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TDH SMM report shows hemorrhage leading indicator; committee discusses prevention and QI projects
Summary
Tennessee’s SMM report (2018–2022) found hemorrhagic diagnoses and procedures were the most frequent SMM group and that SMM rates were higher among non‑Hispanic Black women, older mothers, and those with higher BMI and preexisting chronic conditions.
Emily Lumley, Maternal Health Epidemiologist at the Tennessee Department of Health, presented statewide severe maternal morbidity (SMM) data for 2018–2022 and engaged the Perinatal Advisory Committee on prevention and quality‑improvement strategies.
Key findings presented by Lumley included: 2,795 deliveries had one or more SMM indicators in that period, with 3,786 SMM indicators recorded overall (some deliveries contained multiple indicators). TDH grouped 20 indicators into clinical categories and excluded blood transfusion‑only events from the analytic definition used for this report. Hemorrhagic diagnoses and procedures were the largest group (34 percent), led by disseminated intravascular coagulation (DIC), followed by hysterectomy and shock. Hemorrhage indicators accounted for most of the SMM burden in the dataset.
The analysis showed demographic and clinical disparities: non‑Hispanic Black women experienced the highest SMM rate (112 per 10,000 deliveries), a rate roughly 1.5 times that of Hispanic and non‑Hispanic white women in the same period. SMM rates rose with maternal age (women aged 35+ had more than twice the rate of women aged 25), and higher pre‑pregnancy BMI, preexisting diabetes and hypertension were all associated with higher SMM rates. Deliveries with no prenatal care had the highest SMM rates (224 per 10,000 deliveries), roughly three times the rate of deliveries with prenatal care in any trimester.
Lumley also reviewed delivery characteristics: cesarean and forceps deliveries had higher SMM rates than spontaneous or vacuum‑assisted vaginal births, and higher‑order multiple births had elevated risk. Hospital characteristics showed that level‑4 maternal hospitals—though few in number—accounted for a disproportionate share of SMM deliveries because of their delivery volumes; however, the committee noted wide variation within each level of care.
The committee discussed prevention strategies and quality programs that could reduce hemorrhage‑related morbidity. Suggested actions included routine third‑trimester anemia screening with reflex ferritin testing to accelerate iron treatment, hemorrhage risk assessment on admission and at key labor transitions, early use of uterotonics and hemorrhage devices in algorithms, accessible hemorrhage carts and refrigerated medicines on labor units, and strengthening coordinated responses with transfusion and anesthesia services. Members also emphasized upstream prevention—primary prevention of chronic disease, stronger care coordination to connect patients to primary care before and after pregnancy, and targeted outreach to reduce barriers to prenatal care.
Brenda Barker (Perinatal QI) reported on QI activities: the state’s chronic lung disease QI closed with measurable improvements, AIM Data Center resources are currently available but AIM’s national capacity and data portal are changing, and TDH is planning further QI work (including a potential hemorrhage sprint and a “Home to Thrive” project for well‑nurseries). Hospitals were encouraged to use TDH’s resource hub, participate in QI sprints, and submit data to inform targeted interventions.
