The first time Stacey Holman, MD, asked her colleagues to weigh the amount of blood lost during the delivery of a baby, it did not go well. Measurement, instead of eyeballing an estimate, is backed by research and is a best practice to reduce hemorrhage during births.

“There was a lot of push back,” said Holman, an ob/gyn at Touro Infirmary, a birthing hospital in the LCMC Health system in New Orleans. “Clinicians felt they were pretty good at” coming up with an estimate.

Despite knowing that weighing blood was the evidence-based standard for accuracy, Holman could not persuade her staff to adopt the practice until her hospital joined the Louisiana Perinatal Quality Collaborative.

“This was a major change to say we can’t just eyeball [blood loss] anymore. We need to actually measure it. We need calibrated drapes,” Holman said. “All of those things were additional pieces that the hospital had to buy into. The nurses had to be educated on, and then the doctors had to agree.”

Holman’s hospital was one of the 31 birthing hospitals across the state of Louisiana to participate with the collaborative.

While best practices abound on how to anticipate, treat, and prevent hemorrhage and hypertension during labor, a how-to guide for implementation is often missing, said Veronica Gillispie-Bell, MD, MAS, the medical director of the Louisiana Perinatal Quality Collaborative and ob/gyn at Ochsner Health in Kenner, Louisiana.

Gillispie-Bell led a study of the implementation of the initiative to reduce severe maternal morbidity related to the two conditions, which had been identified in Louisiana as the leading causes of the death of mothers due to pregnancy.

Between the start of the initiative in 2016 and the end of the study period in 2022, the morbidity rate for hemorrhage decreased by 39% across the hospitals from 1162.4 per 10,000 births to 709 (P < .05). The rate for hypertension decreased by 35.4%, from 847.5 per 10,000 births to 547.2 (P > .05), according to the findings published in Obstetrics & Gynecology.

Long-Term Improvement

The collaborative worked with hospitals on three areas to better flag patients who needed earlier intervention. Clinicians started a risk assessment for hemorrhage when patients were admitted to the hospital. And whether a vaginal or cesarean delivery, clinicians weighed blood loss using a scale and equation.

Hospitals also set the goal of providing treatment for severe hypertension within 60 minutes of a sustained high blood pressure reading. Clinicians also received training on implicit bias for racial disparities and improving communication.

Before the start of the intervention, the amount of blood lost during a delivery was only measured 37.4% of the time but increased to 94.3% at the end of the study period.

Timely treatment of hypertension occurred in 71.8% of cases before the start of the study and increased to 80% by the end.

Disparities between Black and White women also narrowed. For outcomes related to hemorrhage, the disparity ratio between the two races dropped from 2.2 in 2016 to 0.88 in 2022.

Gillispie-Bell noted that the impact on Louisiana’s overall maternal mortality remains unclear as statewide data for 2020 through 2022 has not yet been released.

Implementing Strategies

In the absence of formal hospital processes, clinicians can partner with their nursing and surgical staff to ensure every patient receives a standardized hemorrhage risk assessment, Gillispie-Bell said.

Holman said that her hospital also authorized nurses to report high blood pressure readings directly to on-site clinicians. This allowed for immediate medication orders rather than waiting to reach the patient’s primary obstetrician, who was often off-site or occupied with another delivery.

Although individual clinicians can take some lessons from this research and apply it to their practice, lasting change is much more likely to come when hospitals work with statewide collaboratives, said Ann Borders, MD, a maternal-fetal physician at Endeavor Health in Illinois and the executive director of the Illinois Perinatal Quality Collaborative.

“When it’s an ob leader or a nursing leader who’s trying to think about how to get all of the systems in place, it’s possible but it’s hard,” Borders said. “That’s why evidence-based practices oftentimes take time to go through and get in place. Because it can be hard to get all the systems you need in place, all the education you need in place.”

Gillispie-Bell reported receiving grant funding for this research from the CDC and the US Department of Health and Human Services. Holman and Borders reported having no relevant financial disclosures.

Kelsey Mesmer, PhD, is a freelance journalist and journalism professor at Saint Louis University in St. Louis.