The Maternal Health Compact

Susan Mann, M.D., Kimberlee McKay, M.D., and Haywood Brown, M.D.
N Engl J Med 2017; 376:1304-1305April 6, 2017DOI: 10.1056/NEJMp1700485
Audio Interview

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States.

Interview with Dr. Heather Kovich on the challenges facing patients and physicians in rural areas of the United States. (10:07)

In a rural Minnesota town with fewer than 5000 residents, an 18-year-old woman with a term pregnancy goes into labor in a hospital that performs about 75 deliveries per year. Her pregnancy has been uncomplicated, but chorioamnionitis develops during labor and she undergoes a primary cesarean delivery for arrest of descent during the second stage of labor. Her low-risk pregnancy has become high risk — a common story for intrapartum obstetrical care in any hospital, but one that can have deadly consequences in a hospital with fewer resources, including a small staff and limited blood-bank capacity. The woman has a severe postpartum hemorrhage and loses more than 2 liters of blood. She is given the usual uterotonic medications and surgical intervention with B-Lynch suture placement, but they prove ineffective.

The lone obstetrician in the hospital is about to perform a hysterectomy when she recalls a conversation she had 2 weeks earlier with the obstetrical medical director of her hospital system about a program for team training and simulation for obstetrical emergencies that was being offered at her hospital. The director encouraged the obstetrician to reach out regarding safety concerns and left a card with her cell-phone number. Running low on options, the obstetrician contacts the director, who recommends giving the patient a transfusion from the hospital’s very limited blood supply. The director then facilitates consultation with Avera eCARE, a telehealth service that provides real-time specialty expertise to lower-resource care settings.

The teams at Avera arrange transport by helicopter to a tertiary care hospital in Sioux Falls, South Dakota, a 20-minute flight. The patient arrives 2 hours after the initial call was placed, and the telehealth specialists support both the transporting-hospital care team in stabilizing the patient for transport and the receiving care teams in intensive care and interventional radiology. The patient, who was about to have a life-altering and possibly life-threatening hysterectomy, instead undergoes a uterine artery embolization and further stabilization in the intensive care unit (ICU) and is discharged 3 days later.

More than 60% of U.S. hospitals that provide obstetrical care perform fewer than 1000 deliveries per year, or fewer than 3 a day. A review of obstetrical outcomes in 600 rural U.S. hospitals and low-volume, nonteaching hospitals — lower-resource hospitals — revealed that they had higher maternal morbidity than teaching hospitals. The possible issues identified in the lower-resource settings included maintenance of competencies and recruitment of staff.1

In the United States from 1998 to 2008, delivery and postpartum hospitalizations that resulted in maternal mortality and severe maternal morbidity increased by 66% and 75%, respectively.2 The Centers for Disease Control and Prevention and state departments of health have recognized the difficulty of obtaining accurate data pertaining to severe maternal complications and pregnancy-related deaths owing to varied definitions and reporting requirements. Even less information is available regarding the setting in which these cases occurred — urban versus rural and academic centers versus community hospitals. Rural health care centers have been essential for patients, but many of these smaller hospitals have shut down their maternity services.3 For a patient in a rural setting, frequent severe weather and long distances may impede access to a larger hospital. Is it reasonable for these women to drive for hours to get to a larger medical center, or can we do more to support obstetrical practitioners in remote settings?

We believe that Avera’s approach can provide a model for other parts of the country, where a Maternal Health Compact could be created linking lower-resource hospitals with tertiary care hospitals, with the goal of transporting patients to the appropriate facility when possible and making care as safe as possible locally when transport is not an option. Telehealth services in obstetrics can help to bridge the gap in three ways: facilitating transport of patients, supporting care provided remotely, and assisting in local quality-improvement activities.

Under a Maternal Health Compact, a tertiary care hospital provides services to its referring lower-resource hospitals for high-risk patients. Smaller hospitals also benefit from increased collaborations in which, for instance, the tertiary care hospital runs simulations of obstetrical emergencies and assists with quality-improvement activities such as implementation of hemorrhage-treatment algorithms. Such collaborative work can be done in person or through telemedicine connections.

National efforts at improving obstetrical care have stopped short of addressing rare emergencies that can occur in a lower-resource hospital. In 2015, for example, the American Congress of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine released the Obstetric Care Consensus on Levels of Maternal Care, which delineates criteria for identifying women at considerable health risk (such as those with placenta previa, placenta accreta, or preeclampsia with severe features) who should be cared for at a hospital with appropriate staffing and resources to avert obstetrical complications and related deaths.4 Unfortunately, the consensus statement does not address the situation of an 18-year-old with an unexpected severe hemorrhage. Yet with better preparation and planning through a Maternal Health Compact, hospitals could be ready for these crises.

Telehealth is already used in many disciplines in which there is a mismatch between patient needs and specialty expertise, such as dermatology, geriatrics, and mental health, but to our knowledge, there has been no telehealth model for obstetrical care for an acutely high-risk pregnant woman in a lower-resource hospital. In the case of the Minnesota patient, a coordinated telehealth team intervened quickly and effectively; they worked with the rural hospital to stabilize the patient, arranged transport, and prepared the tertiary care hospital.

Through a Maternal Health Compact, physicians and nurses made available to lower-resource hospitals through a video link can help manage on-site obstetrical emergencies. Physicians make recommendations regarding care, while nurses support the nurse in the field by documenting the patient’s course and care in the medical record and facilitating communication with the local pharmacy to obtain necessary medications. The telehealth program developed at Avera, for example, houses under one roof a variety of medical departments — ICU, pharmacy, emergency, and others — to provide continual specialty care to partner care facilities. This kind of coordination is invaluable to patients.

The development and implementation of national standards supports the consistency of obstetrical care. The National Partnership for Maternal Safety, an initiative aimed at reducing maternal morbidity and mortality, released a Consensus Bundle on Obstetric Hemorrhage, in conjunction with the Alliance for Innovation in Maternal Heath (AIM), which recommended that all hospitals that provide obstetrical care develop a standard treatment protocol for postpartum hemorrhage.5 The challenge for the smaller, often rural, hospital has been to determine what the protocol should be for a massive transfusion when their blood bank carries only a fraction of the blood products considered essential for most hemorrhage-treatment protocols. Lower-resource hospitals need site-specific protocols for managing the care of patients with massive hemorrhage. The tertiary care physicians who accept transfers of such patients should help identify resources available at the referring hospitals and partner with them to create such site-specific algorithms, including use of emergency-release blood, fresh frozen plasma, shock garments, and tranexamic acid. The workflow for patients requiring transport should be as efficient and seamless as possible.

Pregnant woman in rural communities cannot afford to lose access to local hospitals; rather, we need to make the care they receive as safe as possible. Team training and simulation of emergencies are common tools of the patient-safety movement, and electronic connectivity and broad implementation of a Maternal Health Compact are the next logical steps for improving patient care, retaining rural care facilities, and recruiting and supporting practitioners in the field.

Disclosure forms provided by the authors are available at

This article was updated on April 6, 2017, at

Source Information

From the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston (S.M.); the Obstetric Service Line, Avera Health, Sioux Falls, SD (K.M.); the American College of Obstetrics and Gynecology, Washington, DC (H.B.); and the Duke University School of Medicine, Durham, NC (H.B.).


The 14th World Rural Health Conference

The Australian College of Rural and Remote Medicine (ACRRM), in recognition of its leadership and success in championing rural practice, is proud to have been invited by the WONCA Working Party on Rural Practice to host the 14th World Rural Health Conference to be held in Cairns from 29 April – 2 May 2017. This important conference will be held in collaboration with the 14th National Rural Health Conference from 26 – 29 April 2017, as part of A World of Rural Health.

The WONCA 14th World Rural Health Conference is an international event that will see delegates from around the world exchange information on the latest developments and challenges in rural family practice and rural and remote health generally.

The World Organisation of Family Doctors (WONCA) is a not-for-profit organisation with 118 member organisations in 131 countries and territories. The WONCA Working Party on Rural Practice consists of up to 20 members with representatives from each of the world’s regions: Europe, Asia, Africa, North America, South America, Australasia / Pacific.

The WONCA Working Party on Rural Practice vision is health for all rural people around the world.

The conference expects 900+ national and international delegates to attend. These will include rural doctors, researchers and academics, teachers, doctors-in-training, medical students, policy makers and administrators from both the public and private sectors.

The program will feature streams based on themes most relevant to all rural and remote health practitioners. These include Social and environmental determinants of health; Leadership, Education and Workforce; Social Accountability and Social Capital, and Rural Clinical Practices: people and services.

The extensive program will include a wide range of plenary sessions and workshops, and a number of excellent keynote speakers have already been confirmed. It also includes clinical sessions to provide skills development and ongoing professional development opportunities.

The World Summit on Rural Generalist Medicine is to be held as a pre-conference event, and potential delegates are welcome to participate in this important optional event.

Please email for any detailed information required relevant to the WONCA 14th World Rural Health Conference in 2017 in Cairns.



A bursary fund exists for medical students, young doctors (in GP training program/Registrars/Resident – in first 5 years of GP practice) and doctors from developing countries, to assist with costs of attendance at the conference.



Supported by

Susur Sungai Kahayan

Palangkaraya, Indonesia

Susur Sungai Kahayan


Salah satu objek wisata yang menjadi andalan di Palangkaraya adalah Sungai Kahayan. Sungai ini adalah salah satu sungai terbesar yang ada di Pulau Borneo. Panjangnya sekitar 250 km dan banyak penduduk yang tinggal di sepanjang sungai ini. Salah satu wisata unik yang tergolong baru khas Palangkaraya yang sedang di gemari saat ini yaitu susur Sungai Kahayan. Anda bisa berwisata susur Sungai Kahayan ini berombongan.

Selama menyusuri sungai, Anda akan disuguhi dengan pemandangan khas hutan-hutan Kalimantan. Di sepanjang perjalanan Anda bisa melihat fauna khas Kalimantan yang tidak bisa ditemukan di tempat lain diantaranya orang utan, uwa-uwa, kera abu-abu dan bekantan. Selain itu, Anda juga bisa mampir ke tempat pemancingan atau situs sejarah dan habitat orang utan di Pulau Kaja. Rute wisata bisa dipilih sendiri sesuai dengan keinginan Anda.


Untuk menikmati wisata eksotis ini, Anda tidak perlu merogoh kocek dalam karena biayanya sangat terjangkau. Satu paket wisata untuk minimal 10 orang dibrandol dengan harga mulai dari Rp 750.000. Harga tersebut sudah termasuk makanan ringan dan fasilitas kapal wisata yang digunakan untuk menyusuri sungai. Kapal ini terbuat dari kayu besi, memiliki kamar tidur, AC, live music dan tempat bersantai.

Akses transport

Bagi Anda wisatawan jauh yang ingin menikmati alam khas Kalimantan ini tidak perlu bingung karena Pemerintah Palangkaraya telah berinisiatif membuat buku panduan wisata untuk para wisatawan.

Anda bisa menghubungi Dinas Pariwisata setempat untuk konfirmasi wisata susur Sungai Kahayan. Untuk menuju dermaga tempat perahu milik Dinas Pariwisata saat Anda sudah tiba di Palangkaraya, Anda bisa naik bis umum atau mobil sewa menuju Kantor DPRD Provinsi Kalteng, letaknya tak jauh dari situ.

Prof Amanda Howe

About the President of Wonca

Amanda Howe took office as WONCA president in Rio, in November 2016.

Amanda has been deeply involved with WONCA since 2000, when she facilitated a workshop for their Working Party on Women and Family Medicine. She is on their Executive, chaired the group from 2007-2009, and hosted an international meeting at UEA in 2009. Professor Amanda Howe was elected RCGP Honorary Secretary in 2009. She practises at the Bowthorpe Medical Centre in Norwich, England and has been Professor of Primary Care at the University of East Anglia since 2001. “I wanted to be a GP when I was a medical student, despite influences from tutors to do otherwise”, says Professor Howe. “I’m fascinated by the role that the GP consultation can play in helping patients make sense of their lives, and overcome physical and mental adversity.”

She remains “in awe” of how resilient patients can be. “It’s a privilege to work with people faced by adversity and illness. People are often very courageous and extremely strong, they really do inspire me, that’s why general practice is such a great place to learn”

New research quantifies genetic mutations caused by smoking

8 November, 2016


Smoking one pack of cigarettes a day could cause 150 extra genetic mutations in lung cells every year, according to new research.

The study, published in the journal Science, analysed the DNA sequence of cells from more than 5,000 cancers from both smokers and non-smokers.

Overall, the study found cancer cells from smokers tended to have a greater number of mutations within certain mutational signatures than non-smokers.

For example, most lung and throat cancers from smokers had many mutations in signature 4. The researchers went on to describe the other individual mutational signatures where they found differences for smokers versus non-smokers, including signatures 2, 5, 13 and 16. The researchers were able to estimate the number of mutations that would be caused in different types of cells.

The results support the theory that smoking causes cancer by increasing the number of mutations found in the cellular DNA, though the exact mechanism by which this happens isn’t completely clear.

Professor Sir Mike Stratton, joint lead author, said: “This study of smoking tells us that looking in the DNA of cancers can provide provocative new clues to how cancers develop and thus, potentially, how they can be prevented.”

Five Things You Might Not Know About Washing Your Hands

Kid washing hands with mother.

Keeping your hands clean is one of the most important steps you can take to avoid getting sick and spreading germs to the people around you. Many diseases and conditions are spread by not cleaning your hands properly. Here are five important things you might not know about washing your hands and why it matters.

  1. Soap is key. Washing your hands with soap removes germs much more effectively than using water alone.[i] The compounds, called surfactants, in soap help remove soil and microbes from your skin. You also tend to scrub your hands more thoroughly when you use soap, which also helps to removes germs.[ii]Make handwashing a habit
  1. It takes longer than you might think. The optimal length of time to wash your hands depends on many factors, including the type and amount of soil on your hands. Evidence suggests that washing your hands for about 15–30 seconds removes more germs than washing for shorter periods.[iii] CDC recommends washing your hands for about 20 seconds, or the time it takes to hum the “Happy Birthday” song twice from beginning to end.
  1. It’s all about technique. Make sure to clean the spots on your hands that people miss most frequently. Pay particular attention to the backs of your hands, in between your fingers, and under your nails. Lathering and scrubbing your hands creates friction, which helps to remove dirt, grease, and germs from your skin.
  1. Don’t forget to dry. Germs can be transferred more easily to and from wet hands, so you should dry your hands after washing.[iv] Studies suggest that using a clean towel or letting your hands air dry are the best methods to get your hands dry.[v],[vi],[vii]
  1. Hand sanitizer is an option. If you can’t get to a sink to wash your hands with soap and water, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Make sure you use enough to cover all surfaces of your hands. Do not rinse or wipe off the hand sanitizer before it is dry.[viii]

Note: Hand sanitizer may not kill all germs, especially if your hands are visibly dirty or greasy,[ix] so it is important to wash hands with soap and water as soon as possible after using hand sanitizer.

Why it Matters

Remember, clean hands save lives. Diarrheal diseases and pneumonia are the top two killers of young children around the world, killing 1.8 million children under the age of five every year.[x] Among young children, handwashing with soap prevents 1 out of every 3 diarrheal illnesses [xi] and 1 out of 5 respiratory infections like pneumonia worldwide.[xii],[xiii]

October 15th is Global Handwashing Day

Handwashing is for everyone…everywhere. Global Handwashing Day is an opportunity to support a global and local culture of handwashing with soap and water, shine a spotlight on the state of handwashing in each country, and raise awareness about the benefits of washing your hands with soap. Although people around the world clean their hands with water, very few use soap to wash their hands because soap and water for handwashing might be less accessible in developing countries.

Get Involved!


[i] Burton M, Cobb E, Donachie P, Judah G, Curtis V, Schmidt WP. The effect of handwashing with water or soap on bacterial contamination of hands. Int J Environ Res Public Health. 2011 Jan;8(1):97-104.

[ii] Burton M, Cobb E, Donachie P, Judah G, Curtis V, Schmidt WP. The effect of handwashing with water or soap on bacterial contamination of hands. Int J Environ Res Public Health. 2011 Jan;8(1):97-104.

[iii] Jensen D, Schaffner D, Danyluk M, Harris L. Efficacy of handwashing duration and drying methods. Int Assn Food Prot. 2012 July.

[iv] Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidemiol Infect. 1997 Dec;119(3):319-25.

[v] Gustafson DR, Vetter EA, Larson DR, Ilstrup DM, Maker MD, Thompson RL, Cockerill FR 3rd. Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial. Mayo Clin Proc. 2000 Jul;75(7):705-8.

[vi] Huang C, Ma W, Stack S. The hygienic efficacy of different hand-drying methods: a review of the evidence. Mayo Clin Proc. 2012 Aug;87(8):791-8.

[vii] Jensen D, Schaffner D, Danyluk M, Harris L. Efficacy of handwashing duration and drying methods. Int Assn Food Prot Annual Meeting. 2012 July 22-25.

[viii] Widmer, A. F., Dangel, M., & RN. (2007). Introducing alcohol-based hand rub for hand hygiene: the critical need for training. Infection Control and Hospital Epidemiology, 28(1), 50-54.

[ix] Pickering AJ, Davis J, Boehm AB. Efficacy of alcohol-based hand sanitizer on hands soiled with dirt and cooking oil. J Water Health. 2011 Sep;9(3):429-33.

[x] Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012 Jun 9;379(9832):2151-61.

[xi] Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev. 2008;1:CD004265.

[xii] Rabie T and Curtis V. Handwashing and risk of respiratory infections: a quantitative systematic review.Trop Med Int Health. 2006 Mar;11(3):258-67.

[xiii] Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. Am J Public Health. 2008;98(8):1372-81.

Posted on October 14, 2016 by Blog Administrator

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