PERS PE C T IV E
The Maternal Health Compact
Rur al He alth C are
The Maternal Health Compact
Susan Mann, M.D., Kimberlee McKay, M.D., and Haywood Brown, M.D.
I n a rural Minnesota town with
fewer than 5000 residents, an
18-year-old woman with a term
pregnancy goes into labor in a
hospital that performs about 75
deliveries per year. Her pregnancy
has been uncomplicated, but cho-
rioamnionitis develops during la-
bor and she undergoes a primary
cesarean delivery for arrest of de-
scent during the second stage of
labor. Her low-risk pregnancy has
become high risk a common
story for intrapartum obstetrical
care in any hospital, but one that
can have deadly consequences in
a hospital with fewer resources,
including a small staff and limited
blood-bank capacity. The woman
has a severe postpartum hemor-
rhage and loses more than 2 liters
of blood. She is given the usual
uterotonic medications and sur-
gical intervention with B-Lynch
suture placement, but they prove
ineffective.
The lone obstetrician in the
hospital is about to perform a
hysterectomy when she recalls a
conversation she had 2 weeks
earlier with the obstetrical medi-
cal director of her hospital system
about a program for team train-
ing and simulation for obstetrical
emergencies that was being of-
fered at her hospital. The direc-
tor encouraged the obstetrician to
reach out regarding safety con-
cerns and left a card with her
cell-phone number. Running low
on options, the obstetrician con-
tacts the director, who recom-
mends giving the patient a trans-
fusion from the hospitals very
limited blood supply. The direc-
tor then facilitates consultation
with Avera eCARE, a telehealth
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Copyright 2017 Massachusetts Medical Society. All rights reserved.
service that provides real-time spe-
cialty expertise to lower-resource
care settings.
The teams at Avera arrange
transport by helicopter to a terti-
ary care hospital in Sioux Falls,
South Dakota, a 20-minute flight.
The patient arrives 2 hours after
the initial call was placed, and
the telehealth specialists support
both the transporting-hospital care
team in stabilizing the patient for
transport and the receiving care
teams in intensive care and inter-
ventional radiology. The patient,
who was about to have a life-
altering and possibly life-threat-
ening hysterectomy, instead under-
goes a uterine artery embolization
and further stabilization in the
intensive care unit (ICU) and is
discharged 3 days later.
More than 60% of U.S. hospi-
tals that provide obstetrical care
perform fewer than 1000 deliver-
ies per year, or fewer than 3 a day.
A review of obstetrical outcomes
in 600 rural U.S. hospitals and
low-volume, nonteaching hospi-
tals lower-resource hospitals
revealed that they had higher
maternal morbidity than teach-
ing hospitals. The possible issues
identified in the lower-resource
settings included maintenance of
competencies and recruitment of
staff.1
In the United States from 1998
to 2008, delivery and postpartum
hospitalizations that resulted in
maternal mortality and severe
maternal morbidity increased by
66% and 75%, respectively.2 The
Centers for Disease Control and
Prevention and state departments
of health have recognized the
difficulty of obtaining accurate
n engl j med 376;14 nejm.org April 6, 2017
The New England Journal of Medicine
The Maternal Health Compact
data pertaining to severe mater-
nal complications and pregnancy-
related deaths owing to varied
definitions and reporting require-
ments. Even less information is
available regarding the setting in
which these cases occurred
urban versus rural and academic
centers versus community hospi-
tals. Rural health care centers
have been essential for patients,
but many of these smaller hospi-
tals have shut down their mater-
nity services.3 For a patient in
arural setting, frequent severe
weather and long distances may
impede access to a larger hospital.
Is it reasonable for these women
to drive for hours to get to a
larger medical center, or can we
do more to support obstetrical
practitioners in remote settings?
We believe that Averas ap-
proach can provide a model for
other parts of the country, where
a Maternal Health Compact could
be created linking lower-resource
hospitals with tertiary care hos-
pitals, with the goal of trans-
porting patients to the appropri-
ate facility when possible and
making care as safe as possible
locally when transport is not an
option. Telehealth services in ob-
stetrics can help to bridge the
gap in three ways: facilitating
transport of patients, supporting
care provided remotely, and assist-
ing in local quality-improvement
activities.
Under a Maternal Health Com-
pact, a tertiary care hospital pro-
vides services to its referring lower-
resource hospitals for high-risk
patients. Smaller hospitals also
benefit from increased collabora-
tions in which, for instance, the
PE R S PE C T IV E
tertiary care hospital runs simu-
lations of obstetrical emergencies
and assists with quality-improve-
ment activities such as implemen-
tation of hemorrhage-treatment
algorithms. Such collaborative
work can be done in person or
through telemedicine connections.
National efforts at improving
obstetrical care have stopped short
of addressing rare emergencies
that can occur in a lower-resource
hospital. In 2015, for example, the
American Congress of Obstetri-
cians and Gynecologists and the
Society for MaternalFetal Medi-
cine released the Obstetric Care
Consensus on Levels of Maternal
Care, which delineates criteria for
identifying women at consider-
able health risk (such as those
with placenta previa, placenta ac-
creta, or preeclampsia with severe
features) who should be cared for
at a hospital with appropriate
staffing and resources to avert
obstetrical complications and re-
lated deaths.4 Unfortunately, the
consensus statement does not ad-
dress the situation of an 18-year-
old with an unexpected severe
hemorrhage. Yet with better prepa-
ration and planning through a Ma-
ternal Health Compact, hospitals
could be ready for these crises.
Telehealth is already used in
many disciplines in which there is
a mismatch between patient needs
and specialty expertise, such as
dermatology, geriatrics, and men-
tal health, but to our knowledge,
there has been no telehealth
model for obstetrical care for an
acutely high-risk pregnant woman
in a lower-resource hospital. In
the case of the Minnesota patient,
a coordinated telehealth team in-
tervened quickly and effectively;
they worked with the rural hos-
pital to stabilize the patient, ar-
ranged transport, and prepared
the tertiary care hospital.
n engl j med 376;14 nejm.org April 6, 2017
The New England Journal of Medicine
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Through a Maternal Health
Compact, physicians and nurses
made available to lower-resource
hospitals through a video link can
help manage on-site obstetrical
emergencies. Physicians make rec-
ommendations regarding care,
while nurses support the nurse
in the field by documenting the
patients course and care in the
medical record and facilitating
communication with the local
pharmacy to obtain necessary
medications. The telehealth pro-
gram developed at Avera, for ex-
ample, houses under one roof a
variety of medical departments
ICU, pharmacy, emergency, and
others to provide continual
specialty care to partner care fa-
cilities. This kind of coordination
is invaluable to patients.
The development and imple-
mentation of national standards
supports the consistency of ob-
stetrical care. The National Part-
nership for Maternal Safety, an
initiative aimed at reducing ma-
ternal morbidity and mortality,
released a Consensus Bundle on
Obstetric Hemorrhage, in conjunc-
tion with the Alliance for Innova-
tion in Maternal Heath (AIM),
which recommended that all hos-
pitals that provide obstetrical care
develop a standard treatment
protocol for postpartum hemor-
rhage.5 The challenge for the
smaller, often rural, hospital has
been to determine what the pro-
tocol should be for a massive
transfusion when their blood bank
carries only a fraction of the blood
products considered essential for
most hemorrhage-treatment pro-
tocols. Lower-resource hospitals
need site-specific protocols for
managing the care of patients
with massive hemorrhage. The ter-
tiary care physicians who accept
transfers of such patients should
help identify resources available at
The Maternal Health Compact
the referring hospitals and partner
with them to create such site-
specific algorithms, including use
of emergency-release blood, fresh
frozen plasma, shock garments,
and tranexamic acid. The work-
flow for patients requiring trans-
port should be as efficient and
seamless as possible.
Pregnant woman in rural com-
munities cannot afford to lose
access to local hospitals; rather,
we need to make the care they
receive as safe as possible. Team
training and simulation of emer-
gencies are common tools of the
patient-safety movement, and elec-
tronic connectivity and broad
implementation of a Maternal
Health Compact are the next log-
ical steps for improving patient
care, retaining rural care facili-
ties, and recruiting and support-
ing practitioners in the field.
Disclosure forms provided by the authors
are available at NEJM.org.
This article was updated on April 6, 2017, at
NEJM.org.
From the Department of Obstetrics and Gy-
necology, Beth Israel Deaconess Medical
Center, Boston (S.M.); the Obstetric Ser-
vice Line, Avera Health, Sioux Falls, SD
(K.M.); the American College of Obstetrics
and Gynecology, Washington, DC (H.B.);
and the Duke University School of Medi-
cine, Durham, NC (H.B.).
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Chen I, Synnes AR, Lim KI. Maternal morbid-
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2. Callaghan WM, Creanga AA, Kuklina
EV. Severe maternal morbidity among deliv-
ery and postpartum hospitalizations in the
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1029-36.
3. Hung P, Kozhimannil KB, Casey MM,
Moscovice IS. Why are obstetric units in rural
hospitals closing their doors? Health Serv
Res 2016;51:1546-60.
4. Obstetric care consensus no. 2: levels of
maternal care. Obstet Gynecol 2015; 125:
502-15.
5. Main EK, Goffman D, Scavone BM, et al.
National Partnership for Maternal Safety
consensus bundle on obstetric hemorrhage.
Obstet Gynecol 2015;126:155-62.
DOI: 10.1056/NEJMp1700485
Copyright 2017 Massachusetts Medical Society.
The Maternal Health Compact
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