(738) Severe Maternal Morbidity In Urban vs Rural Populations Following Patient Safety Bundle Implementation in Hawaii

The Alliance for Innovation on Maternal Health (AIM) has developed evidence-based patient safety bundles (PSB) to decrease severe maternal morbidity (SMM) for several obstetric outcomes including  hemorrhage. In 2021, 10/12 hospitals with birthing facilities in Hawaii adopted AIM safety bundles. 

Hawaii faces challenges in implementing such interventions given its unique geography. Hawaii has 5 urban birthing facilities, all located on the island of Oahu, and 7 rural facilities, located on neighbor islands. Resources, such as blood products, are limited on neighbor islands and transfer to higher level tertiary urban facilities requires air transportation. Our goal was to explore how SMM rates in the setting of obstetric (OB) hemorrhage differ between rural vs urban centers in Hawaii, particularly since AIM PSB implementation.

Study Design: We abstracted data from the AIM Data Center, which provided aggregated SMM rates among OB hemorrhage cases (excluding ectopic pregnancy and spontaneous abortion) for 4 urban and 6 rural birthing facilities in the state of Hawaii, and stratified by year from 2016 to 2023.

Results: A total of 9,527 births were included. Average SMM rates in OB hemorrhage at rural centers ranged from 18.0% to 27.4% over the course of the 2016 to 2023 study period (Figure 1). At the time of implementation of AIM PSB in 2021, SMM rate was 24.2%, fluctuating to 18.0% and 27.4% in 2022 and 2023 respectively. In Hawaii’s urban centers, SMM fluctuated between 18.1% to 24.7% during the study period, with a rate of 22.3% in 2021, decreased to 18.4% by 2023.

Conclusion:

Our analysis showed that Hawaii’s rural centers often have a higher rate of SMM than Hawaii’s urban centers. Our analysis also revealed that urban populations did have a reduction in SMM rates among OB hemorrhage after the implementation of AIM PSB in 2021; rural populations did not see a similar decrease. 

This data supports previous known association between rural residence and increased SMM. Further studies are warranted to identify specific trends and interventions for the unique challenges rural Hawaiian communities face.