Part 3, Chapter 13: Manual Appendix 3-13-A

American Indian and Alaska Native (AI/AN) maternal mortality rates (deaths per 100,000 live births per year) fell steadily from 82.8 in 1958 to 11.8 in 1975.  However, from 1975 to 1986; AI/AN maternal mortality rates have shown little change while the rates for U.S. All Races continued to show decline.  The average AI/AN rate for this period was 8.3.

Based on these data, the Indian Health Service (IHS) has two concerns:  (1) The rate of AI/AN maternal mortality no longer appears to be decreasing, and (2) the general AI/AN maternal mortality rate is above the U.S. All Races mortality rates.

This policy will address these two concerns through the establishment of procedures and standards that focus specifically on several aspects of obstetric care.  Additional important issues in maternal and obstetrical care, which have an important impact on maternal mortality and which must be considered in the development and implementation of comprehensive health services for women and mothers, are addressed in other sections of the Indian Health (IH) Manual, Part 3, Chapter 13, ?Maternal and Child Health.?

The purpose of this policy is to supplement the IH Manual, Part 3, Chapter 13, ?Maternal and Child Health,? Section 2, Maternal and Neonatal Health Services.

The IHS will provide the highest possible technical level obstetric care to AI/AN mothers as determined by accepted national standards.  In so doing, IHS policy, procedures, and standards will be brought into line with current American College of Obstetricians and Gynecologists (ACOG) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommendations and standards with respect to emergency cesarean delivery.

1. To establish standards for obstetric care requiring emergency surgical intervention.
2. To establish procedures in the provision of obstetric emergency surgical care.

1. Indian Health Manual, Part- 3, Professional Services, Chapter 13 ?Maternal and Child Health,? Sections 3-13.2, 3-13.3, and 3-13.4.
2. The 1992 Joint Commission Accreditation Manual for Hospitals and JCAHO.
3. Guidelines for Perinatal Care, Second Edition.  American Academy of Pediatrics and ACOG, 1988.
4. Recommended standards and policy statements from the ACOG, the American Academy of Pediatrics, and the Nurses Association of the ACOG.

1. Each IHS facility that provides full obstetric (full-time obstetrician with appropriate surgical and obstetrical anesthesia support) services must include:
   • Documentation of the services and how the standards of care in this policy and in Chapter 13 apply in the provision of services in the environment of the facility.
   • Appropriately experienced and board certified/eligible obstetrician-gynecologist(s).
   • Appropriately trained, experienced surgical nursing team and/or obstetric/surgical nursing.
   • Appropriate nurse-patient staff ratios.
   • Anesthesiologist or anesthetist.
   • Pediatrician(s) trained and experienced in neonatal resuscitation.
   • Appropriate space, facilities, and equipment.
2. Each IHS facility that provides full obstetric services must have the organizational, administrative, and staffing support for the start-up of emergency cesarean sections within 30 minutes from the time a decision by the responsible physician is made to do a cesarean section and, it must have the pediatric support for neonatal resuscitation at the time of the cesarean section.  In each of these facilities, a written plan will be established, and updated annually, to institute the required responses for an emergency cesarean section.
3. Each IHS facility that provides medical and obstetric low-risk (defined in Chapter 13) services must document that these services include:
   • Providers (physicians or midwives) who are appropriately trained and experienced in the performance of vaginal deliveries.
   • Appropriately trained and experienced nurses.
   • Physicians who are trained and experienced in neonatal resuscitation.
   • Appropriate space, facilities, and equipment.
4. Each IHS facility that provides low-risk obstetric services must document and inform patients and families of the procedures for consultation and referral in high-risk management and emergency treatment of a woman whose low risk pregnancy, labor, or delivery becomes complicated and requires specialized care.  This system includes at least the following elements:
   • Documentation of initial and on-going risk assessments of a woman?s pregnancy.
   • Established and documented relationship with an obstetrician(s) who agrees to provide consultative evaluation and/or management of complicated pregnancies and who agrees to provide emergency consultations and to accept emergency referrals.
   • Administrative and clerical 24-hour support services to provide or arrange for emergency transport of a woman who has a complicated pregnancy, labor, or delivery.
   • Such an IHS facility should consider providing patients with a written statement of the level of services available and documentation that the patient has discussed and understands the statement.

1. Headquarters:  In collaboration with the IHS Senior Clinicians for Obstetrics/Gynecology and Pediatrics And the Chief, Nurse Midwifery, the IHS Maternal and Child Health (MCH) Coordinator monitors compliance with this policy:
   • A Headquarters based multi-disciplinary Maternal Mortality Review Committee (MMRC) will be established to conduct thorough and timely review of all AI/AN maternal deaths occurring in IHS or tribal facilities, referral facilities, and other health care settings or in non-health care settings.
   • Written comments and recorded discussions by the MMRC will be retained in a locked confidential Quality Assurance file in the IHS Headquarters office of the MCH Coordinator.  Procedures ensuring confidentiality under the Privacy Act of 1974 will be followed in the management of patient records being reviewed by the MMRC.
   • Summaries and recommendations generated by the MMRC will be appropriately distributed with full consideration that the material under review is confidential and privileged information.
2. Area:  The Area MCH consultant provides technical assistance and consultation to service units in evaluating their obstetric services and implementing procedures to comply with this policy.  The MCH Area consultant will monitor service unit compliance with this policy and recommend corrective actions to the Service Unit Director and Area Director when necessary.
3. Service Unit:  The Clinical Director is responsible for implementing policy and procedures and monitoring compliance with this policy and for forwarding pertinent medical records to the Area MMRC.

   The Service Unit Director is responsible for the administrative elements required in the implementation of this policy, e.g., entering into contracts with providers and facilities that can provide quality specialty care, ensuring emergency transport services, and providing clerical and support services required in the arrangement of efficient emergency transfer of patients.

   In collaboration, the Service Unit Director, Clinical Director and the Director of Nurses, are responsible for the evaluation of the maternal and obstetrical training needs of the service unit professional staff and for implementation of an appropriate program of in-service and out-of-service maternal and obstetrical training designed to ensure the highest level of professional obstetric and maternal care possible.