Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.
With a seminal article presented in the Lancet less than 25 years ago, Allan Rosenfield and Deborah Maine galvanized the international public health movement to reduce maternal mortality and improve maternal health. Inspired by their message and their legacy, we recently published a call to action for an organized, national approach to decrease maternal mortality and morbidity in the United States.
Although maternal death is rare in the United States, particularly in comparison to the developing world, maternal mortality has not decreased for 3 decades. There continue to be dramatic disparities in health care outcomes–including marked differences in maternal mortality rates–between different socioeconomic and racial groups. Moreover, severe maternal morbidity is a much more prevalent problem than maternal death, affecting tens of thousands of women each year.
Maternal mortality and morbidity rates may even be rising due to a number of reasons. Delaying childbearing and assisted reproductive technology has allowed more women of advanced maternal age to conceive. Obesity has also become a national epidemic and is responsible for increasing rates of hypertension, diabetes, and other chronic diseases affecting pregnancy. The rising cesarean delivery rate has increased the incidence of placenta accreta, a diagnosis associated with a high risk of postpartum hemorrhage and need for postpartum hysterectomy. Recent advances in medicine have also made it possible for women with relatively rare but serious medical conditions, including congenital heart disease, genetic conditions such as cystic fibrosis, transplanted organs, or a history of malignancy, to consider pregnancy. It may even be argued that the lack of universal, comprehensive medical care in the United States affects the baseline health status of women with chronic medical conditions and their subsequent pregnancy outcomes.
Meanwhile, there have been changes in the practice of maternal-fetal medicine (MFM). MFM was established as a subspecialty in the 1970s for physicians focused on the treatment and prevention of medical and surgical complications of pregnancy. In many areas of the United States today, generalist obstetrician-gynecologists, laborists, or other obstetrical providers continue to primarily manage the labor and delivery (L&D) process. Despite the original focus of MFM specialists, there has been an increasing trend in relying on medical subspecialists to treat chronic disease or medical complications in obstetrical patients, and increasing involvement of gynecological oncologists or other surgical specialists to assist in advanced obstetrical surgery. This reliance on nonobstetrical specialists excludes MFMs from many aspects of maternal care.
This shift may be occurring in part because of the increasing popularity of outpatient, consultative MFM practice. Certainly that form of practice offers predictable hours and a greater potential for part-time employment. There is also a vast reimbursement differential between providing obstetrical ultrasound services and providing care for women with significant medical problems, exemplified by the relative time and effort requirements of each, and a marked disparity in the medicolegal burden between outpatient and inpatient services. A recent survey of generalist obstetrician-gynecologists reported that 31% were not satisfied with the MFM services available to them, citing lack of MFM availability, unwillingness of MFM specialists to care for hospitalized patients, and limitation of MFM services to ultrasound and diagnostic procedures among their reasons.
We believe that it is the responsibility of MFM subspecialists to lead the effort to decrease maternal mortality and morbidity in this country. To accomplish this goal, we must engage all obstetrical providers and trainees across the country. In so doing we also hope to reestablish the vital role of MFM subspecialists in the performance and coordination of care in complicated obstetrical cases. Toward this effort, the American Board of Obstetrician Gynecologists (ABOG) sponsored a meeting with participation from the American Congress of Obstetricians and Gynecologists (ACOG), the Society for MFM (SMFM), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) at the annual meeting of the SMFM in Dallas, TX, in February 2012 to: (1) enhance the education and training in maternal care for MFM fellows; (2) improve the medical care and management of pregnant women around the country; and (3) address the critical research gaps in maternal medicine. This article will summarize the initial recommendations for each of those objectives.
Education and training
The fellowship in MFM began as a 2-year program after completion of a 4-year residency in obstetrics and gynecology. In 1996, the fellowship was extended to 3 years, to augment the research component. Currently the ABOG requires fellows to spend a minimum of 12 months on clinical rotations and 18 months on research activities with 6 months’ time designated by the program director for elective activities.
Over the past few decades, however, there have been significant changes in the practice of medicine and residency training in virtually all of the clinical specialties. With the many recent advancements in medical science–the sheer volume of medical research, the accelerating adoption of technology in medicine, the drive toward subspecialization across disciplines–there is no question that the breadth and depth of clinical expertise required of the MFM physician has expanded.
More recently, restrictions on resident and fellow duty hours have increased. In addition to the 80-hour work per week rule instituted in 2003, there is a new limitation to 16 hours per day as the maximum duration of duty for interns. Certainly the goals of such restrictions are valid: to reduce medical errors as a consequence of practitioner fatigue and to improve the quality of life for our physicians in training. However, in essence, there is more to learn in less time. An unintended consequence of work-hour restrictions may be a decrease in the knowledge base, clinical skills and preparation for practice, or advanced training after residency. To respond to these trends, we suggest that ABOG modify the MFM fellowship requirements to include: 18 months of clinical rotations, 12 months of research, and 6 months of elective time. In addition, to enhance training in obstetrical complications and maternal medicine, formal rotations on L&D and in an intensive care unit (ICU) should be required. More specifically, fellows should complete a minimum of 4 months of L&D/inpatient services and 2 months of ICU rotations. Fellows on both of these rotations should actively participate in patient care and resident education as well as fulfill on-call requirements. Only direct, hands-on patient care and responsibility will lead to the knowledge base and experience with obstetrical and critical care complications necessary for MFM physicians. Because serious pregnancy complications are low frequency events, the program must be structured to allow enough time on obstetrical services and ICUs to gain adequate exposure to these relatively rare patients.
ABOG has already responded to the above requests and has recently modified the MFM fellowship requirements to include 15 months of clinical rotations, 12 months of research, and 9 months of elective time. Fellows must now complete 2 months of L&D/inpatient services and a 1-month ICU rotation. These changes will be put into effect in July 2013.
Expanded rotations will certainly increase the exposure of MFM fellows to obstetrical complications and critical care medicine, but there is no doubt that formal rotations alone will not provide the depth of fundamental knowledge and expertise to manage the range of maternal complications necessary for MFM practice. Therefore we offer a number of other suggestions to enhance fellowship training.
It has become clear that it is possible to improve upon the traditional model, combining apprenticeship and didactic education. Both simulation sessions and case-based learning methodologies have been exciting developments in medical training. There are limited data on whether simulations improve clinical training or reduce adverse obstetrical outcomes, but in 2006, Draycott et al demonstrated that simulation training in obstetric emergencies significantly reduced the rate of neonatal hypoxic ischemic encephalopathy. A systematic review of simulation for obstetrical emergencies has also showed that team training resulted in improvement of knowledge, practical skills, communication, and team performance in acute obstetric situations. MFM fellowships should invest more time in simulation programs and case-based learning to educate their trainees in maternal medicine, as well as to collect data on the effectiveness of these learning strategies.
Active certification in advanced cardiac life support (ACLS) should also be required for MFM fellows. The goal is not to earn a piece of paper representing class attendance and passing an examination, but that ACLS principles are reinforced in an ongoing manner through the ICU experience. Simulation of ACLS scenarios for obstetrical patients is an excellent way to maintain this expertise.
The yearly in-service examination administered by the Council on Resident Education in Obstetrics and Gynecology is used to assess the knowledge base and individual progress of obstetrics and gynecology residents, as well as the overall performance of the residency education program. A similar examination for MFM fellows should be developed. While the expense of such a program may limit the ability to administer it yearly, such an evaluation would allow fellowship programs to track the clinical progress of their fellows as well as the attainment of their own education goals. Such a program would allow ABOG to assess the impact of various education initiatives around the country.
The Guide to Learning in Maternal-Fetal Medicine published by ABOG in 2007 is a comprehensive document listing all the appropriate educational objectives for expertise in obstetrical complications, maternal medicine, and critical care. We believe that MFM programs must ensure that their fellows are meeting these expectations. Those programs should also inspire our fellows to pursue careers that include the care of inpatient obstetrical patients and critically ill mothers. The MFM physician will no doubt be part of an interdisciplinary team caring for these patients, with medical subspecialists, anesthesiologists, intensivists, and surgeons, among others. Their expertise in the physiologic changes that accompany pregnancy and depth of knowledge of the potential impact a maternal disorder and its treatment during pregnancy might have on the fetus uniquely equip the MFM specialist to lead such a team.
Toward that end, MFM fellows should receive training in leadership skills. This may be accomplished through formal leadership courses. However, MFM fellows should also participate in quality assurance committees in their departments or hospitals and should be required to conduct a quality initiative project during their fellowship. For example, MFM fellows may be asked to develop simulation models and lead simulation training for obstetrical emergencies such as shoulder dystocia, postpartum hemorrhage, or eclampsia.
To train MFM fellows in the management of medical complications of pregnancy and obstetrical critical care, each fellowship program must enlist faculty members with expertise in these areas. These faculty members would spend most of their time managing medical conditions and complications, both inpatient and outpatient. They should also act as consultants to other MFM practitioners who may have other areas of expertise, and lead the teams that focus on practice guidelines, and safety and quality issues relating to maternal medicine within the department. This would not be much different than the current situation in most MFM divisions where ≥1 physicians are the experts in prenatal diagnosis and therapy. Given the reimbursement structure for maternal medicine, such MFM specialists will likely require departmental or divisional support to devote their attention to clinical practice, education, and research in maternal medicine. Departments wanting to have a MFM fellowship program would have to ensure this type of support, which will provide role models for the MFM fellows and employment options for faculty who opt to utilize their maternal medicine skills after completion of fellowship training. Not all MFM fellowship programs have faculty with extensive expertise in critical care medicine. However, all programs should develop a written plan to manage care for critically ill obstetrical patients in concert with intensivists. Such a plan will identify the faculty members who will be directly responsible for training MFM fellows on their ICU rotations as well as facilitating coordination of care for these patients.
Recommendations for improving education and training programs in MFM are summarized in Table 1 .
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Obstetrical care and service
To effectively combat maternal mortality and morbidity, it is clear we must take a 2-pronged approach. The group of women who are at highest risk for serious maternal complications during pregnancy or who develop complications during their pregnancies and require advanced maternal care must be referred to an appropriate tertiary care institution in a timely manner. However, many of the most common causes of maternal death, such as hypertensive disorders, hemorrhage, and pulmonary embolism, affect seemingly low-risk obstetrical patients. Decreasing maternal mortality overall requires a comprehensive, national effort to educate all obstetrical providers on the prevention and treatment of those disorders, as nearly 58% of hospitals providing obstetric services in the United States operate small- to medium-volume units with <1000 births each.
The concept of regionalized perinatal care was first proposed in Toward Improving the Outcome of Pregnancy (TIOP), a 1976 March of Dimes report published by the Committee on Perinatal Health. This publication stratified maternal and neonatal care into 3 levels of complexity and recommended referral of at-risk patients to centers with the personnel and resources appropriate for their care. TIOP: the 90s and Beyond, known as TIOP II, reaffirmed the importance of a strong regional perinatal health system and provided initial guidelines for the maternal care functions appropriate and required at each level.
Designation of neonatal ICUs (NICUs) as level I (basic), level II (specialty), and level III (subspecialty) was rapidly adopted by national and state agencies in the 1980s. Over the next several decades the neonatal community gathered data that support continued use of these levels of care designations. Nearly all of those studies demonstrated decreased neonatal morbidity and mortality for very-low-birthweight infants born at a facility offering subspecialty care. The American Academy of Pediatrics published the latest definitions for levels of care in 2004 and summarized the evidence to support their recommendations in that document.
Unfortunately the initial concept of regionalized “perinatal” care has become synonymous with regionalized “neonatal” care and has been dissociated from complex maternal care. The priority became transfer of women at risk for delivering preterm neonates, whose care requirements fell outside the scope of their primary institution. In addition to the shift in focus to neonatal care, it has been erroneously assumed that each institution with level III NICU capabilities will be equipped to care for any maternal medical condition, but this is not necessarily the case.
Obstetricians and MFM subspecialists must follow the lead of our neonatal colleagues and establish a stratified system for maternal care. There is every reason to assume that such a maternal care network will benefit complicated maternal patients and lead to improved obstetrical outcomes. We envision a system that is complementary to, but separate from, the NICU level of care designation, based on a particular institution’s ability to provide expertise, facilities, and staffing to care for complicated maternal patients. The centers with the highest level of maternal care would not only act as a referral hospital, ie, simply accepting the transferred patients, but would also assist with patient quality and safety improvement initiatives at the referring centers.
Ideally, a single entity would designate these levels of care at the national level rather than separate designations by each state’s health departments or other agencies. Centralization would facilitate the creation of consistent definitions and standards of service for each level in the system. Consistency across levels would be more informative and useful for community physicians and patients making health care decisions. Adopting a uniform nationwide approach would allow more useful comparisons of outcomes, resource utilization, and cost among and between levels. Standardizing levels of care would also improve the economics of recruiting and retaining experts in maternal medicine and allow referral centers to develop an adequate clinical load for resident and fellow training.
We must also work to improve the quality of care at all institutions that deliver maternal care to decrease maternal morbidity and mortality. This effort may have even more impact than transferring complicated patients to advanced maternal care centers. In an article describing strategies for reducing maternal mortality, Clark described several principles of patient safety that should be applied to all obstetrical services, including: (1) the elimination of variability in the provision of care through the development of standard protocols, and (2) reliance on checklists instead of memory for performance of critical procedures.
Although many educational materials address patient safety, more proscriptive guidelines that emphasize these principles may be useful. Although there are often numerous, reasonable approaches to treatment of various medical conditions, broader use of specific guidelines may reduce medical errors and decrease the fraction of preventable maternal deaths. Many different hospitals and hospital systems now generate their own clinical practice guidelines, which are often based on ACOG bulletins. Creating more national standards, similar to the Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B streptococcus disease, could eliminate this local redundancy of effort while elevating the standard of care across the country.
The United Kingdom instituted a national confidential enquiry system into maternal deaths >50 years ago, now issued as a report, “Saving Mothers’ Lives,” published every 3 years. The goal of this system is to identify remediable factors and to address them in recommendations and guidelines drafted by the Royal College of Obstetrician Gynecologists and National Institute of Health and Clinical Excellence. Their data have shown a significant decrease in the rate of death from thromboembolism. Death from that disorder initially fell in the late 1990s, after publication of the thromboprophylaxis following cesarean delivery report. But an even sharper decline in deaths was seen after introduction of a guideline for prophylaxis during pregnancy and following vaginal delivery. These compelling data confirm that adherence to evidence-based guidelines can save lives.
We believe that national management guidelines for the United States are urgently needed for the following disorders:
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Hypertensive Disorders in Pregnancy.
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Postpartum hemorrhage.
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Prevention of venous thromboembolism in pregnancy and postpartum.
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Diagnosis and management of placenta accreta.
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Management of the obese obstetrical patient.
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Management of cardiac disease in pregnancy.
We continue to believe that the MFM physician plays a critical role in the care of the medically compromised obstetrical patient. That role should not be relinquished to general medical subspecialists or surgeons. While medicine is increasingly moving in an interdisciplinary direction, the MFM specialist should be the expert on all medical and surgical complications as they relate to pregnancy and to the fetus. However, to be a key member of the care team for complicated maternal patients, as the primary provider or consultant to the general obstetrician, MFM physicians must be readily available for inpatient service.
MFM physicians should increase their role in inpatient care because the provision of this care is an integral part of MFM practice and will improve the well-being of high-risk obstetrical patients. With our proposed initiation of maternal levels of care, MFM specialists will be expected and uniquely positioned to provide the sophisticated care needed at institutions where they practice, while assuming leadership, educational, and supervisory roles as medical directors. MFM specialists should be expected to work alongside laborists and generalists as key team members in the delivery of high-risk maternal and fetal care. To recruit and retain physicians in this role, there must be appropriate compensation for the time spent providing the advanced supervision and regional hospital coverage. Medical directorships with stipends to manage inpatient care alongside laborists or generalists, or to directly provide care, is a way to compensate MFM specialists for this role. Known benchmarks for MFM directorships are available from several sources. Reimbursement for inpatient care can be improved through proper coding of this activity. Many practicing MFM physicians would benefit from obtaining further skills in reimbursement and coding via well-recognized courses. SMFM has several of these courses as well as a coding subcommittee that can assist in optimizing documentation for appropriate coding. Hospital administrators must also recognize the impact that availability of MFM specialists has on their volume of neonatal admissions. Beyond financial compensation, academic advancement should be considered for the performance of a MFM inpatient directorship role. Finally, MFM specialists should seek education on practice management and leadership to fulfill the roles they will increasingly assume.
While there are many outstanding centers for multidisciplinary fetal care across the country, there are no current models for comprehensive maternal care. It is unclear what the ideal model would look like, or if there are multiple blueprints for care that may vary by hospital system or region. However, these models should all incorporate the following components: (1) preconceptional counseling for women known to have significant medical problems; (2) consideration of referral vs comanagement options, particularly in regards to the optimal delivery institution; (3) promotion of management guidelines to care for maternal patients with significant medical problems; (4) communication between multidisciplinary care providers and discussion of complex cases at regular multidisciplinary case conferences; (5) data collection on short-term and long-term outcomes; and (6) smooth transitions of care at the end of the pregnancy. Table 2 summarizes these recommendations to improve obstetrical care and service.
