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A physician describes how using improvement skills helped her team improve maternal health in their rural community.
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Lessons Learned about Reducing Maternal Mortality in Rural Settings

By Angelo Lima | Tuesday, April 2, 2019

Rural health care providers all over the world share a devotion to caring for patients who are also friends, neighbors, and family members. While coping with limited staff and resources in isolated areas can be challenging, living and working in tightknit communities also means getting the satisfaction of seeing the results of one’s dedication to patient safety on a regular basis.

This is what Daniela Contage Siccardi Menezes, OB/GYN, found when she decided to focus her efforts on improving maternal mortality at one of the hospitals she oversees as the Quality and Patient Safety Regional Manager for the Associação Congregação de Santa Catarina, the hospital association in Brazil. The Hospital de Clínicas Nossa Senhora da Conceição (HCNSC) is in the rural part of Rio de Janeiro, approximately 80 miles north of the state’s capital. The hospital is staffed by almost 500 employees who serve over 100,000 community members. Its maternity ward is the only one serving the population of Três Rios and the surrounding municipalities. Like many hospitals in rural areas of Brazil, HCNSC is underfunded and understaffed, so staff often find it challenging to take active steps towards quality improvement, but Menezes was determined not to let a lack of resources get in the way of improving care for the community. 

Drawing upon her experience from working with IHI on the Salus Vitae patient safety initiative, Menezes shares (with the assistance of IHI project coordinator, Angelo Lima) how a resource-constrained organization got results and brought life-changing improvements to their community.

On the Need to Focus on Reducing Maternal Mortality

The Hospital de Clínicas Nossa Senhora da Conceição was first added to my portfolio in September of 2017. My first order of business was to assess the hospital’s quality and patient safety. As with any health care setting, I came across plenty of opportunities for improvement, but the one that was keeping me and my team awake at night was the high rate of maternal deaths.

Our maternity unit is only meant to care for low-risk pregnant women, but there are no nearby hospitals who care for high-risk pregnant women, and the hospitals in larger municipalities are often overcrowded. Consequently, our maternity unit becomes the only choice for many high-risk expectant mothers. 

After looking through the data, I found that 10 women had died in our maternity unit in 2017. As I began to study in detail each of the cases, I found that the common thread across all cases was a delay in identifying the severity of risk in each patient.

When I entered this data into a run chart, I was able to see that our hospital had 33 days between each of the 10 deaths in 2017. This means almost one maternal death every month. The data showed me where I needed to focus my efforts. 

The name we chose for our project was “Maternidade Segura.” This roughly translates to “safe maternity.” My original calculations showed me that our hospital’s maternal mortality rate was 519 maternal deaths per 100,000 live births. This number becomes even more alarming when compared to the national maternal mortality rate for Brazil. It was 70 maternal deaths per 100,000 live births at the time.

On Getting Leadership and the Right Team on Board

After I identified the issue, I prepared the data so I could approach the hospital’s leadership and lay out my case. I appealed to their hearts by showing them the evidence of avoidable deaths of 10 women and mothers who should have returned home to their families. I explained that I wanted to start a quality improvement project and asked them to allow me to put together a team to work with me.

Once I got permission to start the project, I identified staff members who showed an interest in quality improvement. This was important because I only spent about one day per week physically present at this hospital. There were some weeks I was unable to visit the hospital at all. I had to make sure I organized a team of people who welcomed change and who would be proactive about quality improvement.

On the Changes That Were Key to Success

  • Start with staffing and training — We had to address the fact that we had three nurse technicians on staff who worked weekdays from 8:00 AM to 5:00 PM on the maternity ward. On nights, weekends, and holidays, the maternity ward only had two nurse technicians.We needed to increase capacity and hire more staff, but making that change would take time and money. What could we do in the meantime? We decided to train and equip the one registered nurse and all the nurse technicians to identify high-risk patients using the Maternal Early Warning Score (MEWS) and put protocols in place to guide next steps once a high-risk patient was identified. We trained the nurse to use the SBAR tool to communicate with the doctors and their teams when she identified a high-risk patient. We also trained all other members of the team to do the same.
  • Create a designated intake room — We also needed a room where we could receive patients and assess their risk score. We found a spare room and identified the tools we needed — such as thermometers and blood pressure meters — which were scattered all over the maternity ward. We organized them in one accessible space and created an intake room.
  • Work as a team — We strategized together about how to use the resources we already had. We made sure that all staff had access to what they needed. We made “the right thing to do” the easy and obvious choice for staff. We put protocols in place to guarantee that staff would be able to anticipate complications.
  • Standardize good care — We made risk assessment a standard process. All patients were evaluated and had their MEWS scores assessed during their intake process, and routine checks were performed by the nurse technicians every six hours following admission to the maternity unit. If the nurse technician identified a high MEWS score, they followed a standard communication protocol to signal the nurse and the doctor using the SBAR tool. Once the doctor received the communication, they address the patient’s needs or, if necessary, had the patient transferred to the nearest ICU.
  • Provide daily feedback — We measured adherence to patient assessment and provided the team with daily feedback. We didn’t do this at the beginning of the project, but after a few PDSA cycles of providing weekly feedback, we realized that feedback was needed more often. We had daily team huddles — which were sometimes conducted using a social networking app — as it became clear that it was important for us to go over what worked well and what didn’t work and why every day.

Most of our improvement ideas did not put any financial burden on the hospital. We eventually hired two more registered nurses. This allowed us to make sure we had one nurse to cover the day shifts, one to cover the night shifts, and one to cover weekends and holidays.

On Setting and Surpassing Goals

We started the project on December 1, 2017. It was scheduled to run until November 30, 2018. The original goal was to bring our maternal mortality rates down to the national rate. Instead, we went 371 days without any maternal deaths. (Unfortunately, one woman died because of surgical complications during her postnatal period.) Our next goal is to go another 1,000 days without another maternal death.

One Family’s Story

We went 200 days into the project without any maternal deaths. The staff was happy and morale was high. We were about to celebrate our success to date when a patient named Ana (not her real name) was admitted. She was in grave condition, but we didn’t give up. We followed our protocols and, after some time, we were able to revive her, stabilize her condition, and transfer her to the nearest ICU. Ana and her healthy newborn twins returned home safely to their family.

Três Rios is a very small town. Since this is the only hospital in the area, hospital staff frequently run into patients at places like the grocery, get to know them, and sometimes even develop friendships with them. Ana was someone who bonded with the staff. She and her family celebrate the twins’ birthday every month, and hospital staff are always invited to the event!

I always think about the women who did not make it home to their families, the husbands who are raising their children as single fathers, and the children who won’t ever get to know their mothers. Ana’s story could have been a very sad one. Instead, she is living proof of the importance of our work.

Editor’s note: This interview has been edited for length and clarity.

Angelo Lima is an IHI Project Coordinator.

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