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Monday Dec 18, 2017

At Home or Abroad, ALSO Training Improves Maternal Outcomes

During the recent AAFP Board of Directors meeting, we heard updates regarding several programs funded by the AAFP Foundation(www.aafpfoundation.org) and the many successes we have enjoyed, including developing and sustaining free clinics, supporting ongoing training of medical students and physicians in Haiti, and hurricane relief efforts.

[mother holding newborn infant child baby]

One long-term partner that has benefited from the Foundation's support is the Advanced Life Support in Obstetrics (ALSO) program. With programs in more than 60 countries and more than 120,000 successful learners around the globe, ALSO continues to grow and positively impact the lives of mothers and their infants. Family physicians take a systems and teamwork approach to improving health care, and U.S. family physicians can be proud of their role in improving maternal outcomes internationally.

At the biennial ALSO International Partners Meeting in Seattle in October, we heard presentations from our partners in Colombia, Costa Rica, India, Iraq, Mexico, Nepal, Nigeria, Palestine, Rwanda, Tanzania, Scandinavia and Venezuela. This year's theme was the impact of postpartum hemorrhage on maternal morbidity and mortality. Each country presented its statistical information related to postpartum hemorrhage and the impact on maternal and neonatal outcomes of standardized approaches to recognize risk factors for hemorrhage, institution of active management of the third stage of labor, and early recognition and treatment of hemorrhage using ALSO mnemonics and algorithms.

In almost every country, ALSO International Partners reported that consistent expansion and application of ALSO training has been shown to reduce the incidence of postpartum hemorrhage and decrease maternal morbidity and mortality rates. In many countries, blood transfusions are not readily available, and the improved outcomes have been made without expanding access to blood products. In many of the Indian subcontinental and African communities where consistent refrigeration is challenging, oxytocin is not a first-line treatment option for uterine atony. Therefore, misoprostol has become a mainstay of life-saving therapy (although there are ethical challenges in some countries because of the drug's potential to be used in termination of pregnancy).

Severe Setbacks in Venezuela

The most striking and disheartening report at this year's meeting came from the Venezuelan ALSO program representative, Dr. Juan Andres Perez Wulff. Perez Wulff has more than 10 years of experience in reducing maternal deaths through the implementation of ALSO educational offerings throughout his country. However, in the last two years, catastrophic economic collapse in Venezuela has brought ALSO educational efforts there to a halt. With the nation's ongoing political unrest, no foreseeable economic turnaround, and no funds to replace training equipment necessary for ALSO courses, our colleagues in Venezuela spoke of an inability to continue their educational efforts.

Perez Wulff reported that Venezuelan physicians have joined in protests against their repressive government and are scrambling on a daily basis for the bare necessities to deliver medical care. He said maternal morbidity and mortality are skyrocketing well beyond the already high rates that preceded the gains achieved by instituting ALSO as a national program before the economic collapse.

Since Perez Wulff's presentation, generous donations from the ALSO instructor group here in the United States, managed through the AAFP Foundation, are making it possible to restore mannequins and other necessary training equipment for our colleagues in Venezuela. However, the lack of food and basic medical supplies may make the challenge of turning the tide on maternal mortality insurmountable.

Rising Maternal Mortality in the United States

Here at home, we have the most expensive health care system in the world, but it certainly is not the best. Are we surprised? Maternal mortality is rising in the United States.(qz.com) Women in rural communities, poor urban neighborhoods and those belonging to ethnic minorities have much higher rates of morbidity and mortality and poorer maternal outcomes(www.npr.org) in general. However, affluence, high educational levels and easy access to care do not ensure absolute protection.

A recent editorial in The New England Journal of Medicine(www.nejm.org) suggested that it is time to refocus on maternity care in the United States. I am one of 60 clinicians of various backgrounds and training on a maternal mortality review panel in Washington that is looking at maternal deaths from all causes. Although our state appears to have a mortality rate that is much lower than average, there are clearly some trends that deserve attention. As the U.S. population becomes more obese, mothers with obesity, particularly those with a body mass index (BMI) greater than 60-70, have become a challenging population to care for, with higher rates of gestational diabetes, gestational hypertension, preeclampsia, labor dystocia, venous thromboembolism, complicated cesarean delivery, postpartum hemorrhage and maternal death.

Although it might be simple and expedient to categorically state that all pregnant women with a BMI above 70 should deliver in a regional perinatal medical center with specialized expertise and equipment, the reality is quite different. Many tertiary care communities do not have the resources to support women who might relocate for such specialty care, much less provide support for their families. In a crisis, transportation is quite challenging, as airlift capability may be limited or nonexistent for patients with excessive BMI, and transfer of care may take too long via ground transportation.

The answer will require multiple approaches; a fundamental necessity will be a strong primary care medical home with access to nutritional management, preventive health care and chronic disease management coordinated with prenatal care and obstetrical management. Assisting in pre-pregnancy planning with appropriate use of long-acting reversible contraception to help patients achieve healthier metabolic status before beginning a pregnancy is an appropriate role for the family physician-directed medical team.

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Posted at 02:59PM Dec 18, 2017 by Carl Olden, M.D.

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