Creating a Culture of Safety and Quality for Mothers and Babies

There has been a quiet evolution taking place in the obstetric (OB) world involving UConn Health, but it’s about to get much noisier as new practitioners get settled and word gets out in the medical and patient communities reasserting UConn Health’s reputation as the preeminent hospital and regional resource for prenatal care, labor and delivery, and postpartum services.

Molly A. Brewer, DVM, MD, MS, and chair of the Department of Obstetrics and Gynecology at UConn Health, has been guiding the department’s growth and transition toward creating a comprehensive center of excellence for women’s health, embracing the triad of quality patient care, education and research.

“Our mission is to ensure extraordinary, quality- and safety-focused patient care, with a wide range of services that are performed efficiently, seamlessly and cost effectively,” explains Brewer. “Our focus is on enhancing safe delivery for mother and child, educating our various constituencies, reducing or mitigating emergencies, and ensuring that we can make a difference in our patient’s health and wellbeing throughout their lives.”

That challenge includes ensuring an array of preventative and best-practice OB/GYN services, with particular focus on labor and delivery quality, and emphasis on postpartum care, an area where America lags.

Addressing maternal morbidity in the United States

The maternal mortality numbers in the United States tell a sobering story: As a nation, we rank near the top of the industrialized world in maternal mortality ratio, at approximately 18 per 100,000 pregnancies, representing 800 deaths annually.

Nationally, Black and American Indian/Alaska Native women are about three times as likely to die from a pregnancy-related cause as white women. The maternal death ratio for Black women (37.1 per 100,000 pregnancies) is 2.5 times the ratio for white women (14.7) and three times the ratio for Hispanic women (11.8).

Causes of death vary widely, with death from hemorrhage most likely during pregnancy and at the time of birth, and deaths from heart conditions and mental health-related conditions (including substance use and suicide) most common in the postpartum period. Typical mortality causes include cardiovascular conditions, infection or sepsis, cardiomyopathy, hemorrhage, thrombotic pulmonary or other embolism, and cerebrovascular accidents.

But issues also driving maternal mortality include racial disparities in quality of care, lack of education for pregnant women and their partners, limited or inconsistent access to providers, cultural barriers, misinformation and a dearth of appropriate postpartum care.

Reducing maternal mortality through research, education and action

The Obstetrics, Labor and Delivery (L&D) and Maternal Fetal Medicine (MFM) teams at UConn Health work side-by-side to care for the obstetric patients in the ambulatory and inpatient setting.

Kathleen M. Zacherl, MD, maternal medical director for Labor and Delivery and assistant professor in obstetrics and gynecology, completed her residency at the UConn School of Medicine and joined the UConn Health faculty six years ago.

“I recognized the opportunity to help prepare our team and students for any contingency – our goal was, and remains, working toward achieving best-possible outcomes for every patient,” Zacherl says. “Molly [Brewer] was incredibly supportive and shared my commitment to strengthening our program, adhering to national standards, and creating a reputation as the best hospital in the region for having your baby and for maternal care.”

Zacherl and the L&D team have implemented new quality and safety protocols, including a protocol for women at risk of postpartum hemorrhage. Changes include faster access to blood supplies, medications and instruments, and multiple simulations involving the full array of providers needed in an emergency.

Other programs now in place include hypertension training to prevent or limit potential seizures and strokes, cardio-vascular interventions, and COVID-19 protocols. A major focus also has been reducing emergency or planned cesarean sections (C-sections), an area where UConn has seen tremendous success. The UConn John Dempsey Hospital has received high marks from The Joint Commission, a U.S.-based international medical accrediting organization serving more than 22,000 health care organizations, for reducing C-sections.

Additionally, the Leapfrog Group, a national nonprofit organization that reports on the safety and quality performance of U.S. health care facilities, in partnership with Newsweek magazine, creates a list of top-performing maternity hospitals. UConn’s John Dempsey Hospital was one of only three maternity hospitals in Connecticut to make the list.

According to Carrie Ferrindino, Labor and Delivery nurse manager, the current cesarean rate at UConn Health in 2020 was 19.75%, well below the national target set by the U.S. Department of Health and Human Services.  That, she adds, bests the most recent national average of 24.5% that was reported to the Leapfrog Group from participating hospitals.

Focus on operational and academic excellence, and community outreach

The MFM team recently added three new physicians, greatly expanding and strengthening community outreach, operational services and academic training capabilities. Andrea D. Shields, MD, MS, and Richard K. Wagner, MD, worked together at Baylor College of Medicine in San Antonio and come from military backgrounds – Shields was in the U.S. Air Force, and Wagner in the U.S. Army. The third new physician, Shontreal M. Cooper, MD, is an active U.S. Army member.

Shields and Wagner met in San Antonio in 2016 through a mutual mentor, where they established their MFM practice and worked together to build a successful OB/GYN department with 22 physicians and genetic counselors. In Farmington, Shields is focusing on academics and research, and Wagner on strengthening UConn’s operational foundation and patient services.

“I knew UConn’s clinical and academic reputation; the opportunity to help develop and direct the School of Medicine’s MFM fellowship program was a really attractive proposition,” Shields says. “I talked Rich (Wagner) into joining me – he’s an operational powerhouse, and we work well together. We knew we could help craft and operationalize a modern academic and clinical MFM program, working with Dr. Stephanie Bowers, the division chief for obstetric services at UConn Health, and her OB team in the ambulatory setting.”

Shields, who earned her master’s degree in clinical investigation and transactional science, is running the MFM fellowship and boosting research in maternal quality and safety, strengthening their research program by improving dissemination of their work at regional and national meetings, and through manuscript publications.

Additionally, she is hoping to attract more funded research. As the principal investigator for an Agency of Healthcare Research and Quality (AHRQ) $1.9 million grant, Shields and a team of national experts are creating a multi-disciplinary simulation course, Obstetric Life Support (OBLS), to teach first responders the correct techniques to use when responding to maternal cardiac arrest. The UConn John Dempsey Hospital will be the first hospital in the country to study this simulation program in a randomized trial.

Wagner echoes Shields’s philosophy of filling the gap that currently exists in full-service MFM health care, and the need to reduce MFM-related mortality. His charge, he says, is operational expansion, getting better known in local communities, providing support and educational opportunities for smaller hospitals serving more rural patients, and building UConn Health’s reputation as a regional destination for maternal quality and safety.

“We need to be known for having strong clinical functions for high-risk patients and excellent customer experiences to attract new clients and get the attention of referring physicians,” Wagner explains. “We are a resource for community providers and their patients, and want to be recognized for ease of access, prompt delivery of care, and efficient, fully integrated documentation processes.”

Community outreach and education are critical MFM components

Another essential component for helping pregnant women and reducing maternal and infant mortality is reaching out to communities of color and penetrating cultural, racial, socio-economic and educational barriers, says Cooper, who completed her MFM fellowship at UConn Health. Her personal goal is to focus on health equity, and to help close the “trust gap” between the community and physicians.

A strong social media advocate, she currently has more than 130,000 TikTok followers, works with the Connecticut Department of Public Health, and is involved in a reproductive justice program at Yale University. Utilizing social media tools, she explains, is a powerful way to navigate the mistrust and misinformation that exists in the community, and to provide accurate data and direction through a medium that people turn to regularly, even though much of the content they read is wrong, misleading or anecdotal at best.

Cooper also is spearheading an effort to train interested medical students as doulas, professionals who provide continuous physical, emotional and informational support to a mother before, during and shortly after childbirth. The first cohort of UConn medical students as doulas will be in place in 2022.

“We want to be seen by patients and referring physicians as the ‘go-to’ full-service maternal-fetal medicine center for ambulatory and inpatient needs,” Shields observes. “Connecticut already has one of the lowest MFM mortality rates in the country, and we are viewed as one of the top L&D hospitals. We are committed to making ourselves the safest place to deliver in Connecticut; the best way to do that is to become an integral player in the patients’ continuum of care, from pre-conception to postpartum. We see ourselves as the ‘orchestral conductors’ for specialized, high-risk delivery.”

Photography courtesy of UConn Health