Maternal mortality has been steadily increasing over the past decade, both in California and in the United States. The rate of maternal deaths in California in 1999 was 8.0 deaths per 100,000 live births, and by 2008 it had increased to 14.0. In 2006, the California Department of Public Health Maternal, Child and Adolescent Health Program initiated the California Pregnancy-Associated Mortality Review, or CA-PAMR, in collaboration with the California Maternal Quality Care Collaborative and the Public Health Institute to investigate the reasons for the rise in maternal mortality. CA-PAMR reviews medical records of maternal deaths, and we are fortunate to have the voluntary service of a statewide, multidisciplinary group of leading clinical experts in maternal health. This committee determines the causes of maternal mortality and identifies quality improvement opportunities in maternity care and public health strategies to prevent maternal deaths. Funding for CA-PAMR is provided by the Federal Title V Maternal and Child Health Block Grant Funds.

The following findings were taken from the recently released April, 2011 report, “The California Pregnancy-Associated Mortality Review Report From 2002 and 2003 Maternal Death Reviews,” available at: http://www.phi.org/pdf-library/2011-6-2MaternalDeathReview2002-03.pdf.

Women who died were, on average, poorer (based on payer source at labor and delivery) and less educated than the general population of women giving birth in California. There were high rates of obesity among the pregnancy-related deaths, and obesity or excessive gestational weight gain was determined to be a contributing factor in one of four deaths where data on weight was available.  

Racial/ethnic disparities continue to persist: African-American women have a four-fold higher risk of maternal death. African-American women were more likely than other groups to have been overweight or obese and were also more likely than other racial/ethnic groups to have died of cardiovascular-related causes. CA-PAMR will continue to explore potential explanations for these disparities and will continue efforts to eliminate this gap in health equity.

An important finding of this project was that over a third of pregnancy-related deaths were determined to have had a good or strong chance of being prevented, and several opportunities for improvement have been identified. With funding from the state Maternal, Child and Adolescent Health program, the California Maternal Quality Care Collaborative has been developing resources for health care providers to address the quality of care issues identified by CA-PAMR. One example is the Obstetric Hemorrhage Toolkit, which was developed to improve readiness, recognition, response and reporting of hemorrhage, a common cause of maternal death. The Collaborative also works with several county health departments to implement pilot projects to improve maternity outcomes. For more information on these resources, please visit www.cmqcc.org. 

Medical record review of pregnancy-related deaths has been a valuable tool to increase the accuracy of reporting for this important health indicator. We have identified additional pregnancy-related deaths, provided greater specificity on the underlying causes of death, and have re-evaluated the leading causes of death. For example, after case review, cardiovascular disease was found to be the leading cause of pregnancy-related deaths in 2002-2003; yet this health condition did not appear in the top five causes when only death certificate data were examined. A fuller description of the methodology utilized by CA-PAMR is included in the report (see link above) and may be of use to states that are considering initiating pregnancy-related mortality reviews.

For more information, contact Christy McCain, Research Scientist at the Public Health Institute, www.phi.org or christymccain@cruzio.com.