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Sentinel Event Alert 66: Eliminating disparities for pregnant patients

Editor’s Note: In June 2022, the White House issued a report stating that the United States is facing a maternal health crisis.1 The Joint Commission has been actively working to help address the myriad and complex causes of maternal mortality and morbidity. This Sentinel Event Alert delves into eliminating barriers and racial disparities causing mortality and morbidity in pregnant and postpartum patients. In addition, The Joint Commission is issuing a Quick Safety that addresses mental health conditions and their role in maternal death. 
Black tennis star Serena Williams faced life-threatening complications five years ago while giving birth to her daughter in an emergency cesarean section.2 In a recently published book, “Arrival Stories: Women Share Their Experiences of Becoming Mothers,” Williams writes, “Giving birth to my baby, it turned out, was a test for how loud and how often I would have to call out before I was finally heard.” Her essay describes the complications she faced and how she needed to insist repeatedly while in labor for treatment appropriate for her history of blood clots in her lungs. The dismissal of symptoms and the tendency not to respond to a patient’s concerns commonly leads to a sentinel event. In Serena’s case, she was fortunate that her complications were eventually treated, and a sentinel event was avoided. Williams now serves as an advocate for maternal health care.

Higher pregnancy-related mortality and morbidity rates for people of color demonstrate how racial and ethnic disparities are quality and patient safety issues. Data show that:

  • Non-Hispanic Black people are three times more likely than white people to die of pregnancy-related causes, according to the Centers for Disease Control and Prevention (CDC).3 
  • Native American pregnant patients are twice as likely to die than white pregnant patients.4
  • For Black and Native American people over the age of 30, mortality for pregnancy-related causes is four to five times higher than it is for white people.4
  • For Black pregnant patients with at least a college degree, the mortality rate is 5.2 times higher than that of their white counterparts.4 

Sentinel Event Alert