Identifying Racial Disparities Based on PA-PSRS Maternal Complication Reports: Limited Demographic Data Results in Inconclusive Findings
Data from the National Vital Statistics System reflect a maternal mortality rate for non-Hispanic Black or African American mothers that is 2.6 times higher than for non-Hispanic White mothers.1 Although the definition upon which the maternal mortality statistics are based differs in many ways from the definitions of reportable patient safety events in Pennsylvania, the Patient Safety Authority (PSA) sought to determine whether reports of maternal complications in the Pennsylvania Patient Safety Reporting System (PA-PSRS)† suggest a similar disparity.
We queried PA-PSRS for reports submitted between 1/1/2023 and 6/7/2024 under the event type/subtype Complication of Procedure/Treatment/Test – Maternal Complication (“maternal complications”). We also used the most current year of live birth statistical data available from the Pennsylvania Department of Health (DOH)3 for comparison‡. After excluding data with an unknown race from both datasets, we calculated the distribution of live births and maternal complications by race. Compared to the proportion of live births by Black mothers, we found that the distribution of maternal complications was higher than expected for Black/African American§ mothers across all reports (incidents and serious events) and lower than expected when looking at serious event reports only.
We also calculated rates* based on maternal complications per 1,000 live births for Black/African American mothers and White mothers. Across all reports (incidents and serious events), the rate was 1.36 times higher for Black/African American mothers than for White mothers; however, for serious event reports only, the rate was 1.29 times higher for White mothers than for Black/African American mothers.
Although we did not find the level of disparity in maternal complications for Black/African American mothers that might be expected based on maternal mortality statistics, we cannot be fully confident in these results for several reasons. One noteworthy limitation relates to the PA-PSRS reports that were excluded due to an unknown race (i.e., responses of Not asked or Patient declined to answer); excluded data accounted for 17.7% of all reports (incidents and serious events) and 10.7% of serious event reports. Many of the excluded reports identified patient ZIP codes in areas with higher proportions of live births by Black mothers; therefore, the distribution and rates for Black/African American mothers may have been higher if race had been specified in those reports.
While we have seen major progress in the reporting of race data to PA-PSRS since 2022, there is still room for improvement. PSA encourages all acute care facilities in Pennsylvania to ensure that accurate and complete demographic data are being captured in your internal event reporting systems and provided in your reports to PA- PSRS. Continued improvements in reporting will lead to higher confidence in our findings.
† PA-PSRS is a secure, web-based system through which Pennsylvania hospitals, ambulatory surgical facilities, abortion facilities, and birthing centers submit reports of patient safety–related incidents and serious events in accordance with mandatory reporting laws outlined in the Medical Care Availability and Reduction of Error (MCARE) Act (Act 13 of 2002).2 All reports submitted through PA-PSRS are confidential and no information about individual facilities or providers is made public.
‡ These data were provided by the Pennsylvania DOH. The DOH specifically disclaims responsibility for any analyses, interpretations, or conclusions. Although the most current year of available live birth data, from 2022, does not align with the time frame of PA-PSRS reports in this analysis, the live birth distribution by race has been relatively consistent over the past five years.
§ The Pennsylvania DOH lists the race category as Black; PA-PSRS lists the race category as
Black/African American.
* Rates were calculated solely for a point of comparison; they do not reflect a true rate of maternal complication events in Pennsylvania.
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Hoyert DL. Maternal Mortality Rates in the United States, 2021. NCHS Health E-Stats. 2023. DOI: https://dx.doi.org/10.15620/cdc:124678.
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Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). DOH website. https://www.health.pa.gov/topics/Documents/Laws%20and%20Regulations/Act%2013%20of%20 2002.pdf. Published 2002. Accessed June 11, 2024
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ennsylvania Department of Health. Birth Statistics (2022). DOH website. https://www.health.pa.gov/topics/HealthStatistics/VitalStatistics/BirthStatistics/Pages/birth- statistics.aspx. Accessed June 11, 2024.
CHANGEMAKERS STORIES THAT MAKE A DIFFERENCE
Newborn Tragedy Inspires Safety Interventions
The birth of a couple’s first child went from one of the most exciting moments of their lives to a nightmare no parent ever wants to have, following a long and complicated
delivery that required an uncommonly used vacuum extraction delivery. At first, the baby boy seemed perfect and healthy; however, due to several post-delivery medical errors, he went undiagnosed with a subgaleal hemorrhage that resulted in his death eight hours later.
A subgaleal hemorrhage is a rare but potentially lethal emergency in newborns caused by bleeding between the skull and scalp. It is typically caused by a rupture of emissary veins in the skull connecting areas of the brain—especially with vacuum-assisted births—and can lead to hypovolemic shock, anemia, coagulopathy, and death. Treatment includes bandage compression, aggressive administration of blood products, and surgery.
Despite the challenges of maintaining transparency in healthcare when things go wrong, the newborn facility’s patient safety and quality committee had a duty and will to reflect on their errors, identify process improvement strategies for implementation, and share the story. The team learned from their extensive review of this event that opportunities existed in education, assessment skills, and the need for the development of a tool that would enable staff to identify potential brain bleeds in these cases more quickly.
The committee developed necessary education and a tool that is now mandatory for all staff in the maternity departments: All newborns delivered with an instrumental assist, such as vacuum delivery, must have surveillance observations and examination at 1, 2, 3, 4, 6, 8, and 12 hours of age. In addition to baseline newborn observations (i.e., activity, color, heart rate, respiratory rate, and temperature), staff visually inspect the scalp and palpate the head to look for any ballotable mass or movement of fluid (gravity dependent) in the scalp. They note the color and head shape, including displacement of the ears or pitting edema (swelling), and a head circumference. If there are changes in the newborn from the immediate baseline, staff reach out for a bedside evaluation by the neonatal intensive care unit (NICU) or pediatric provider and order a complete blood count.
This team also has shared this unfortunate, but impactful story with other newborn facilities for awareness and education, to help prevent mistakes from recurring and promote further innovations protecting the safety of one of our most vulnerable patient populations.
