PT  - JOURNAL ARTICLE
AU  - Borem, Paulo
AU  - Gushken, Andrea Keiko Fujinami
AU  - Gushken, Ana Paula
AU  - Pacagnella, Rodolfo de Carvalho
AU  - Petenate, Ademir Jose
AU  - Tuma, Paula
AU  - Pedrilio, Livia Sanches
AU  - Nariño, Santiago
AU  - Barker, Pierre
AU  - Barros, Claudia Garcia de
AU  - Vernal, Sebastian
TI  - A Comprehensive Strategy to Mitigate Institutional Maternal Mortality: Lessons From a Quality Improvement Initiative in Brazilian Maternity Hospitals
AID  - 10.9745/GHSP-D-24-00130
DP  - 2025 Dec 31
TA  - Global Health: Science and Practice
PG  - e2400130
VI  - 13
IP  - 2
4099  - http://www.ghspjournal.org/content/13/2/e2400130.short
4100  - http://www.ghspjournal.org/content/13/2/e2400130.full
SO  - GLOB HEALTH SCI PRACT2025 Dec 31; 13
AB  - Key FindingsThe “4Rs” clinical sequence—Recognize, Rescue, Reassess, and Refer—implemented with a quality improvement framework and tailored Job Instruction training is an effective approach to managing the principal life-threatening conditions responsible for institutional maternal mortality.The intervention was associated with a 34.2% decrease in the institutional maternal mortality ratio (iMMR) when comparing the baseline to the implementation period in 19 public Brazilian maternity hospitals.While maternal deaths increased after the quality improvement implementation period due to a staggering number of COVID-19 deaths during the pandemic, deaths from the 3 targeted life-threatening conditions either remained stable or decreased even further, suggesting the sustainability of the established processes during the initiative.Key ImplicationStructured, systematic, and auditable methodologies to redesign the care process can help improve maternal care outcomes. This approach can inform strategies to reduce iMMR worldwide if replicated and scaled in different settings.Introduction: Many pregnancy-related deaths can be avoided if health care workers reliably provide prompt, evidence-based care during the final stages of pregnancy and delivery. We report the impact on the institutional maternal mortality ratio (iMMR) of a quality improvement (QI) initiative that focused on establishing timely and reliable obstetric care in public Brazilian hospitals for the primary causes of maternal deaths.Methods: The QI initiative used a quasi-experimental time-series design implemented in 19 Brazilian maternity hospitals comparing 3 periods: baseline (January 2018 to November 2019), implementation (December 2019 to March 2021), and post-implementation (April 2021 to September 2021). We used a sequential approach, referred to as the “4Rs” (Recognize, Rescue, Reassess, and Refer), with the Modified Early Obstetric Warning Score (MEOWS) as a key tool, to identify clinical deterioration and implement care bundles directed at the management of 3 principal life-threatening conditions around the time of birth: postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy (HDPs). Clinical staff received tailored training and support within a structured learning system that brought multiple teams together to rapidly test and implement evidence-based changes.Results: Comparing the baseline with the implementation period, run charts detected an overall reduction of 34.2% in all causes of maternal deaths (from 83.7 to 55 deaths per 100,000 live births). Additionally, the iMMR due to the 3 analyzed life-threatening conditions decreased by 60.9% between baseline and the combined implementation and post-implementation periods (from 44.1 to 17.2 deaths per 100,000 live births); postpartum hemorrhage-related deaths were reduced by 72.9% (from 11.7 to 3.17 deaths per 100,000 live births) and sepsis-related deaths were reduced by 100% (from 20.4 to 0 deaths per 100,000 liv births). No changes by HDP-related deaths were observed. There was a 178% increase in iMMR by all causes (mainly attributed to COVID-19) during the post-implementation period, but deaths related to life-threatening conditions either remained stable or decreased even further.Conclusion: Optimization of the steps in a care sequence and reliable implementation of care bundles directed at the principal life-threatening conditions around the time of birth, using QI, tailored training, and the MEOWS tool, seem to be feasible and promising approaches for reducing iMMR.