My name is Joan Porcaro. I'm the director of client relationship management here at WTW. And I'm both honored and pleased to be joined today by Dr. Stephen Porter-- an OB/GYN-- who also serves as the chief executive officer at Risk LD.
Welcome, Dr. Porter.
STEPHEN PORTER: Thank you so much for having me, Joan.
JOAN PORCARO: Thank you for being here with us today.
We're also joined by Lori Adams. Lori serves as a patient safety and risk manager at COPIC Insurance Company. Welcome, Lori.
LORI ADAMS: Thanks, Joan. Happy to be here.
JOAN PORCARO: And again, welcome to you both with the WTW six-part podcast series on maternal and infant safety. We are not only focused on patient safety, but we also are looking at avenues to reduce that liability for our care team.
In today's discussion, we'll focus on the trends in liability and claims management in that realm. So, let's begin with the first question. So, I think I'll direct this one to Lori. What types of claims are we seeing nationally?
LORI ADAMS: The OB claims that we're seeing are really known events and predictable events. The risks haven't really changed over the years. But what we need to keep in mind is what's changing in the OB world is the indemnities paid for those claims. OB continues to be one of the areas with nuclear verdicts. And some would actually say thermonuclear verdicts.
And so, where we're seeing most of these claims come from are labor management issues such as inter-amniotic infections, sepsis. And we're seeing a lot of shoulder dystocia claims with brachial plexus injuries, obstetrical hemorrhage, cardiovascular events, your operative deliveries such as your vacuums, your forceps. I think what's important for us is this underscores the importance of the patient safety bundles and other platforms to improve perinatal safety, which we'll talk about later. But they're widely available.
JOAN PORCARO: Thank you, Lori. So, my next question I'd like to direct to Steve. What types of injuries are sustained? Can you tell us more?
STEPHEN PORTER: Sure. And I want to talk both about morbidity and mortality. And starting with mortality, Joan, the numbers are really quite staggering. We saw an increase in maternal mortality between 2021 to 2022 from about 24 deaths per 100,000 live births, all the way to approaching 33 deaths per 100,000 live births. So, the United States has the highest maternal mortality rate of any industrialized nation. And it's a problem that's really getting worse year after year.
Recent CDC data shows that about 25% of these maternal deaths occur on the date of delivery or in the immediate postpartum period within one week of delivery. And that underscores the vital importance of inpatient perinatal patient safety programs like we're talking about today. Beyond maternal deaths, we know that for every maternal death, there are at least 70-- what we call near misses.
Now, these are clinical events that do not result in mortality but result in severe maternal morbidity. Now, what do we mean by that? The CDC actually defines severe maternal morbidity as an unexpected outcome of labor and delivery that results in significant short or long-term health consequences to a pregnant person. And these include unexpected severe medical or surgical complications that we see in the peripartum period, emergency surgeries, ICU transfers, heart attacks, kidney failure, heart failure, respiratory failure. Some of the worst things that can happen to a pregnant patient when the patient is coming into the hospital for a labor and delivery.
Separate from maternal events, we've also been tracking adverse neonatal outcomes. Several years ago, the California Maternal Quality Care Collaborative introduced a metric called the UNC, the unexpected complications in term newborns. And that was subsequently adopted by the Joint Commission as a quality metric. And this tracks things like neonatal demises. Babies who have to be transferred to another hospital for a higher level of care. Cases of severe birth trauma resulting in intracranial hemorrhage, nerve injury or severe neurologic injury or respiratory compromise.
So, these are some of the worst things that can happen to a mom or a baby during and after labor and delivery. And what's more shocking is that when we look at the maternal deaths, more than 80% of those are considered preventable. And OB is the one area of the hospital where patients show up at the hospital expecting a good outcome as they should, right? A pregnant patient coming to the hospital for labor and delivery expects to go home healthy mom, healthy baby. And therefore, the gap between those expectations and reality is particularly stark in cases of adverse obstetric outcomes.
One more point I'd like to make. I'd be remiss if I didn't touch on the yawning racial disparities in pregnancy health outcomes. We know that women of color in the United States are three to four times more likely to experience pregnancy-associated mortality compared to their white counterparts. And that's not just related to social determinants of health. That is unconscious bias. And in some cases, overt bias and how those forces manifest in hospital settings. So, I did want to-- it would be remiss if I didn't touch on that as an equally important problem.
JOAN PORCARO: Thank you, Steve. I can say the data is pretty sobering. So, what are some of the factors that are driving those injuries, Lori or Steve?
LORI ADAMS: What we're seeing in OB and what we've been seeing for several years is women waiting longer to have babies. So, as you're older, you have increased in pre-medical conditions-- pre-existing medical conditions. And so, we're seeing that we're getting better at multiple gestation, which increases the risk to the mom. And in pregnancy, increasing c-section rates are leading into some complications during pregnancy, labor, and delivery.
We also see workforce issues. And you're all aware of this as we're seeing a nursing shortage. So, we don't have as many nurses to do as much. But one important issue that we've seen over the last five years-- and I've actually experienced this in my own life-- is the hospital that I started and worked at for the first five years of my career closed and has now become an OB desert.
So, this is a place where there's no OB providers. There's no OB deliveries. And it's forcing women to travel 30 to 60 minutes. And it's estimated by the CDC that 36% of counties are OB deserts, where there's no availability to nursing care. And this is a two-sided issue because not only do these women not have a place to go to deliver when they have a complication, they're ending up in emergency rooms. And emergency doctors who aren't really trained in obstetrics are now having to manage obstetrical complications.
STEPHEN PORTER: I think Lori absolutely hit the nail on the head. And I just want to build on some of her comments. When we talk about pre-existing medical conditions, we see much higher rates of super morbid obesity, poorly controlled diabetes, poorly controlled hypertension. And increasingly, pre-existing heart conditions leading to heart failure and other complications.
So, in some sense, the reproductive age population is medically more complex than what we were seeing 30 or 50 years ago. But I also want to build on some of the structural and systems level forces that Lori underscored. And it's genuinely hard to imagine this from areas of medical saturation like where I practice in Boston. But across the country, there simply aren't enough doctors. There aren't enough nurses. There aren't enough facilities in which patients can safely deliver their babies.
We know that four million patients live in counties with no OB/GYN physician. We know that 100,000 nurses left the profession between 2020 and 2021. And more than 200 hospitals closed their labor and delivery units over the past decade, creating these maternity deserts that Lori mentioned. And we're starting to see this borne out by the data with a 40% increase in maternal mortality in the year 2021 alone.
LORI ADAMS: Yeah. And I think in addition to that, a study-- a recent study done has said that only 10% of physicians PA-- nurse practitioners-- coming out of school plan to work in a rural area.
JOAN PORCARO: Thank you both. Again, sobering information to consider when we think about some of the pressures that come from staffing issues alone that does place a lot of concern and stress on the care team. So, let's pause a bit and turn our discussion to prevention. What are some of those considerations, possibly evidence-based, some of the new trends that are on the horizon for the care team, Lori?
LORI ADAMS: The thing is we don't lack resources to make these better. The resources are out there. Every single state has a perinatal collaborative that you can join. And those collaboratives lead you into these aim safety bundles. So, these are safety bundles for hemorrhage, for hypertension, for sepsis that you can Institute in your hospital. They include education. They include drills. They include debriefs on the drills. So, they're widely available.
And I think that-- Steve mentioned earlier the California collaborative-- their perinatal collaborative-- maternal collaborative. They have done an outstanding job. And they are the most robust collaborative out there. And the nice thing is their resources are available to you. You can go on their web page and download. You want to do a simulation, go on there. Download it and use it.
They're widely available. They do podcasts. And they do webinars that you can get on and learn. And they should-- they're really a model for how to do it right. And they have successfully decreased their mortality rate by 60% following these bundles. And they have one of the lowest mortality rates in the United States. So, we know these things work.
TeamSTEPPS through AHRQ is another nice resource. I will say earlier when I mentioned about the ED physicians who are now dealing with OB patients. ACOG within the last month has come out with three algorithms for emergency rooms for pregnant women. One for cardiovascular disease. One for preeclampsia, and one for eclampsia. So, these are nice algorithms to have in your ED.
So, like I said, we are not lacking resources. Everyone just needs to get in and look at those resources, educate yourself, and roll out the changes within your health care systems.
JOAN PORCARO: Thank you, Lori, very much for that recap. Steve or Lori, will technology play a role in providing clinical support to a laboring patient? What do you think the next level of care is going to look like?
STEPHEN PORTER: Well, absolutely. And I see technology as an important complement to all of the tools that Lori just mentioned. And technology can help by alerting objectively to patients who are manifesting high-risk conditions. Technology can help by providing evidence-based clinical decision support at the point of care. And technology can help by helping to monitor trends over time.
I'm going to say that one more time. Technology can help by monitoring trends over time. Our software (please note: this software is specifically owned by Risk LD) platform provides early warning and clinical decision support at the point of care on labor and delivery. And was developed out of a 10-year process by the OB quality and patient safety unit at a large academic medical center in Northeast Ohio.
We looked retrospectively at drivers of adverse outcomes on the OB service line and the clinical conditions were the usual suspects that we've been talking about hemorrhage, hypertensive disorders of pregnancy, HIE, and severe neurologic injury, shoulder dystocia. But a closer look revealed that most of these cases were either the result of lack of situational awareness. Just not knowing about that problem until it was too late or improper clinical decision making.
And so when we stepped back and looked at the system, we said, well, wouldn't it be great if we had a technology ideally one that would integrate with our electronic medical record that could alert us in real time to patients who are developing high-risk conditions, thereby elevating the situational awareness of those patients. And a technology that could also automate access to and delivery of our patient care guidelines.
So, we think of technology really as a safety net, as a complementary tool to the other tools that Lori was describing to the tool kits and the safety bundles. We have technology safety nets in so many other industries. Why don't we have them on labor and delivery?
One more point I'd like to make about technology. We can imagine using technology to create remote monitoring hubs. You all have maybe heard of the e-ICU. Well, think e-labor and delivery where from a remote monitoring center-- a remote monitoring hub-- nurses, advanced practice providers, even physicians can monitor patients at rural and critical access hospitals, providing guidance to teams taking care of patients in those settings and assisting with transfers of care where necessary. So, I see technology not just as a safety net for current systems, but as part of what it will look like to design the labor and delivery of the future.
LORI ADAMS: Steve, I think that's a really good point because what we're seeing is women who have to travel 30 minutes or 60 minutes to go to the doctor miss prenatal appointments. And we know significant things can happen at a single prenatal appointment. So, giving them the option to bring the care to them will really increase equity across all moms out there.
JOAN PORCARO: Thank you. I appreciate your thoughts on the issue of technology. I know that we're all looking forward to see where some of the newer advances in technology are going to take us. And we all agree that we want it to help us create a safer environment. And at this particular point, we're coming to a close on our session. And I always ask my guests what is one takeaway point you'd want to leave with the listeners?
Lori, do you want to start first?
LORI ADAMS: I think obstetrics is unique in that it's the one time where you're taking care of two patients. And it has a very emotional component because when parents get pregnant, they spend their entire pregnancy with visions of their labor and delivery experience and taking the baby home. For them, a perfect baby is the expectation. For us, the perfect outcome is our mission.
When unexpected obstetrical events happen, they're deeply emotional for everyone involved. No one comes to work wanting to harm someone. But at this point, we are failing our mothers. We are failing our parents. And we really, really have to step up and do better.
JOAN PORCARO: Thank you, Lori. Dr. Porter.
STEPHEN PORTER: Thank you, Joan. The numbers are clear. We have an appalling public health crisis at the moment. We have unacceptably high levels of maternal morbidity and mortality. And it's important that we stay focused on that problem. It's equally important that we recognize the solutions that are out there. Solutions that are available to hospitals now, to hospitals, to labor and delivery teams, to quality departments that are looking to manage their perinatal risk. So while there is an exorbitant problem and like any complex problem, it will take multifaceted solutions, we do have solutions available now, and let's use them.
JOAN PORCARO: Well, I want to first thank Dr. Steve Porter for joining us today.
STEPHEN PORTER: Thank you so much, Joan. It's been a pleasure.
JOAN PORCARO: And as always, Lori, I appreciate your time and expertise. Thank you also for joining us today.
LORI ADAMS: Thank you so much, Joan. It was really wonderful to be here today and talk about this important topic.
JOAN PORCARO: And in closing, I want to thank our audience. And those who have tuned into our discussion, I hope you will be joining us for future podcast discussions in the coming weeks and months. And again, thank you for listening to our podcast WTW Vital Signs.
SPEAKER 2: Thank you for joining us for this WTW podcast, featuring the latest thinking on the intersection of people, capital, and risk. WTW hopes you found the general information provided in this podcast informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors.
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