Abstract
Objectives
This cross-sectional study of hospital emergency departments (EDs) in Arkansas sought to (1) assess ED experiences and capabilities related to obstetric emergencies and (2) characterize the differences in ED practices for pregnant and postpartum patients between hospitals with and without obstetric services.
Methods
Online survey invitations were distributed to department managers at hospital EDs across Arkansas in August 2023. The 40-question survey collected hospital characteristics, ED experiences with and capacity to manage obstetric emergencies, and staff training history and interest. Responses were descriptively analyzed, and differences in proportions between hospitals with and without obstetric services were calculated.
Results
Managers for 51 (61%) of the 84 eligible EDs responded. Seventy-one percent of EDs (35/49) had an urgent transport of a pregnant or postpartum patient, and 43% (20/47) had a birth in the prior 12 months. EDs in hospitals without obstetric services were less likely to report a birth (27% versus 56%), to have the capacity to perform some obstetric procedures such as administering uterotonic drugs (58% versus 100%), and to require assessment of postpartum status in the electronic health record (0% versus 33%). The majority (16/35; 46%) of responding ED managers had not offered obstetric emergency training to staff in the last 2 years.
Conclusion
Although obstetric emergencies are not uncommon in the Arkansas hospital EDs represented in this study, many EDs have gaps in their preparedness to identify and manage these cases. Key opportunities for improving preparedness in this sample include training staff and requiring assessment of both pregnancy and postpartum status for women of reproductive age.
The Bottom Line.
There is limited data on emergency department (ED) practices related to obstetric complications. We conducted a cross-sectional survey with managers of 51 (61%) hospital-based EDs in Arkansas to assess EDs’ experiences with, and capability to manage, obstetric emergencies. During the prior year, a precipitous birth occurred at roughly 1 in 3 EDs, and an urgent transport of a pregnant or postpartum patient occurred at 2 in 3 EDs. Key opportunities to improve ED practices include implementing consistent assessment of postpartum status and providing staff training on obstetric topics.
1. Introduction
1.1. Background
The state of maternal health in the United States has been described as a “crisis.”1 Maternal mortality rates are 2 to 3 times higher than in other high-income countries,2 and at least 80% of these deaths are considered preventable.3 Problems related to pregnancy are among the top 10 reasons for emergency department (ED) visits among women 15 to 64.4 After birth, up to 12% of women seek care in the ED for postpartum concerns.5 In one California study, two-thirds of women who died from pregnancy-related causes received care in an ED during the prenatal or postpartum period, and 40% visited an ED 3 or more times.5 Additionally, the closure of labor and delivery services at many rural hospitals may increase the number of patients presenting to EDs with obstetric complications.6 As a common source of care, EDs can contribute to improving maternal outcomes.7
1.2. Importance
There is limited research regarding the policies, practices, and resources of EDs related to the management of obstetric complications.8 State-based maternal mortality review committees (MMRCs) assess the circumstances surrounding maternal deaths to identify contributing factors. The Centers for Disease Control and Prevention (CDC) analyzed MMRC data from 13 states and found that limited experience with obstetric emergencies among ED staff contributed to some deaths.9 To prevent maternal deaths, the CDC’s report recommended that ED staff members ask patients about their recent pregnancy history and receive obstetric emergency simulation training.9 In Arkansas, a state with one of the highest maternal mortality rates and the location of this study, the MMRC also recommended dissemination of obstetric protocols to EDs and simulation training for ED staff.10
The extent to which EDs are prepared to identify and manage obstetric emergencies may also be a factor in maternal health disparities. Prior studies suggest low-income and racial minority patients—2 groups with worse maternal outcomes—are more likely to seek care at the ED during pregnancy and the postpartum period.11,12 Black women, in particular, suffer from maternal mortality rates 2.6 times higher than non-Hispanic White women13 and are 50% more likely to seek care in the ED during pregnancy.11,14 Pregnant and postpartum women seeking care in the ED are also more likely to have risk factors for poor maternal outcomes, such as substance abuse, obesity, and late initiation of prenatal care.12,14
1.3. Goals of This Investigation
We conducted a statewide survey of EDs’ preparedness to identify and manage obstetric emergencies to inform the design of an obstetric simulation training program for ED staff. The objectives of this study were to (1) assess experiences and capabilities related to preparedness for obstetric emergencies in Arkansas EDs and (2) characterize the difference in ED practices for pregnant and postpartum patients between hospitals with and without obstetric services.
2. Methods
2.1. Study Design and Setting
This study is a cross-sectional assessment of hospital-based EDs in Arkansas. Arkansas is a largely rural state with a population of 3 million people. In 2022, Arkansas recorded 35,471 births.15 According to the National Center for Health Statistics, Arkansas’s maternal mortality rate for 2018 to 2022 was 43.5 deaths per 100,000 live births, one of the highest reported state rates16 and similar to rates in Central America.17 Among 84 hospitals with EDs in Arkansas in 2023,18 35 also provided obstetric services.19 Over 60% of counties do not have hospital-based obstetric services, and at least 4 rural Arkansas hospitals closed labor and delivery units between 2020 and 2024.19 Study procedures were reviewed and determined to be exempt by the Institutional Review Board of the University of Arkansas for Medical Sciences (protocol #275720).
2.2. Survey Design
Our survey instrument consisted of 40 questions that assessed hospital and respondent characteristics (module 1), ED experience with and practices related to obstetric emergencies (module 2), ED capacity to manage obstetric emergency procedures (module 3), and staff training history and interest (module 4). The hospital characteristics collected in module 1 included geographic location, ED patient volume, ED staffing, and presence of obstetric services. Respondent characteristics included job position, clinical training, years of experience, and gender.
For modules 2 and 3, we modeled questions after a prior national survey of rural hospitals lacking obstetric services.8 Following review by team members, including 2 obstetricians, 2 emergency physicians, and a nurse who provides obstetric emergency training, we made clarifying corrections and added multiple questions on obstetric-related ED policies and processes not addressed in the prior survey. Module 2 asked about EDs’ experiences with obstetric emergencies in the past 12 months, such as precipitous births and urgent transports of pregnant/postpartum patients. Obstetric-related practices assessed included fields in the electronic health record (EHR) regarding pregnancy status and postpartum status, and the presence of obstetric emergency protocols and response teams. For obstetric procedures, respondents were asked to rate whether their ED had the capacity to perform the procedure or whether it lacked staff and/or supplies for the procedure. The list of obstetric emergency procedures was derived from the World Health Organization’s “Monitoring Obstetric Emergency Care” handbook,20 as in the prior survey,8 with an added question assessing blood transfusion capabilities recommended in massive transfusion protocols for obstetric hemorrhage.21,22
Questions in module 4 assessed whether EDs had provided staff with training on obstetric emergency topics in the past 2 years and whether they had conducted drills or simulations on obstetric emergencies or other topics. For a list of 17 obstetric emergency topics, participants were asked to rate the likely interest of their ED staff in training on that topic, as either “very interested,” “somewhat interested,” or “not interested.” Finally, respondents were asked to rate their ED’s preparedness for obstetric emergencies as “very prepared,” “somewhat prepared,” or “not at all prepared.”
2.3. Survey Administration
We collected survey responses using the web-based Qualtrics software. All 84 hospital-based EDs in Arkansas were eligible to participate, including specialty (eg, pediatric) hospitals. We distributed the survey invitation through the University of Arkansas for Medical Sciences’ stroke program, which coordinates a statewide network of EDs participating in monthly collaborative calls. The survey was introduced during a monthly call, after which the stroke program coordinator distributed email invitations to the ED managers with current contact information (n = 73 EDs), requesting one response per ED. Invitation emails included a document listing all survey questions to assist with the preparation of responses. We were unable to directly invite managers of the 11 hospital EDs for which we could not locate contact information for the current ED manager.
To maximize response rates, ED managers who completed the survey received a $25 electronic gift card. Periodic reminder emails were sent to managers at EDs with no survey response. The Arkansas Hospital Association also distributed messages to the leadership at eligible hospitals requesting that they encourage staff to participate. The survey was open to collect responses between August and September 2023. Two responses that were received from free-standing EDs and did not meet the eligibility criteria were removed from the dataset prior to analysis. Each hospital’s address was cross-referenced with the United States Department of Agriculture’s 2024 Rural-Urban Continuum Codes. Hospitals in counties with a Rural-Urban Continuum Code of 5 (“nonmetro–urban population of 20,000 or more, not adjacent to a metro area”) or higher were considered rural.
2.4. Analysis
We performed descriptive analyses for ED and respondent characteristics. The proportion of EDs reporting obstetric experiences, practices, and capacity was stratified by the presence of obstetric services at the hospital. Missing or “don’t know” responses are excluded from calculations of proportions and median values and identified in table footnotes.
3. Results
3.1. Characteristics of Study Subjects
Responses were submitted for 51 EDs, which represent 61% of all hospital-based EDs in Arkansas at the time of the survey (Table 1). Fifty-seven percent of EDs (29/51) were located in rural counties, and 43% (22/51) in nonrural counties. The median number of ED visits in 2022 was 10,785—23% (11/48) of EDs reported fewer than 5000 annual visits, and 25% (12/48) had more than 30,000 annual visits. Regarding the number of staff working ≥20 hours a week, ED managers reported a median of 4.5 (range: 0, 19) emergency physicians and 14 (range: 3, 110) registered nurses. Only 3 EDs reported no emergency physician working ≥20 hours a week (Table S1). The median number of staff in all other clinical roles was zero, and 49% (25/51) of EDs had only physicians and registered nurses among the full-time staff (data not shown). EDs were served by a median of 2 (range: 1, 17) ambulance vehicles.
Table 1.
Characteristics of facilities and respondents.
| Characteristic | Responding EDs, n/N (%) or median (range) |
|---|---|
| Facility characteristics | |
| Location | |
| Rural county | 29/51 (57%) |
| Nonrural county | 22/51 (43%) |
| Total ED visits, 2022a | |
| <5000 | 11/48 (23%) |
| Between 5000 and 9999 | 12/48 (25%) |
| Between 10,000 and 19,999 | 7/48 (15%) |
| Between 20,000 and 29,999 | 6/48 (13%) |
| ≥30,000 | 12/48 (25%) |
| Median no. ED staff working ≥20 hours per week | |
| Emergency physicians | 4.5 (0, 19) |
| Family physicians | 0 (0, 7) |
| Physician assistants | 0 (0, 6) |
| Advanced practice nurses (APRNs) | 0 (0, 12) |
| Registered nurses | 14 (3, 110) |
| Emergency medical technicians (EMTs) | 0 (0, 30) |
| Median no. of ambulances serving facilityb | 2 (1, 17) |
| Presence of obstetric services | |
| Currently provides obstetric services | 28/51 (55%) |
| Never offered obstetric services | 12/51 (24%) |
| Obstetric services closed | 11/51 (22%) |
| Distance to nearest hospital with obstetric services, among EDs withoutc | |
| <30 miles | 10/22 (45%) |
| 30-60 miles | 12/22 (55%) |
| Respondent characteristics | |
| Position | |
| Nursing director | 19/51 (37%) |
| Department manager | 22/51 (43%) |
| Otherd | 10/51 (20%) |
| Clinical background | |
| Nursing | 51/51 (100%) |
| Years in current position | |
| <1 y | 16/51 (31%) |
| 1-4 y | 20/51 (39%) |
| 5-9 y | 11/51 (22%) |
| ≥10 y | 4/51 (8%) |
Percentages adjusted for missing/don’t know responses.
APRN, advanced practice nurse; ED, emergency department; EMTs, emergency medical technicians.
Three responses missing.
Two responses missing and 4 responses “unknown.”
One response missing.
Other include chief nursing officer, nurse/nurse educator, ED director, and program director/manager.
Fifty-five percent (28/51) of participating EDs were located in a hospital with obstetric services including a labor and delivery unit. At the hospitals without obstetric services, 24% (12/51) never had obstetric services, and 22% (11/51) reported that their labor and delivery unit had closed sometime in the past. Obstetric services were available at a smaller proportion of responding rural EDs (14/29; 48%) than nonrural EDs (14/22; 64%). Among responding hospital EDs without obstetric services, 55% (12/22) reported a distance between 30 and 60 miles to the nearest hospital with labor and delivery services.
The respondents completing surveys on behalf of their ED included department managers (22/51; 43%), nursing directors (19/51; 37%), and other nurse manager roles (10/51; 20%). Ten (19%) respondents reported other job titles such as chief nursing officer, nurse educator, or program director/manager. The clinical background of all respondents was in nursing.
3.2. Experiences With Obstetric Emergencies
At least 1 patient had given birth in the prior 12 months at 43% (20/47) of EDs (Table 2). The proportion of EDs with births was higher for hospitals with obstetric services (14/25; 56%) than for those without (6/22; 27%). Among hospitals with obstetric services, the median number of births in the ED was 2 (range: 0, 10). Over 70% of EDs (35/49; 71%) had an urgent transport of a pregnant or postpartum patient, and close to half (22/47; 47%) had an obstetric patient with an unanticipated adverse outcome in the prior 12 months. Unsuccessful attempts to transfer pregnant or postpartum patients occurred at 8 EDs (17%).
Table 2.
Experiences with obstetric emergencies.
| Experience with obstetric emergencies | All EDs, n/N (%) | OB services available, n/N (%) |
|
|---|---|---|---|
| Yes | No | ||
| Birth in the ED in the past 12 moa | 20/47 (43%) | 14/25 (56%) | 6/22 (27%) |
| Median no. of births in the ED in the past 12 mo (range)a | 0 (0, 10) | 2 (0, 10) | 0 (0, 5) |
| Close call or unanticipated adverse maternal outcome in the past 12 mob,c | 22/47 (47%) | 12/26 (46%) | 10/21 (48%) |
| Urgent transport of pregnant or postpartum patient in the past 12 mob,d | 35/49 (71%) | 19/27 (70%) | 16/22 (73%) |
| Attempt to transfer a pregnant or postpartum patient in the past 12 mo, but transfer was delayed or not possibleb,e | 8/46 (17%) | 4/24 (17%) | 4/22 (18%) |
Percentages adjusted for missing/don’t know responses.
ED, emergency department; OB, obstetrics.
Four responses missing.
One response missing.
Three responses “don’t know.”
One response “don’t know.”
Four responses “don’t know.”
3.3. Practices and Training for Obstetric Emergencies
Pregnancy status was included as an EHR field in nearly all EDs (47/49; 96%), but was only a required field for 15 EDs (15/49; 31%; see Table 3). The proportion of ED EHRs requiring completion of pregnancy status for female patients of reproductive age was more than twice as high for EDs in hospitals with obstetric services (39% versus 19%). Postpartum status was a required field for reproductive-age women in 9 EDs (9/46; 20%) and a suggested field in 16 (16/46; 35%). Twenty-one EDs (21/46; 46%) had no postpartum status field, and this proportion was higher for EDs in hospitals without obstetric services (74% versus 26%). The proportion of EDs that prioritized pregnancy/postpartum status in the triage index was higher at hospitals with obstetric services (9/28; 32%) than those without (2/19; 11%).
Table 3.
Practices and training related to obstetric emergencies in Arkansas EDs.
| Practice or policy | All EDs, n/N (%) | OB services available, n/N (%) |
|
|---|---|---|---|
| Yes (n = 28) | No (n = 23) | ||
| ED practices and policies related to obstetric emergencies | |||
| EHR has field on pregnancy statusa,b | 47/49 (96%) | 27/28 (96%) | 20/21 (95%) |
| Required field (hard stop) | 15/49 (31%) | 11/28 (39%) | 4/21 (19%) |
| Not required | 32/49 (65%) | 16/28 (57%) | 16/21 (76%) |
| EHR has a field on postpartum statusa,c | 25/46 (54%) | 20/27 (74%) | 5/19 (26%) |
| Required field (hard stop) | 9/46 (20%) | 9/27 (33%) | 0/19 (0%) |
| Not required | 16/46 (35%) | 11/27 (41%) | 5/19 (26%) |
| Pregnant/postpartum patients are moved up in the triage indexa,d | 11/47 (23%) | 9/28 (32%) | 2/19 (11%) |
| ED has an obstetric emergency response protocola,c | 26/46 (57%) | 14/25 (56%) | 12/21 (57%) |
| ED has identified the obstetric emergency response teama,d | 11/47 (23%) | 8/25 (32%) | 3/22 (14%) |
| Training and self-rated preparedness for obstetric emergencies | |||
| ED has access to training resources to prepare for obstetric emergenciese,f | 29/44 (66%) | 20/25 (80%) | 9/19 (47%) |
| ED offered training to staff on any obstetric topic in the last 2 ye,g | 16/35 (46%) | 9/18 (50%) | 7/17 (41%) |
| ED conducted any emergency drills/simulations for any obstetric emergency in the past yeare,h | 10/47 (21%) | 8/26 (31%) | 2/21 (10%) |
| Respondent rating of facility’s preparedness to identify and manage obstetric emergenciese | |||
| Very prepared | 16/49 (33%) | 10/28 (36%) | 6/21 (29%) |
| Somewhat prepared | 27/49 (55%) | 13/28 (46%) | 14/21 (67%) |
| Not at all prepared | 6/49 (12%) | 5/28 (18%) | 1/21 (5%) |
Percentages adjusted for missing/not sure/don’t know responses.
ED, emergency department; OB, obstetrics.
One response missing.
One response “not sure.”
Four responses “not sure.”
Three responses “not sure.”
Two responses missing.
Five responses “not sure.”
Fourteen responses “not sure.”
Two responses “not sure.”
The majority of EDs in the sample had not provided obstetric emergency training to staff in the last 2 years. Sixteen (46%) EDs offered training on any obstetric topic, and 10 (21%) EDs performed emergency drills or simulations on an obstetric topic. The proportion of EDs that performed obstetric drills was >3 times higher among EDs in hospitals with obstetric services (8/26; 31%) than those without (2/21; 10%). Only one-third of respondents rate their ED as “very prepared” for obstetric emergencies (16/49; 33%).
3.4. Capacity to Perform Obstetric Emergency Procedures
Over 90% of EDs represented in the survey had the capacity to perform 5 of the assessed procedures, including performing basic neonatal resuscitation, administering anticonvulsant medications for preeclampsia/eclampsia, and performing assisted vaginal delivery (see Table 4). EDs without obstetric services had a lower capacity to perform 6 of the 10 procedures. For example, the capacity to administer uterotonic drugs for obstetric hemorrhage was present at 100% (24/24) of EDs with obstetric services and 58% (11/19) of those without. A greater difference in capability was observed for removing retained products of delivery (100% versus 44%) and performing cesarean deliveries (100% versus 9%). The procedure for which the lowest proportion of EDs reported capability was massive transfusion with at least 6 units of uncrossmatched O-negative red blood cells (24/46; 52%).
Table 4.
Capacity to perform obstetric emergency procedures in Arkansas EDs.
| Existing capacity to perform the procedure | All EDs, n/N (%)a | OB services available, n/N (%) |
|
|---|---|---|---|
| Yes | Nob | ||
| Administer intravenous or injection antibiotics to both mother and infantsa | 50/50 (100%) | 28/28 (100%) | 22/22 (100%) |
| Perform basic neonatal resuscitationa | 50/50 (100%) | 28/28 (100%) | 22/22 (100%) |
| Administer anticonvulsant meds for preeclampsia and eclampsiaa,b | 49/49 (100%) | 28/28 (100%) | 21/21 (100%) |
| Conduct blood transfusiona | 49/50 (98%) | 27/28 (96%) | 22/22 (100%) |
| Perform assisted vaginal deliverya | 49/50 (98%) | 28/28 (100%) | 21/22 (95%) |
| Manually remove a placentaa,c | 36/43 (84%) | 26/26 (100%) | 10/17 (59%) |
| Administer uterotonic drugsa,c | 35/43 (81%) | 24/24 (100%) | 11/19 (58%) |
| Remove retained products of deliverya,d | 36/46 (78%) | 28/28 (100%) | 8/18 (44%) |
| Plan or policy for an emergency cesarean in the case of maternal demise or other indicationa | 33/50 (66%) | 28/28 (100%) | 5/22 (23%) |
| Perform surgery (eg, cesarean section)a | 30/50 (60%) | 28/28 (100%) | 2/22 (9%) |
| Deliver massive transfusion with ≥6 units of uncrossmatched O-negative red cellsa,d | 24/46 (52%) | 18/25 (72%) | 6/21 (29%) |
Percentages adjusted for missing/don’t know responses.
ED, emergency department; OB, obstetrics.
One response missing.
One response “don’t know.”
Seven responses “don’t know.”
Four responses “don’t know.”
3.5. Interest in Obstetric Emergency Training
Sixteen (16/49; 33%) respondents reported their hospital management would be “very likely” to request ED staff participate in obstetric emergency simulation training, whereas 27 (27/49; 55%) responded “moderately likely” and 6 (6/49; 12%) responded “not likely” (data not shown). Among the 17 training topics assessed (Table 5), respondents were most frequently “very interested” in vaginal/precipitous birth (40/49; 82%), cardiac arrest in pregnancy (37/49; 76%), stabilization of the newborn (37/49; 76%), and acute hypertension and seizure in pregnancy/postpartum (36/49; 72%). The training topics for which the least number of respondents were “very interested” were cesarean delivery (16/49; 33%), shoulder dystocia (18/49; 37%), peripartum cardiomyopathy (23/49; 47%), altered physiology of pregnant and postpartum patients (24/49; 49%), and maternal mental health (25/49; 51%).
Table 5.
Interest in obstetric emergency training topics among Arkansas EDs.
| Training topic | All EDs “Very Interested,” n/N (%) | EDs “Very Interested” by OB service availability, n/N (%) |
|
|---|---|---|---|
| Yes | No | ||
| Vaginal/precipitous birth | 40/49 (82%) | 22/28 (79%) | 18/21 (86%) |
| Cardiac arrest in pregnancy | 37/49 (76%) | 22/28 (79%) | 15/21 (71%) |
| Stabilization of the newborn | 37/49 (76%) | 19/28 (68%) | 18/21 (86%) |
| Acute hypertension and seizure in pregnancy and postpartum | 36/49 (73%) | 20/28 (71%) | 16/21 (76%) |
| Postpartum hemorrhage | 35/49 (71%) | 21/28 (75%) | 14/21 (67%) |
| Stroke in maternity patients | 33/49 (67%) | 19/28 (68%) | 14/21 (67%) |
| Pulmonary edema in maternity patients | 33/49 (67%) | 20/28 (71%) | 13/21 (62%) |
| Heavy vaginal bleeding in pregnancy | 32/49 (65%) | 20/28 (71%) | 12/21 (57%) |
| Maternal sepsis | 32/49 (65%) | 19/28 (68%) | 13/21 (62%) |
| Venous thromboembolism and other embolisms | 30/49 (61%) | 16/28 (57%) | 14/21 (67%) |
| Use of obstetric consult services | 28/49 (57%) | 12/28 (43%) | 16/21 (76%) |
| Obstetric life support | 27/49 (55%) | 15/28 (54%) | 12/21 (57%) |
| Maternal mental health | 25/49 (51%) | 16/28 (57%) | 9/21 (43%) |
| Altered physiology of pregnant and postpartum patients | 24/49 (49%) | 15/28 (54%) | 9/21 (43%) |
| Peripartum cardiomyopathy | 23/49 (47%) | 15/28 (54%) | 8/21 (38%) |
| Shoulder dystocia | 18/49 (37%) | 8/28 (29%) | 10/21 (48%) |
| Cesarean delivery | 16/49 (33%) | 9/28 (32%) | 7/21 (33%) |
Two responses missing.
ED, emergency department; OB, obstetrics.
4. Limitations
This survey study relied on respondents’ self-reports to assess ED policies, practices, and capabilities related to obstetric emergency preparedness. Although more than half of the survey questions had been included in 1 prior survey, the psychometric properties of the questionnaire have not been tested. Terms used in survey questions, including “obstetric emergency” and “close call” may have been interpreted differently among respondents. Responses related to prior training and experiences with obstetric emergencies in the unit may be subject to recall bias, possibly decreasing the number of events reported. Only 1 response was collected per ED, typically completed by the nursing manager or director, and other staff may perceive their ED’s policies and practices differently. Furthermore, the presence of a policy or resources to support a practice does not guarantee that those practices will be adhered to during patient care.
This study was also geographically limited to Arkansas, and the findings may not be generalizable to other states. States like Ohio and Iowa have ongoing obstetric simulation training and quality improvement programs for EDs that have reported improvements in ED staff knowledge and skills,23 although the effects on practices and outcomes are not yet known. These programs are encouraged by national organizations, such as the Alliance for Innovation on Maternal Health, and are likely to increase across the country.
5. Discussion
This statewide survey found that obstetric emergencies are not uncommon in Arkansas EDs. During the prior year, a precipitous birth occurred at roughly 1 in 3 EDs, an urgent transport of a pregnant or postpartum patient occurred at 2 in 3 EDs, and an unanticipated adverse maternal outcome occurred at 1 in 5 EDs. Although national estimates of the incidence of births in the ED are not available,24 precipitous labor occurs for 3% of births.25 In a prior national survey of rural EDs without obstetric services, 28% had a precipitous birth during the prior year.8 Although this study reports a similar percentage for EDs without obstetric services, precipitous births were twice as common at EDs in hospitals with obstetric services. Reports of unanticipated adverse maternal outcomes were more commonly reported in this study (47% versus 32%) than in the national survey, while delayed transports were similar (17% versus 21%). This study adds to previous research by demonstrating that EDs in hospitals with obstetric services may treat patients presenting with obstetric complications equally or more frequently compared with EDs without obstetric services.
The practices reported by managers at participating EDs suggest both strengths and opportunities to improve preparedness to identify and manage obstetric emergencies. Although near universal incorporation of pregnancy status into the EHR across Arkansas EDs is positive, most EHRs did not require this field to be completed for all female patients of reproductive age, which could result in missed or delayed identification of obstetric emergencies. Of particular concern is the high proportion of Arkansas EDs that do not include postpartum status in the EHR, as just over half of pregnancy-related deaths occur between 7 and 365 days postpartum,3 when women may no longer be under obstetric care. Some high-risk obstetric complications, such as preeclampsia/eclampsia and peripartum cardiomyopathy, can occur de novo in the postpartum period and present with nonspecific signs and symptoms.26,27 Without knowledge of the patient’s postpartum status, clinical staff may misdiagnose and mistreat these complications.28
The capacity to perform 9 of 11 emergency obstetric procedures was present across almost all Arkansas EDs located in hospitals with obstetric services. The only procedure that was not available at more than half of EDs was delivering massive blood transfusion with at least 6 units of uncrossmatched O-negative red cells, which are required under several obstetric hemorrhage protocols.22 More than half of EDs at hospitals without obstetric services lacked the capability for 5 assessed procedures. Compared with the national survey, a greater proportion of Arkansas EDs without obstetric services could perform vacuum/forceps-assisted vaginal delivery and remove retained products of delivery. However, a smaller proportion could administer uterotonic drugs and perform surgery than the national rural sample. Previous surveys were conducted prior to the changes in state abortion regulations following the Supreme Court’s decision in Dobbs versus Jackson Women’s Health Organization. This study does not capture the extent to which abortion restrictions, which took effect in Arkansas in June 2022, have impacted obstetric emergency preparedness in EDs.
An unexpected finding of this study is that self-rated preparedness for obstetric emergencies was higher among managers of EDs without labor and delivery services than among ED managers in birthing hospitals. Hospitals without obstetric services also had fewer births in the ED. It is possible that the EDs with a greater frequency of obstetric cases could be more aware of gaps in preparedness as a result of these experiences. This difference in perception may be similar to the Dunning-Kruger effect, in which the least skilled and/or experienced individuals overestimate their competence.29 As a result, ED management at hospitals without obstetric services may require more outreach to engage in training and other preparedness activities.
The experiences with precipitous birth and delayed or unsuccessful transfer in this sample highlight the need for preparedness in EDs without obstetric services. Under the Emergency Medical Treatment in Labor Act, patients in active labor are considered unstable until delivery of the baby and placenta and should only be transferred when a physician determines the benefits of transferring the laboring patient outweigh the risks.30 There can also be delays in locating a receiving hospital with the appropriate level of care for stable obstetric patients with acute complications. The results of this study confirm the need for, and managers’ interest in, training for ED staff on obstetric emergencies. Prior surveys of emergency medicine trainees and teaching faculty documented a lack of confidence in managing obstetric emergencies.31,32 Only one-third of Arkansas EDs had provided training to staff on any obstetric topic, and most respondents considered their ED to be less than well-prepared for obstetric emergencies. Precipitous birth, a stressful event for ED staff,24 was the training topic with the highest interest among managers responding to this survey. Additional research with ED staff is necessary to understand their interest in training. Simulation training can increase ED staff skills and confidence to manage births and obstetric complications33,34 and has been recommended by professional associations35 and MMRCs.9 Although obstetric emergency simulation trainings have typically been limited to facility-led efforts, programs in multiple states are expanding the availability of training for ED staff. In Arkansas, the University of Arkansas for Medical Sciences is providing on-site training to any ED in the state under the Perinatal Improvement of Outcomes and Safety for Everyone (PRIMROSE) program funded by the Health Resources and Services Administration.
In summary, EDs in Arkansas provide care to patients with obstetric complications and ED managers have a strong interest in obstetric emergency training. Key opportunities to improve preparedness of Arkansas EDs to handle these cases include incorporating postpartum status into the EHR and assessments for all women of reproductive age, strengthening capabilities to manage severe obstetric hemorrhage, and increasing the provision of obstetric emergency training to ED staff. Obstetric emergency preparedness is just as important for EDs in hospitals with obstetric services as for those without.
Author Contributions
JACK: Conceptualization, funding acquisition, methodology, investigation, formal analysis, and writing—original draft.
TT: Data curation, formal analysis, and writing—review and editing.
LP: Project administration and writing—review and editing.
GK: Methodology and writing—review and editing.
KK: Writing—review and editing.
PAM: Writing—review and editing.
JMM: Writing—review and editing.
LR: Conceptualization, methodology, and writing—review and editing.
Funding and Support
This study was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $5 million with 0% financed with nongovernmental sources (FAIN# U7A46847). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US Government. For more information, please visit HRSA.gov.
Conflict of Interest
All authors have affirmed they have no conflicts of interest to declare.
Acknowledgments
The authors wish to thank Dr Ariel Noble, Baylee Field, Courtney Kocum, Dr Lauren Evans, and Pam Brown for their contributions to survey development and/or distribution; Dr Ryan Strebeck for his contribution to simulation training development; and Erin Gloster for her assistance with manuscript submission.
Footnotes
This study was reviewed and determined to be not human subjects research by the Institutional Review Board of the University of Arkansas for Medical Sciences (protocol #275720).
Supervising Editors: Dan Mayer, MD, and Henry Wang, MD, MS
Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.acepjo.2025.100274.
Supplementary Materials
References
- 1.The White House . U.S. Government; 2022. White House blueprint for addressing the maternal health crisis. [Google Scholar]
- 2.Gunja M., Gumas E., Masitha R., Zephyrin L. The Commonwealth Fund; 2024. Insights into the U.S. Maternal Mortality Crisis: an international comparison. [DOI] [Google Scholar]
- 3.Trost S., Beauregard J., Chandra G., et al. Centers for Disease Control and Prevention; 2022. Pregnancy-related deaths: data from maternal mortality review committees in 36 US states, 2017-2019. [Google Scholar]
- 4.Cairns C., Kang K. 2022. National hospital ambulatory medical care survey: 2020 emergency department summary tables. [DOI] [Google Scholar]
- 5.California Department of Public Health . California Department of Public Health; 2018. The California pregnancy-associated mortality review: report from 2002 to 2007 maternal death reviews. Maternal, Child and Adolescent Health Division. [Google Scholar]
- 6.Anderer S. More than half of US rural hospitals no longer offer birthing services—here’s why. JAMA. 2024;331(10):815–817. doi: 10.1001/jama.2024.1278. [DOI] [PubMed] [Google Scholar]
- 7.US Department of Health and Human Services . U.S. Department of Health and Human Services; 2020. The surgeon general’s call to action to support maternal health. [Google Scholar]
- 8.Kozhimannil K.B., Interrante J.D., Tuttle M.S., Gilbertson M., Wharton K.D. Local capacity for emergency births in rural hospitals without obstetrics services. J Rural Health. 2021;37(2):385–393. doi: 10.1111/jrh.12539. [DOI] [PubMed] [Google Scholar]
- 9.Petersen E.E., Davis N.L., Goodman D., et al. Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423–429. doi: 10.15585/mmwr.mm6818e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Arkansas Department of Health . Arkansas Department of Health; 2021. Arkansas maternal mortality review committee: 2018 Arkansas maternal mortality case summary and committee recommendations. [Google Scholar]
- 11.Preiksaitis C., Saxena M., Zhang J., Henkel A. Prevalence and characteristics of emergency department visits by pregnant people: an analysis of a national emergency department sample (2010–2020) West J Emerg Med. 2024;25(3):436–443. doi: 10.5811/westjem.60461. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Malik S., Kothari C., MacCallum C., Liepman M., Tareen S., Rhodes K.V. Emergency department use in the perinatal period: an opportunity for early intervention. Ann Emerg Med. 2017;70(6):835–839. doi: 10.1016/j.annemergmed.2017.06.020. [DOI] [PubMed] [Google Scholar]
- 13.Hoyert D. Maternal mortality rates in the United States, 2020. 2022. NCHS Health E-Stats. Published online 2022. [DOI] [PubMed]
- 14.Landis R.K., Stein B.D., Griffin B.A., Saloner B.K., Terplan M., Faherty L.J. Disparities in perinatal and emergency care receipt among women with perinatal opioid use disorder in Medicaid, 2007 to 2012. J Addict Med. 2023;17(6):654–661. doi: 10.1097/ADM.0000000000001199. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Osterman M.J.K., Hamilton B.E., Martin J.A., Driscoll A.K., Valenzuela C.P. Births: final data for 2022. Natl Vital Stat Rep. 2024;73(2):1–56. [PubMed] [Google Scholar]
- 16.National Center for Health Statistics . Centers for Disease Control and Prevention; 2024. Maternal deaths and mortality rates: each state, the District of Columbia, United States, 2018-2021.https://www.cdc.gov/nchs/maternal-mortality/mmr-2018-2022-state-data.pdf [Google Scholar]
- 17.World Health Organization Trends in maternal mortality 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization. 2025. https://data.unicef.org/resources/trends-in-maternal-mortality-2000-to-2023/
- 18.Arkansas Department of Human Services Arkansas hospitals with emergency rooms. Arkansas Department of Human Services. https://humanservices.arkansas.gov/wp-content/uploads/Arkansas_Hospital_Emergency_Rooms.pdf
- 19.The PRIMROSE Project Maternity care access in Arkansas. Arkansas Maternal Health Scorecard. https://ar.maternalhealth.us
- 20.World Health Organization . World Health Organization; 2009. Monitoring obstetric emergency care: a handbook. [Google Scholar]
- 21.Butwick A.J., Goodnough L.T. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anaesthesiol. 2015;28(3):275–284. doi: 10.1097/ACO.0000000000000180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Lagrew D., McNulty J., Sakowski C., Cape V., McCormick E., Morton C. Improving health care response to obstetric hemorrhage, a California Maternal Quality Care Collaborative toolkit. California Maternal Quality Care Collaborative. 2022 [Google Scholar]
- 23.Mitzman J., Pfeil S.A., Rahurkar S., et al. Virtual obstetric emergency simulations: enhancing knowledge, skills, and confidence of emergency medicine and obstetric professionals. Am J Perinatol. 2025;42(6):773–780. doi: 10.1055/a-2419-8810. [DOI] [PubMed] [Google Scholar]
- 24.Callahan M. Emergency delivery. Emerg Med Clin North Am. 2023;41(2):281–294. doi: 10.1016/j.emc.2022.12.002. [DOI] [PubMed] [Google Scholar]
- 25.Martin J.A., Hamilton B.E., Osterman M.J., Curtin S.C., Matthews T.J. Births: final data for 2013. Natl Vital Stat Rep. 2015;64(1):1–65. [PubMed] [Google Scholar]
- 26.Parker S.E., Ajayi A., Yarrington C.D. De novo postpartum hypertension: incidence and risk factors at a safety-net hospital. Hypertension. 2023;80(2):279–287. doi: 10.1161/HYPERTENSIONAHA.122.19275. [DOI] [PubMed] [Google Scholar]
- 27.Sharma K.J., Kilpatrick S.J. Postpartum hypertension: etiology, diagnosis, and management. Obstet Gynecol Surv. 2017;72(4):248–252. doi: 10.1097/OGX.0000000000000424. [DOI] [PubMed] [Google Scholar]
- 28.Boushra M., Natesan S.M., Koyfman A., Long B. High risk and low prevalence diseases: eclampsia. Am J Emerg Med. 2022;58:223–228. doi: 10.1016/j.ajem.2022.06.004. [DOI] [PubMed] [Google Scholar]
- 29.Kruger J., Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77(6):1121–1134. doi: 10.1037//0022-3514.77.6.1121. [DOI] [PubMed] [Google Scholar]
- 30.Borhart J., Voss K. Precipitous labor and emergency department delivery. Emerg Med Clin North Am. 2019;37(2):265–276. doi: 10.1016/j.emc.2019.01.007. [DOI] [PubMed] [Google Scholar]
- 31.Janicki A.J., MacKuen C., Hauspurg A., Cohn J. Obstetric training in emergency medicine: a needs assessment. Med Educ Online. 2016;21(1) doi: 10.3402/meo.v21.28930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Robinson D.W., Anana M., Edens M.A., et al. Training in emergency obstetrics: a needs assessment of U.S. emergency medicine program directors. West J Emerg Med. 2018;19(1):87–92. doi: 10.5811/westjem.2017.10.35273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Brolinson M., Tondo-Steele K., Chan M., Gable B. Multidisciplinary in situ simulation to improve emergency obstetric care. BMJ Simul Technol Enhanc Learn. 2020;6(3):190–191. doi: 10.1136/bmjstel-2019-000488. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Polnaszek B.E., Griffin L.B., Whelan A.R., et al. Obstetric emergency simulation: a pre/post survey analysis of high-fidelity teamwork among emergency department physicians. R I Med J (2013) 2024;107(7):36–38. [PubMed] [Google Scholar]
- 35.Emergency Nurses Association, Association of Women’s Health, Obstetric and Neonatal Nurses Emergency care for patients during pregnancy and the postpartum period: Emergency Nurses Association and Association of Women’s Health, Obstetric and Neonatal Nurses Consensus Statement. Emergency Nurses Association. 2020 [Google Scholar]
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