expect to die in childbirth.

And that was the exact title of the NPR/ProPublica Lost Mothers Series in 2017. This piece described a white NICU nurse who died at the hospital she worked for due to complications of HELLP Syndrome. A long and detailed overview of the missed clues during labor and the immediate postpartum period was presented. Many other articles were published within this series and deserve another review.

And here we are, 2023, six years later, with the same scenarios playing out. Patients exhibiting signs and symptoms of distress. Patients verbalizing “something is wrong,” and those words falling on deaf ears, or onto team members who do not have adequate resources to support them. Or both. 80% of maternal deaths are preventable…at least.

13% of maternal deaths occur on the day of delivery. 13%.

Let’s do the math:
In 2021, it is reported that 1,205 women died of maternal causes. While that number is likely inflated due to COVID, let’s look at 2019, the last year without COVID diagnoses: 754. That is approximately 2 maternal deaths per day. 13% of 754 is 98. Approximately 98 women died on the day of delivery in 2019. That is approximately 2 per week.

In 2021, that number was 156, which reflects 3 maternal deaths on the day of delivery every week. An average of a maternal death, on the day of delivery, every 2 days, in 2021. That seems impossible in the United States of America.

Don’t Blame the Pregnant Person for their Own Death
There have been many discussions on social media this week about the death of Tori Bowie. Many of those continue the amplify and elevate the real issues of systemic bias, racism, and not listening to Black women’s concerns about their own bodies. But there is something that is looming in the background that needs to be immediately addressed: Blaming the patient. Did Tori use drugs? Did Tori seek early prenatal care? Was Tori compliant with her prenatal care? What? Are we back to blaming the patient?

In 2019, Dr. Monica McLemore and Valentina D’Efilippo published a piece in Scientific American, To Prevent Women from Dying in Childbirth, First Stop Blaming Them.

It is abundantly clear that this piece needs to be read and reread over and over. “Stop blaming women for their own deaths.” If it were only that simple. And trust me, it should be. No woman should be blamed for her own maternal death.

Here is a question you should ask yourself right now: If Tori were a white track star, would you have asked the same questions? Would you have assumed that by the color of her skin that she would be more apt to be compliant in her care? Seek out early prenatal care? Drug use even considered as a discussion point? These are questions that require very honest and deep self-reflection. Project Implicit can be a way to begin to create a pathway for self-reflection and an assessment of internal bias.

Data Speaks Volumes
The National Perinatal Information Center stratifies many maternal and neonatal outcomes by race and ethnicity for member hospitals. And in the aggregate, the following continue to be true, and follow the scientific literature very closely:
  • Black women continue to have the highest rate of cesarean delivery.
  • Black women continue to have the highest rate of severe maternal morbidity.
  • Black women continue to have the highest rate of preeclampsia.
There is a tremendous amount of work to do. Many organizations continue to work side-by-side to provide meaningful changes to the care of all women, but with an intentional focus on assuring the highest quality care for Black women.

Listen to Black women. Don’t make assumptions about Black women. But most importantly, support initiatives that support Black women in their communities.

And let’s all work towards a goal of reducing 13% of maternal deaths on the day of delivery to zero. No woman should lose her life by giving birth to a new life.

#13toZero
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Maternal Mental Health Awareness Month

May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need.

Elizabeth Rochin, PhD, RN, NE-BC | May 4, 2023

Posted under: Maternal Health, Mental Health

“I couldn’t bring myself to tell my doctors or nurses, or the doctors and nurses in the NICU about the way I was feeling. I was already that “bipolar patient.” I had used opiates for a few years to cope with the pain that depression brought with the disease. I could feel myself becoming more and more depressed and desperate for help, but thought that if I asked for help, my baby would be taken away from me. My bipolar disorder had haunted me for most of my adult life, had labeled me, and now with a new baby, had no one to reach out to. Each time I left the NICU, I thought it would be the last time I would see my baby. That feeling was so traumatic, and even though my baby is now 1 year old, I still relive that fear every day.” –A.R., during a postpartum interview

Overview
May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need. Compound this maternal mental health need with the public health crisis of racism and a stark picture emerges of women and birthing people in need of tremendous support. There are many facets that must be addressed within maternal mental health—access to care, transportation, stigma, insurance coverage, stable housing, to name a few. An area of concern that has been identified is that of opioid use disorder during pregnancy. A greater prevalence of comorbid psychiatric disorders, physical and sexual abuse, intimate partner violence, and chronic pain disorders likely contribute to disproportionate rates of opioid use and misuse in women and particularly women during pregnancy. Beyond opioid use are other substances that are used frequently to mask mental health symptoms that can be treated by other means. But that treatment costs money and access can be sparce depending on location and availability of providers.

The National Perinatal Information Center continues to track maternal mental health outcomes, including substance use disorder. In 2019, substance use disorder (ICD O99.3XX) was coded in 1.9% of patients (n = 334,402) and by September 2023, 2.3% were coded with substance use disorder (n = 325,195). While that number might not seem high, it continues to reinforce the need to remain vigilant in assessing patients in the prenatal, intrapartum, and postpartum period.

In the time period October 1, 2021 through September 30, 2022, 30-40 patient records were coded with postpartum psychosis (ICD -10 F53.1). In seeing this information, I thought about the patient behind the data. I wondered what their support systems were like. I wondered if they had support, or if they were alone in their suffering. I hope these women had what they needed to not only bring life into this world, but also had those to support them while they nurtured that new life.

Maternal mental health directly impacts the outcomes of a newborn. Perinatal mood disorders are some of the most identified maternal mental health concerns and are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In addition to perinatal mood disorders, there are other mental health diagnoses that must be appreciated, including pre-existing psychiatric illness (major depression, bipolar disorder, schizophrenia, etc.) that often is underreported and undertreated due to stigma and fear of reporting. During the month of May, it is critical to recognize certain elements of maternal mental health that must be addressed:
  1. Destigmatize mental illness: Stigma is a complex phenomenon, that has three different types: public, self and institutional. Self-stigma develops from shame, blame and internalization of mental illness, which is most often fueled by public and institutional stigma. Supporting women and birthing people experiencing maternal mental health illness, and reducing shame and self-blame, is critical in achievement of treatment regimens and continued engagement with healthcare providers.

  2. Screening women for mental health during the postpartum period: NICU’s across the United States have begun to engage in various forms of screening and intervention to assist in reducing stress and depressive symptoms in mothers during newborn admission. In many cases, maternal mental health concerns remain under identified and undertreated during a NICU stay, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. Mendelson et al performed a systematic review and metanalysis of NICU programs designed to evaluate for postpartum depression and anxiety and found it increasingly important to evaluate maternal mental health during NICU admissions to assure engagement and understanding of treatment and discharge plans.

  3. Disparities in maternal mental health treatment: Overall, Black women are 3-4 times more likely to die during childbirth or within the first year after delivery. Increasingly, studies describe inequity in mental health screening, identification, and treatment for women of color and other vulnerable populations. Sidebottom and colleagues described the findings of their study in which African American, Asian, and non-white women were less likely to be screened for postpartum depression than their white counterparts. In addition, this study also revealed that women insured by Medicaid and other state programs were less likely to be screened than those women with private insurance.

  4. Access to care: Psychiatrists, psychologists, social workers, and others can be difficult to access, particularly in rural environments. Paying for these services can be difficult, if not impossible, as many providers may not accept Medicaid or patients may not have the means to cover services not covered by insurance. Credentialed/certified community health workers (CHW) can be an invaluable resource for supporting patients in seeking resources for maternal mental health care. Psychiatric Mental Health Nurse Practitioners (PMH-NPs) can also be a vital community resource for patients. Supporting legislation to provide avenues for advanced practice is key in further developing this critical community resource. Advocating for coverage for postpartum maternal mental health is critical to supporting mothers in our communities. Finding new and innovative ways of using and supporting telehealth and digital access to maternal mental health access is imperative. But this access to mental health is dependent upon providers, access to broadband, technology, treatment (medication/therapy) and the cycle begins anew.



Telehealth Access Wheel: Foundational Needs for Telehealth (NPIC, 2023).

This month, it is essential that we create space to discuss maternal mental health, and to develop sustainable strategies for treatment and maternal well-being. Whether that be in a prenatal visit, admission to Labor and Delivery, during a NICU visit, or in the community, as a nation we must be prepared to destigmatize maternal mental health, assure equitable care and access, and create a compassionate course of treatment for women and birthing people who continue to suffer in silence.


References
Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. The Lancet. 2020;395(10242):e112-e113. doi:10.1016/S0140-6736(20)31371-4

Ouyang JX, Mayer JLW, Battle CL, Chambers JE, Salih ZNI. Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units. NeoReviews. 2020;21(11):e708-e715. doi:10.1542/neo.21-11-e708

Patrick SW, Schiff DM, Prevention C on SUA. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-4070

Patrick SW, Barfield WD, Poindexter BB, Committee on Fetus and Newborn C on SU and P. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 2020;146(5). doi:10.1542/peds.2020-029074

Kendig S, Keats JP, Hoffman MC, et al. Consensus Bundle on Maternal Mental Health. Obstet Gynecol. 2017;129(3):422-430. doi:10.1097/AOG.0000000000001902

Pescosolido BA. The Public Stigma of Mental Illness: What Do We Think; What Do We Know; What Can We Prove? J Health Soc Behav. 2013;54(1):1-21. doi:10.1177/0022146512471197

Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions to Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1870
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Restoration of Black Autonomy and Joy in Perinatal Nursing Leadership

There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Elizabeth Rochin, PhD, RN, NE-BC | April 13, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Six years ago, the Black Mamas Matter Alliance launched Black Maternal Health Week, a week each April that would highlight and amplify the unacceptable and sustained increase in Black maternal deaths . Within the global COVID-19 pandemic, the outcome disparities within Black and Brown maternal health communities continued to grow and were impacted at greater rates. On April 13, 2022, Vice President Kamala Harris convened Cabinet secretaries to address the ongoing maternal morbidity and mortality crisis in the United States. The President’s FY23 budget included $470 million to address additional maternal disparities projects, including supporting the perinatal health workforce.

The perinatal health workforce has become an important discussion point, as the need for community health workers, doulas, and other Black maternal health advocates center conversations about the needs of Black mothers and parents. While there is a significant need for a community health focus, inpatient obstetric care requires intentional focus and strong leadership. As reported by the CDC and MMRIA report, 13% of maternal deaths occur on the day of delivery. Inpatient obstetric teams require experienced nursing leadership to support the infrastructure and care delivery required to provide high quality, respectful, and culturally competent care. Open nursing leadership positions within Women’s and Children’s service lines that were once rarely available or open now sit vacant for weeks, and in some cases, months. An area of healthcare leadership that is not often studied is that of frontline perinatal nursing leaders.

So how does this connect to Black Maternal Health Week? There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Weeks ago, Synova Associates and the National Perinatal Information Center launched a white paper that reported on the effects of chronic stress on perinatal nursing leaders (Supporting Perinatal and Neonatal Nurse Leaders: Identification and Moderation of Chronic Stress, IRB #1321780). These nursing leaders represented inpatient settings throughout the United States such as neonatal intensive care (NICU), labor and delivery, postpartum, well-baby nurseries, lactation services, antepartum, and those nursing leaders who are responsible for multiple units. The findings of this study revealed significant racial disparities in many areas, including turnover intent (p < .001), job control (p < .001) and organizational constraints (p < .001).

Based on the results of this study, the following recommendations are suggested for hospital leadership to address:
  1. Healthcare leaders and communities must be made aware of the extrinsic stressors that exist for Black/African American and diverse perinatal nursing leaders. Within this study population, stressors were described as physical symptoms (chest pain, shortness of breath, p < .001) that cannot be ignored, and require additional research and development for strategies by and for those most impacted by these findings. We cannot discuss the physical impacts upon Black nursing leaders without recognizing racism and structural barriers that create environments that impact physical health.

  2. Turnover intention, particularly as described in this study (“I won’t be working here one year from now” p < .001) for Black and Brown perinatal nursing leaders must be more thoroughly explored, and the urgency of this finding addressed. It will be important to replicate this study within other service lines to establish if these findings are unique to perinatal services, or if these findings are more global to diverse nursing leaders regardless of setting.

  3. Job Control, or the perceived ability to make decisions or the freedom to decide how to work, was also significantly decreased for Black and Brown nursing leaders (p < .001). In addition, organizational constraints (hospital rules/procedures; adequate help from others) was also significant (p < .001), which continues to generate further need for examining systems and structures in place that create these real and/or perceived barriers to effective leadership. Exploring these differences is critical and may aid in better understanding turnover intent as well as the symptoms of chronic stress described within Black perinatal nurse leaders. #structuralbarriers
During Black Maternal Health Week, it is important to center the conversation around Black women and birthing people and the continued unacceptable outcome disparities that exist despite data saturation. While assuring the health, well-being, and bodily autonomy of our diverse patients and communities continues to be a priority in our healthcare systems, it is just as important to ensure that we are providing that same level of effort and intensity at assuring the health and well-being of Black nursing leaders within our systems. During Black Maternal Health Week this year, celebrate the richness and diversity of Black communities and Black perinatal leaders. Support the Black Mamas Matter Alliance and the Restoration of Black Autonomy and Joy. Commit ourselves to amplifying Black voices and experiences and follow their lead for innovative and sustainable solutions to eradicating Black maternal morbidity and mortality.


References
National Minority Health Month. NIMHD. Accessed April 9, 2022. https://www.nimhd.nih.gov/programs/edu-training/nmhm/

Black Maternal Health Week. Black Mamas Matter Alliance. Accessed April 9, 2022. https://blackmamasmatter.org/bmhw/

Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C. Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2020;0(0):1-13. doi:10.1080/14767058.2020.1781809

Di Mascio D, Khalil A, Saccone G, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. 2020;2(2, Supplement):100107. doi:10.1016/j.ajogmf.2020.100107
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13 to Zero

Preventable maternal morbidity and mortality requires an organizational commitment that is patient-centric.

Elizabeth Rochin, PhD, RN, NE-BC | March 30, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Inpatient maternal mortality continues to be a significant challenge to healthcare teams in the intrapartum period. Recognition and awareness of inequities in birth outcomes must be a priority for healthcare teams. Preventable maternal morbidity and mortality requires an organizational commitment that is patient-centric.

In many instances, 13% may not sound so high. That is 13 out of 100. You might not think much of it.

But if you were to hear that 13% of maternal deaths occur on the day of delivery, that might change your mind considerably (https://reviewtoaction.org/sites/default/files/2022-10/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf). Of 1,018 deaths reviewed from 36 states, 132 occurred on the day of delivery. That’s approximately 4 patients per month or 1 patient per week. And keeping in mind that this data is not from all states, this number is most likely higher. Building into this model that 84% of these deaths were determined to be preventable creates an even greater sense of urgency.

A study (2020) exploring maternal deaths from 2002 – 2014 during the intrapartum period revealed the following:
  • Black women were three (3) times more likely to die during the intrapartum/in-hospital period than their white counterparts.
  • Three or more severe maternal morbidity indicators were present on admission, including coagulopathy, fluid/electrolyte imbalance, hypertension, and neurological disorders.
  • Acute myocardial infarction, followed by amniotic fluid embolism, and pulmonary edema/acute heart failure were the primary drivers of mortality.
While a study reviewing data from 2002 – 2014 may seem a bit dated, there are still common themes associated with today that must continue to drive the conversation:
  • Cardiovascular disease still contributes to the rate of intrapartum maternal mortality.
  • Black women continue to be 3-4 times more likely to die during or after pregnancy.
To bring more awareness to this issue, the National Perinatal Information Center is embarking on 13 to Zero. This call to action is designed to bring awareness to the continued issues surrounding intrapartum mortality and how to build sustainable quality improvement to reduce and eliminate preventable inpatient maternal mortality.

What does 13 to Zero look like?
  • Using data to inform decisions and quality improvement initiatives, including race and ethnicity data stratification.
  • Recognition of birth outcome disparities and strategic plans in place to address.
  • Measuring and supporting psychological safety within healthcare teams.
  • Foundation of cultural humility and respectful patient care.
The STEEEP acronym (Institute for Healthcare Improvement; National Academy of Sciences, Engineering, and Medicine) focuses obstetric care in a way that can connect teams to purpose:
S: Safe
T: Timely
E: Equitable
E: Efficient
E: Effective
P: Patient-centric

Creating and sustaining high-reliability and equitable inpatient quality improvement programs is critical to eliminating preventable maternal mortality.

High-Reliability Quality Improvement: Layers of Success
Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?
  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?
  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?
  • Do they routinely ask about outcome disparities?
  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?
  • How engaged is the Board in reviewing and understanding maternal health QI projects?
  • Does the Board of Directors/C-suite have a shared mental model of the social drivers/determinants of health specific to maternal care?
  • Do unit leaders have an opportunity to routinely engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?
Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?
  • What does physician leadership look like?
  • Do they work well together?
  • Are they committed to the same outcomes and priorities?
  • Are they committed to including the voices of those most impacted in perinatal project planning?
  • In other words, are patients of color or others based upon identified social needs invited to participate in QI initiatives within the unit?
  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?
  • Have they assessed the activation and readiness of their teams to engage in QI work?
Frontline Care Teams
Let's explore the teams themselves, the team members who will be closest to the work.
  • Are they ready to engage in QI work?
  • Are Doulas considered part of the frontline care team?
  • Did the team have any input in creating the QI project?
  • Are there identified champions and informal leaders?
  • Is there bandwidth available?
  • How many other projects and initiatives are underway?
  • Is this considered a priority among many others?
  • Is the team multidisciplinary and includes all facets of care?
  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?
  • When was the last time your healthcare teams participated in respectful care training?
  • Are the measures/objectives/metrics in line with the communities you serve?
  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
How will your team be successful in your journey from 13 to Zero?

NPIC can assist your team in assessing, measuring, and developing action plans to support your journey to Zero. Reach out to Elizabeth Rochin to learn more (Elizabeth.Rochin@npic.org).







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Patient Safety Awareness Week

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

Elizabeth Rochin, PhD, RN, NE-BC | March 14, 2023

Posted under: Maternal Health, Other, Quality of Care

Last week on LinkedIn, I posted about a young Black woman who died at a hospital shortly after giving birth. She and her boyfriend had been asking for the nurses to call the doctor about the symptoms she was experiencing. Per the report of her boyfriend, the nurses could not call her doctors because “they would get upset.”

Where do I even begin to address the multiple factors that created this tragedy?

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

In 2001, the Institute of Medicine (now known as the National Academies of Sciences, Engineering, and Medicine) published Crossing the Quality Chasm: A New Health System for the 21st Century. This landmark document created a conceptual definition of quality, including a focus on care that is:
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient and
  • Equitable
Let’s return to the scenario described above, and dissect it:

Patient and Boyfriend Asking for Help with Symptoms
April Valentine was a first-time mother and selected her birth hospital as she would “have a Black doctor and a doula to support her” (https://www.theguardian.com/society/2023/mar/03/california-investigation-centinela-hospital-los-angeles-black-woman-death-childbirth). According to April’s boyfriend and father of the baby, April could not feel her legs for a few hours. She had an emergency cesarean section and died shortly after the birth of her baby.

Could there have been an outcome that had resulted in a healthy mom and baby? I would like to think that this scenario could have and would have played out under the right circumstances and in the right environment.

But what is the “right environment?” What type of environment would view the patient as “the expert” in their own experience? In their symptoms? Doesn’t the patient know themselves best? In the past few weeks, I have offered multiple examples of patients who expressed concerns about symptoms, only to be dismissed (or a thermostat adjusted so a feverish patient wasn’t so chilled) and suffered harm (or death).

Welcome to High Reliability
Healthcare teams hear the term “high reliability” and immediately think of two things: hard work and more work. And in some cases, they would be right. But “high reliability” is more than a term. It is a state of mind and a state of perpetual readiness. And high-reliability organizations do not occur overnight. These are processes that take years to create, and even longer to sustain. They require the perfect blend of leadership, accountability, and teamwork It is a shared and common purpose that has a few core tenets:
  1. Sensitivity to operations: Awareness of risks and how to mitigate them, including the use of patient outcomes data as a driver of improvement.

  2. Reluctance to simplify: Avoiding overly simplistic reasons for why things fail (communication failure, understaffing, inadequate training). Why did these particular issues occur? What are the reasons behind them? Simply stating “we were understaffed” does not answer the underlying reason(s) for staffing issues.

  3. Preoccupation with failure: Organizations that recognize the importance of addressing near-misses and finding solutions to reduce repetition.

  4. Deference to expertise: Recognition of the importance of the voices of those closest to the patient or to the work, and systems that support “hierarchy” may not have all of the answers to make an informed decision.

  5. Resilience: Teams are in a state of readiness, are prepared and ready to respond to system failures or issues “outside the norm” (https://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/hroadvice/hroadvice.pdf_
Let’s Return to April’s Story
Imagine for a moment that April had been cared for by a healthcare team that had a foundation of quality and safety as its common purpose and utilized the core elements of a high-reliability organization. Perhaps this is what would have resulted:
  1. April’s care team might have recognized that Black women (even young Black women) are 3-4 times more likely to die in or around childbirth. The team might have considered potential bias and potential forms of institutional racism that may create barriers to safe patient care.

  2. The healthcare team might have deferred to April’s own experience and expertise in her symptoms. She couldn’t feel her legs…what could some of the issues have been? Lack of mobility? Laying in one spot for too long? Something physiologic or worse?

  3. April’s care team might have been more comfortable in calling her providers if there had been a strong, underlying current of psychological safety.
Psychological Safety
Perhaps nothing screams more about this story than the perceived lack of psychological safety within the unit.

“Couldn’t call the doctors because “they might get upset”

Psychological safety has been defined in several ways, but one of the best definitions I have found is an environment that creates the experience of an individual “to be enabled to raise concerns, near misses, and potential errors without fear of negative consequences”. Psychological safety has been discussed in the literature and social media over the last few years, in part due to the challenges of the COVID-19 pandemic. Psychological safety requires crucial conversations about hierarchies within organizations and the importance of team communication. When addressing psychological safety within a healthcare team, it is essential to dissect parts of a unit culture that may need to be addressed more fully. That type I have experienced exceptional leadership dyads within perinatal care. Unfortunately, I have also been witness to those that are a true embodiment of the lack of teamwork and synergy required for patient safety.

Call to Action
I hope a lasting legacy of April’s unfortunate death will shed a light on how important a strong patient safety foundation can be. As we recognize opportunities to address and elevate patient safety, let’s commit to the following actions today:
  1. Recognizing patient care quality must be a daily priority.

  2. Recognizing the patient as an expert in their care.

  3. Recognizing high-reliability opportunities that can promote patient care and multidisciplinary teamwork.

  4. Elevate the concept of psychological safety as a national patient safety goal.
Thank you for everything you do for the care of your teams, patients, families, and communities.

Let’s make every day Patient Safety Awareness Day.

NPIC can assist your team in assessing, measuring, and developing action plans to support psychological safety, and tracking its impact on patient outcomes. Reach out to Elizabeth Rochin to learn more (Elizabeth.Rochin@npic.org).


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The Devastating Impact of Sepsis

Early on in my journey of becoming an advocate for C-diff awareness a quote that has stuck with me. “We are all patients or will be one day.”

Meghan Mimnaugh | February 21, 2023

Posted under: Other, Quality of Care

Earlier this month, our blog focused on An Introduction to Sepsis Survivors Week. Sepsis Survivors Week focuses on the patients and families who are impacted by this life threatening condition. This week, we introduce guest blogger and NPIC team member, Meghan Mimnaugh, to tell the story of how sepsis has impacted her life.


My mother’s death had a significant impact not only on my life but also on the life of everyone she knew. She died on August 5, 2012 of a Hospital Acquired Infection (HAI) called Clostridium Difficile or C-diff. Although C-diff was the underlying cause her cause of death was listed as sepsis. I remember early on in my journey of becoming an advocate for C-diff awareness a quote that has stuck with me. "We are all patients or will be one day." After spending over a decade advocating for patient safety awareness, overuse of antibiotics is a commonly unknown issue to the public. Antibiotics are important medications and are critical to the treatment of sepsis.

According to the Center for Disease Control, Sepsis is the body's extreme response to an infection. In my mother's case it was C-diff.

Every hour that treatment is delayed for sepsis patients results in an increase in mortality. While it is imperative to preserve antibiotics for infections that really need them, it is also crucial to prescribe antibiotics in a timely manner to patients with sepsis.

According to Sepsis Alliance,

"Studies investigating survival and sepsis deaths have reported slightly different numbers, but it appears that on average, approximately 30% of patients diagnosed with severe sepsis do not survive...Until a cure for sepsis is found, early detection and treatment is essential for survival and limiting disability for survivors."

It is important to know how to advocate for yourself and your loved ones. There is plenty of information on sepsis including:

https://www.sepsis.org/
https://www.cdc.gov/sepsis/






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An Introduction to Sepsis Survivors Week

Sepsis Survivors Week is in two weeks. Let’s create an environment where sepsis is caught before the downstream impact can occur.

Elizabeth Rochin, PhD, RN, NE-BC | February 3, 2023

Posted under: Maternal Health, Quality of Care

On the day I was supposed to be discharged from the hospital, I began to feel sick. I began to experience fever, chills, overall feeling of weakness, became short of breath, and felt like my heart was racing. I told my doctors all of my symptoms, but was quickly brushed off and was told that I was likely “just anxious about being a new mother.” Some tests were run and my White Blood Cell (WBC) count was higher than the previous tests, but again I was brushed off and told, “An elevated WBC count is normal after child birth.” — April Chavez, in April Chavez, Survived Sepsis

In two weeks, Sepsis Survivors Week will kick off and there will be stories of women, patients, and families who have been impacted by sepsis during pregnancy and after delivery. NPIC will share some of those here, but it is important to highlight a few items before we get there that deserve our attention now.

Normalization of Deviance
About three weeks ago, I blogged about the Normalization of Deviance and it became NPICs highest viewed blog. Why? Because every healthcare provider has experienced it in one way or another. At one level or another. And we are all seeking solutions.

Symptoms brushed off as “just anxious about being a mother?” Check the Normalization of Deviance box. (And a few other boxes too, but that’s another blog).

White blood cell count elevated with symptoms? “An elevated white blood cell count is normal after childbirth.” This one should be easy…the term “normal” was tossed in there to normalize the symptoms and findings (you guessed it…check that box again).

So How Do We Un-Normalize Symptoms of Sepsis in Pregnancy?
There is a challenge to sepsis in that in many ways it can different from other risks to pregnant and postpartum patients. Postpartum Hemorrhage? You can quantify (or should quantify) blood loss. Severe hypertension? Preeclampsia? Blood pressure, swelling, edema. Sepsis is a bit more insidious. The World Health Organization defines maternal sepsis as a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period (up to 42 days). What I am describing above are the symptoms that lead to sepsis, and how we as healthcare providers can break the chain and halt the progression of sepsis in its tracks.

Swiss Cheese Model and Near Miss/Error


If you have ever taken a TeamSTEPPS or other course in patient safety or risk management, invariably you will be introduced to the "Swiss Cheese Model” of patient error prevention. In essence, all of the holes line up perfectly to allow for an error or event to occur. Recognition of signs and symptoms of infection that lead to sepsis is the first step. Let’s use April’s story and sepsis recognition as an example:

Hole 1: Fever, chills, weakness, racing heartbeat/Dismissed

Hole 2: Shivering from fever/Dismissed (and thermostat of room turned up to provide warmth)

Hole 3: Symptoms continued/“New mom anxiety” and prescribed an anti-anxiolytic (symptoms dismissed)

How many more holes needed to be passed through? NONE. There were too many already! How many team members did not think to signal to someone that this was not normal? That these symptoms should be addressed?

AIM Sepsis in Obstetric Care Bundle
In 2022, the Alliance for Innovation on Maternal Health (AIM) launched the Sepsis in Obstetric Care Bundle. This patient care bundle provides teams the tools and elements needed to ensure consistent, standardized communication and care to prevent the downstream effects of infection and sepsis. Every hospital should be implementing this patient care bundle and readying their teams to be aware of the signs and symptoms of infection and sepsis.

There are a few key takeaways from this bundle:
  1. Readiness: Create a culture that utilizes non-hierarchical communication so that all team members, including the patient, feel empowered to speak up about a concern and know that their input is valued by the entire care team. We can educate all day long. But that education means nothing if teams will not listen to the patient and their concerns about new symptoms.

  2. Recognition and prevention: Provide patient education focused on general life-threatening pregnancy and postpartum complications and early warning signs, including sepsis signs and symptoms other than fever, and instructions for whom to notify with concerns. Ditto.

  3. Response: Initiate facility-wide standard protocols and policies for assessment, treatment, and escalation of care for people with suspected or confirmed obstetric sepsis. If you have only prepared your obstetric departments to respond to infection or sepsis in an obstetric patient, your chain of survival is already broken.

  4. Reporting/Systems Learning: Conduct multidisciplinary reviews for systems improvement of each sepsis case to assess the screening program, the quality of care provided to patients with sepsis, and whether instances of bias may have impacted care.

  5. Respectful/Equitable Care: Because maternal mortality and severe maternal morbidity related to sepsis disproportionately affect Black, Indigenous, and Hispanic people because of systemic racism, but not race itself, it is necessary to mitigate this bias by having a high index of suspicion for sepsis.
So, let’s un-normalize our response to infection and sepsis. And yes, I get it…many things may “look” like infection. In many instances, sepsis may require a differential diagnosis and other symptoms to recognize. But it is important to recognize them and not dismiss them.

Let’s ensure a culture and environment in which many more patients with sepsis survive. Better yet, let’s create an environment where sepsis is caught before the downstream impact can occur. Learn more about sepsis at https://www.sepsis.org/ and share your own experiences about sepsis and the care of patients who have survived during Sepsis Survivors Week.


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Normalization of Deviance—Part 2

Behaviors and actions that would normally be condemned have become normalized and excused. Behaviors that create a ripe environment for errors and patient harm are not addressed. This is normalization of deviance.

Elizabeth Rochin, PhD, RN, NE-BC | January 17, 2023

Posted under: Other, Quality of Care

Last week, I blogged about a topic that is very important to me, and quite frankly, is a key driver for NPIC membership—Normalization of Deviance.

It would seem that this topic is of great interest to many in the healthcare community. Within days, this blog has been viewed hundreds of times and generated a great deal of discussion, particularly surrounding bullying, “bad behavior,” and “behavior that is tolerated due to ‘expertise.’” I received multiple direct messages on LinkedIn, and thought I would share some overarching themes (changed a bit to protect individuals) and thoughts for the future:

“Turnover among the staff is so high. Preceptors are tired, the staff is tired, and no one seems to notice. There seems to be new staff all of the time, policies seem to get updated every other day, and teams can’t keep up.”

“Over time, [they] have reduced staffing numbers to a point that is no longer safe. Caring for two (2) patients in active labor has become the norm and not the exception.”

“Poor behavior is excused because someone is considered a clinical ‘expert’—their skills make up for their behavior.”

“’They have always acted that way’. People report the behavior but nothing is ever done. The culture of the unit is in peril, but nothing seems to change. We’ve simply gotten used to it over time.”

So, while most of the literature surrounding the Normalization of Deviance is focused on systems and processes, perhaps it is time to also devote as much energy towards actions (and inactions) over time that left unchecked create stressors and moral injury to those working within healthcare.

What many of these individuals describe are behaviors and actions that have been “normalized” and accepted behaviors that create negativity, isolation, and feelings of frustration, apathy, and complacency.

There is a multitude of studies, commentaries, and other media that relay the issues that exist within toxic work environments. Spend a day on social media, and it becomes increasingly concerning the sheer magnitude of this issue. And the turnover it creates, perpetuating the continued cycle of frustration, apathy, and complacency.

It is time that this issue is labeled for what it truly is…normalization of deviance. Behaviors and actions that would normally be condemned have become normalized and excused. Behaviors that create a ripe environment for errors and patient harm are not addressed. Accepting what was once unacceptable. Remember the discussion of the Shuttle Challenger disaster last week when introducing the concept of Normalization of Deviance? Rank and seniority became more important than expertise. Aerospace engineers found themselves having to prove harm rather than relying on their knowledge and expertise to avoid harm in the first place (When Doing Wrong Feels So Right: Normalization of Deviance - PubMed (nih.gov)).

What if your teams treated the management of deviant behaviors a risk management issue? A risk mitigation issue? Would you handle deviant behavior differently if it was handled as a threat to patient safety? Would you handle staffing shortages differently? Accepting what was once unacceptable?

Call intimidation and bullying in perinatal care what they are…normalization of deviance. Accepting what was once unacceptable.

So, how do we break the cycle? How do we move beyond accepting poor behavior and moving towards a more civil and collegial work environment? How do we ensure that we are providing an environment that is both patient AND staff centered and focused?
  1. Culture comes from the top: Does your Board of Directors/Trustees know what Normalization of Deviance is? And the real risks it presents to patients? Teams? Organizations? Strategy?
  2. If your organization has not reviewed the Shuttle Challenger disaster proceedings and report, I strongly recommend its use in risk mitigation. There are excellent lessons about how people and processes allowed for the movement of the unacceptable to the acceptable. Some of these changes took time. Others were quick and unrecognized.
  3. Create an organization that does not stigmatize event reporting or near-miss reporting. Does your organization classify intimidation or bullying as a near-miss? If not, why not?
Let’s end this on a positive note. There are many hospitals and healthcare organizations that have prioritized eliminating the normalization of deviance and created risk reduction programs that connect all team members to a common goal and purpose: elevate patient care AND team cohesion. While the space shuttle program IS rocket science, creating positive, enriching work environments is not.

Make 2023 the year where normalization of deviance IS normalized in our conversations, and eventually eliminated as a threat to patient safety.


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The Normalization of Deviance and Maternal Health Outcomes

There are a few terms that are used throughout healthcare quality improvement: Cognitive bias, confirmation bias, and normalization of deviance (NoD). What is normalization of deviance and what impact does it have on maternal health outcomes?

Elizabeth Rochin, PhD, RN, NE-BC | January 12, 2023

Posted under: Maternal Health, Other, Quality of Care

Healthcare workers, including providers, nurses, respiratory and occupational therapists, and so many others, enter healthcare to make a difference for patients, and their communities, and (let’s face it), create a sustainable livelihood and career.

At the end of the day, there is the desire to support individuals and communities from illness to wellness, and more recently, to support prevention efforts to avoid illness in the first place. The issues surrounding maternal health have accelerated in the past decade, particularly with the launch of the 2017 NPR/ProPublica Lost Mothers Series. Some would say that it was this work of journalism that catapulted maternal health to the discussion it is today. Not only did the journalists show the stark data on maternal deaths and mortality, but they showed the faces of those women who died and told their stories, which created (and quite frankly forced) the discussion of maternal health into the public domain. In addition, these stories also began to illuminate the stark inequities that exist, including the rates of death of Black and Brown women when compared to white women (3-4 times, and even today that data is dismissed).

Since then, a great deal of emphasis has evolved into discussions of maternal morbidity and mortality.

There are a few terms that are used throughout healthcare quality improvement: Cognitive bias, confirmation bias, and normalization of deviance (NoD) (there are others, but the focus here will be on NoD).

Cognitive bias was first described in the 1970s, as human behaviors that simplify situations that can seem complicated or uncertain. Confirmation bias is the process of only accepting data that is consistent with preconceived ideas, opinions, or thoughts. Normalization of deviance is the acceptance, over time, of processes and solutions that are broken or defective, and essentially, “normalize” poor outcomes and/or performance.

Normalization of Deviance is a term that originated with the Shuttle Challenger disaster in 1986. Sociologist Diane Vaughn described the process as “people within the organization became so accustomed to a deviation that they don’t consider it as deviant, despite the fact that they far exceed their own rules for elementary safety.” When Doing Wrong Feels So Right: Normalization of Deviance - PubMed (nih.gov)

So, what is the Normalization of Deviance:
  • Gradual reduction of safety standards (to a new normal) after an absence of negative outcomes, which reinforces the “Band-Aids” of workarounds, shortcuts, and other changes to processes when sustainable solutions are not available. Normalization of Deviance: Concept Analysis - PubMed (nih.gov)
  • Has the potential to exist in EVERY healthcare environment if left unchecked.
  • Requires just the right combination of exhaustion and frustration when processes are broken, which lead to workarounds, shortcuts, and “MacGyver” type fixes.
What Normalization of Deviance is NOT:
  • An individual issue. This type of behavior and reaction is a systemic issue and takes time to fester and grow. While each individual is responsible for the care of a patient or community, the “snowball effect” of individual responses creates a more global (and more dangerous) situation.
So, how does the Normalization of Deviance connect to maternal safety?

The latest Centers for Disease Control Report of Maternal Mortality Review Committees outlined the most recent maternal death data. Of the maternal deaths, 13% occurred on the day of delivery. While many programs focus on postpartum care in the community, between 6 weeks through 1 year postpartum (and beyond), we cannot overlook the importance of elevating care during the immediate labor/delivery/postpartum period which includes teams that rely on one another for the provision of high-quality care.

Dr. Christine Morton in 2014 described the issue surrounding the normalization of deviance in maternal health as the intersection of assuming childbirth to be risk-free and inherently risky, and clinicians not understanding practice patterns and maternal outcomes data tracking (Morton, C. (2014). The problem of increasing maternal morbidity: Integrating normality and risk in maternity care in the United States. Birth, 41(2)). While data capture and evaluation have improved since 2014, many of these same issues still exist in 2023.

States that are currently working through the AIM Safe Reduction of Primary Cesarean Birth Bundle know the normalization of deviance far too well. If your cesarean section rate is above 50%, you have probably heard the following statements:

“Our patients are sicker.”
“Our patients are older.”
“Our patients have more comorbidities.”
“Our patients _______________ (you fill in the blank).”

Don’t get me wrong…there are very specific indications why a cesarean section should occur. Cesarean birth can save the life of the mother, baby, or both.

But when cesarean section becomes the normal route of delivery and not the exception, fostering and supporting an intended vaginal birth can almost seem like a “workaround.”

Think about the care processes you have “normalized” that are anything but normal:
  • Vital signs in delivering women (“She has a higher heart rate because she is pregnant, no reason for worry”).
  • Setting alarm parameters just a “bit higher” than normal.
  • Dismissing data outcomes because you know your “patients are sicker than that” (and they might be…but the data you enter and validate is the data that comes out).
If you are not comfortable with the term Normalization of Deviance, that is okay. But it is a term that your unit and hospital should embrace and explore what “normalizations” your teams have created…they are there, but it takes courage, curiosity, and transparency to find them and to create a true culture of patient AND staff safety.

One of the primary reasons hospitals reach out to NPIC is to benchmark themselves against similar size hospitals, birth volumes, payers, and acuities. Your data is your data, and easy enough to track (potential confirmation bias). When you compare your data to another group of facilities much like yours, the difference may be minimal or may be significant, and variations in practice patterns may emerge.

Transparency and a true culture of safety that openly supports the identification of shortcuts, workarounds, errors, and near-misses is the only culture that will stall and eliminate the Normalization of Deviance.

The National Perinatal Information Center (NPIC) provides maternal and newborn data reporting and analytics for hospitals across the US. With the most robust and longest-tenured linked mother/baby database in the nation, NPIC has partnered with hospitals to offer better insights into their data and practice patterns. Those conversations have evolved into understanding how data comparison and benchmarking can support internal quality improvement programs and reduce the normalization of deviance in outcomes. If you would like information on building a more resilient maternal and newborn quality improvement program, contact NPIC at inquiry@npic.org.
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