Having a baby safely delivered without maternal, foetal or delivery complications has not always been a walk in the park. The occasional catastrophe of a mother or baby dying or being seriously injured tended to increase and intensify over the years.

In 1990, maternal mortality rate in the US was in equivalence with the rates of the Eastern European countries, which was just over one death in 10,000 births. However, it was double the rate in comparison with other developed countries like Canada.

The maternal mortality rate per 100,000 live births in 2008 was 24 in the US, compared with 12 in Canada, six in Japan and 12 in the UK, according to a 2010 World Health Organisation report. Additionally, the number of infants who died during the first year of life was seven per 1,000 live births in 2009 in the US, compared with five in Canada, five in the UK and two in Japan, according to the World Bank.

Many guidelines on improving quality have been published by the American College of Obstetricians and Gynaecologists, but the world of obstetrics did not quite catch up. There was no hurry to change something that has been working in the past, albeit the results. Enter Dr Steven Clark, who made the leap to close the gap in the numbers of maternal mortality rates in the last decade.

The birth of Clark’s evidence-based approach

Steven Clark, an obstetrician and gynaecologist from Wisconsin, was taking care of poor and uninsured pregnant women in the late 1970s and early 1980s and gained his competency through the rare diseases he had the opportunity to witness and care for.

He later moved up the ranks at Intermountain Health System in Utah. There, he met Brent James, and through James’ patient-safety movement to get all doctors to treat patients with the same conditions the same way, had inspired Clark to do the same thing with obstetrics.

This was the birth of Clark’s evidence-based approach. The Hospital Corporation of America (HSA) which is the US’s largest private healthcare delivery system, would provide Clark with monthly data of birth units beginning in the late 1990s. He would find hospitals that were outliers and fly to the locations to review the hospital charts.

“One third of the time, the problem was poor-quality data; one third of the time there was a perfectly good explanation for the problem; and one third of the time there was something that needed to be fixed,” says Clark, who is now in the faculty of Baylor College of Medicine in Houston.

He made protocols such as the use of oxytocin

In trying to come up with an approach that works, Clark first quantified the problems and allowed doctors and nurses to go through their own data. The next step was to involve local influencers, such as the head of department at the local hospital. Then, the intervention was crafted and iterated when the problems arise. Finally, the doctors were given the choice to opt out in certain cases.

Among Clark’s notable protocols that he made was the standardisation of the use of oxytocin. He wrote the protocol down and had others follow it, to eliminate the dangers of what high dosage of the medication could do instead of the norm of helping the uterus contract during labour.

Clark also recommended standardising the use of inflatable leg cuffs on women undergoing caesarean sections to prevent pulmonary embolisms. Numbers of loss due to the embolism dropped to only one in six years following his recommendation, compared to seven in the last seven years.

Consistency helps mothers and babies

Starting from 2004 onwards, Clark had standardised many obstetric practices including outlines on handling common and also at times, dangerous medications. Together with his colleagues, Clark managed to lower the maternal mortality rate to just 6.4 deaths in every 100,000 live births, which was half of the national average.

Concurrently, the number of lawsuits and litigation costs also decreased significantly. Many of his approaches and recommendations became the standard care in the US.

The maternal mortality rate in the US remains to be high when compared to other wealthy countries. However, the mitigation exercises are in place to avoid the rare disastrous case. Research has also proved Clark’s hunch; consistency helps mothers and babies. MIMS

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