Improving Maternal Care Remains Critical in U.S.

Patient Transitions, Communication and Hand-Off Issues are Among the Leading Causes of Safety Incidents in Maternal Care

WILLOW GROVE, Pa., Sept. 16, 2025 -- In honor of this year's World Patient Safety Day (WPSD) theme – "Safe care for every newborn and every child" – ECRI published findings from a data analysis on contributing factors to safety events in maternal care, and resources to mitigate risk and improve outcomes for moms and newborns.

Maternal mortality remains a persistent challenge in the U.S. In 2023, the World Health Organization (WHO) named the United States one of seven countries that experienced a significant rise in maternal mortality over the last two decades. Provisional CDC data suggest that in 2024, there were 19 maternal deaths for every 100,000 live births, an increase from the previous year.

Safety Sprint: Maternal Care

ECRI and the ISMP PSO conducted a safety sprint aimed at helping healthcare providers implement best practices for safe maternal care transitions, including transfers between providers or between healthcare settings.

The collaborative learning system includes actionable tools to create improvement plans and track progress with a focus on data-driven and evidence-based best practices. ECRI worked with these teams over several months to establish their improvement projects, with support from ECRI patient safety advisors and experts from ISMP.

Data Analysis in Maternal Care

ECRI and the ISMP PSO's dataset, the largest of its kind in the U.S., includes over 7 million safety events submitted by healthcare providers nationwide, which ECRI analyzes to identify the greatest causes of patient harm and evidence-based guidance to improve care.

ECRI and the ISMP PSO conducted three separate data analyses. A total of 25,793 perinatal patient safety events from 2023 were collected, and a sample size of 375 perinatal safety events were analyzed. Of those events, 310 were found to be relevant. In addition, an analysis of 100 maternal health related root cause analyses (RCAs), received between 2022 and 2024, was conducted.

Almost half of those 310 safety events involved an unanticipated medical emergency, including hemorrhage, eclampsia, and other issues such as shoulder dystocia, which is a medical emergency for both the mother and newborn.

Data Findings

The analysis showed several contributing factors that lead to maternal health-related patient safety events. The top 3 were:

Communication and hand-off issues during patient transitions
Underlying medical conditions
Delayed response (lack of immediate response by the care team to a concerning symptom or problem)

The majority of these safety events occurred during the transition between labor and delivery and the operating room. This underscores the need for stronger systems to ensure safety during this vulnerable care transition.

Although it's a relatively small sample size from self-reported data, these findings point to recurring challenges that healthcare leaders should take a systematic approach to address.

For more information, download the Patient Safety Event Data Snapshot for Maternal Health.

Key Takeaways

Uncontrolled pain is not only traumatic to the maternal health patient, but it can also be a signal of an impending problem.
The data demonstrated that no root causes were found in 42% of the RCAs. This may signal that organizations are viewing these serious safety events as unavoidable. While some events do happen without warning, the RCA process should highlight contributing factors, identify opportunities for early recognition, and pinpoint processes that could be improved for the teams that respond to serious maternal safety events.
Maternal health patients seek care across the healthcare continuum, and maternal health events can happen in any healthcare setting, not just labor and delivery. Healthcare organizations should focus improvement efforts on anticipation of and preparedness for emergent changes in condition in maternal health patients in all care settings. This can include conducting risk assessments and drills and ensuring that supplies are readily available to facilitate team response.
Healthcare organizations should increase event reporting in prenatal and postpartum care areas so that such events can be tracked and analyzed.

Transitions Present Safety Vulnerabilities

Along the maternal care continuum, a pregnant patient may experience multiple transitions within their care, including transfers between providers or between healthcare settings. A comprehensive, patient-centered approach to care coordination and communication is paramount to ensure safe, accurate, and timely care transitions.

However, when key patient information (e.g., clinical condition, medical history, preferences, access to care) is missed, incorrect, or delayed, or when that information is not communicated clearly and accurately to the patient and other caregivers, it can have devastating consequences for the pregnant patient. As indicated by the literature and by reports submitted to ECRI and the ISMP PSO, issues related to maternal health transitions occur regularly.

Resources to Improve Maternal Care

In honor of World Patient Safety Day (WPSD), ECRI is sharing several tools and resources to drive improvement in maternal care:

Tools to Guide Improvement Plans

Maternal Health Driver Diagram
Improvement Plan Template

Insights on Best Practices

Evidence-Based Approaches for Optimizing Postpartum Discharge Procedures
Peripartum Midwife Care for Improving Birth Outcomes
Best Nursing Practices for Fetal Monitoring
Role of Private Doulas in Labor and Delivery

ECRI's Maternal Care Expertise

Evidence-Based Insights

As an AHRQ-designated Evidence-based Practice Center, ECRI generates clinical evidence assessments (CEAs) that give healthcare providers a clear view of the safety and effectiveness of interventions and treatments. For example, ECRI recently published a white paper of findings on the safety and effectiveness of the COVID vaccine for pregnant women.

Maternal Safety in Federally Qualified Health Centers

Since 2009, ECRI has worked with federal partners to provide resources, education, and tools on obstetrics and maternal safety to all federally funded community health centers nationwide. This work includes webinars, virtual conferences, continuing education courses, risk assessment tools, sample policies and templates, and other resources on topics such as continuity in care for obstetrics patients, promoting maternal health and safety in the fourth trimester, and improving quality of obstetrics care from a primary care perspective. Community health centers, particularly those in remote areas, are a key aspect in improving access to high-quality care for medically underserved patients.

About ECRI

ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings. With a focus on technology evaluation and safety, ECRI is respected and trusted by healthcare leaders and agencies worldwide. For more than fifty-five years, ECRI has built its reputation on integrity and disciplined rigor, with an unwavering commitment to independence and strict conflict-of-interest rules. ECRI is the only organization worldwide to conduct independent medical device evaluations, with labs located in North America and Asia Pacific. ECRI is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality and a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services. ECRI acquired The Institute for Safe Medication Practices (ISMP) in 2020 to address one of the most prolific causes of preventable harm in healthcare, medication errors; then acquired The Just Culture Company in 2024 to transform healthcare workplace cultures – thus creating one of the largest healthcare quality and safety entities in the world. Visit www.ecri.org to learn more.

SOURCE ECRI