WILLOW GROVE, PA — ECRI has released new findings on maternal care safety, underscoring persistent vulnerabilities in the U.S. healthcare system and outlining strategies to reduce risks for mothers and newborns.
Maternal mortality in the United States continues to climb. The World Health Organization recently identified the U.S. as one of seven countries with a significant increase in maternal deaths over the past two decades. Provisional CDC data shows 19 maternal deaths per 100,000 live births in 2024, up from the prior year.
As part of its “Safety Sprint: Maternal Care,” ECRI and the Institute for Safe Medication Practices (ISMP) Patient Safety Organization (PSO) analyzed more than 25,000 perinatal safety events reported in 2023 and reviewed 100 maternal health-related root cause analyses from 2022 to 2024. Nearly half of the 310 most relevant events examined involved unanticipated medical emergencies such as hemorrhage, eclampsia, or shoulder dystocia.
The analysis identified three leading contributors to maternal safety events: communication failures during patient handoffs, underlying medical conditions, and delayed responses to urgent symptoms. Many incidents occurred during transitions from labor and delivery to the operating room, highlighting a high-risk stage in the care continuum.
Other findings pointed to systemic challenges. In 42% of the root cause analyses, no contributing factors were identified, raising concerns that organizations may regard some serious maternal safety events as unavoidable rather than preventable. ECRI emphasized that even in unpredictable cases, healthcare teams should focus on early recognition, preparedness, and process improvements.
Key recommendations include expanding event reporting beyond labor and delivery to prenatal and postpartum care, strengthening communication protocols during transitions, and conducting readiness drills to ensure rapid responses in emergencies.
“Safe care for every newborn and every child begins with protecting maternal health across the full continuum of care,” ECRI noted in its report. “A comprehensive, patient-centered approach to coordination and communication is critical to preventing avoidable harm.”
The findings reinforce the urgency for U.S. healthcare providers to adopt systematic, evidence-based practices that better safeguard mothers and infants during one of the most vulnerable phases of medical care.
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