Maternal Mortality Largely Preventable, Large Study Shows

Troy Brown, RN

March 12, 2015

The top five causes of maternal mortality in California are cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism, according to a recent study. The researchers also found that 41% to 70% of these cases might be preventable.

Elliott K. Main, MD, from California Maternal Quality Care Collaborative, Stanford University, Palo Alto, and the Department of Obstetrics and Gynecology, California Pacific Medical Center, San Francisco, and colleagues report their findings in the April issue of Obstetrics & Gynecology.

"We identified significant differences among the five leading causes of pregnancy-related death when compared with each other or with the California birth population for race, age, parity, gestational age, [body mass index], timing of death, induction, and delivery method," the authors explain. "Our findings point to specific actions to improve clinical recognition and response for each cause of death described subsequently."

"These findings also underscore the need for focused approaches to improve care such as hospital-based safety bundles for hemorrhage, preeclampsia, and venous thromboembolism prevention as well as comprehensive programs for patient education, communication, and teamwork development," the authors write. "Reversing increases in maternal mortality and severe morbidity requires the combined efforts of public health, clinical and hospital leaders, and their institutions."

The researchers used data from linked California birth and death certificates to identify pregnancy-related deaths from 2002 to 2005. They studied medical records, autopsy reports, and coroner reports to identify cause of death, clinical and demographic characteristics, chances for altering outcomes, contributing factors, and opportunities for quality improvement.

The researchers identified 207 pregnancy-related deaths. In addition to the top five causes, pregnancy-related deaths were caused by cerebrovascular accidents, sepsis from multiple nonobstetric sources, anesthesia complications, and other medical diagnoses, each of which affected from one to three women.

Among the top causes of mortality, the researchers found "differing patterns for race, maternal age, body mass index, timing of death, and method of delivery." For example, black women made up 6% of the births, but 39% of cardiovascular diseases deaths and 22% of all pregnancy-related deaths.

"Of the California birth cohort, 41% were 30 years or older compared with 67% of preeclampsia deaths, 75% of hemorrhage deaths, and 78% of amniotic fluid embolism deaths (P<.001), whereas the age distribution of women who died of cardiovascular disease and venous thromboembolism mirrored that of the California birth cohort," the authors explain.

"Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths," they add.

Patient-Related, Facility-Related Factors

Among preeclampsia deaths, the leading patient factors were delays in seeking medical care (42%), underlying medical conditions (39%), and probable knowledge deficit regarding severity of a symptom or condition (39%).

Among patients who died from hemorrhage, patient factors frequently identified were delays in seeking medical care (40%) and refusal of blood products among Jehovah's Witness adherents (20%).

Hemorrhage was the cause of death most frequently associated with facility factors including inadequate staff knowledge (42%), systems issues such as lack of massive transfusion protocols (30%), and problems with care coordination such as delays in administration of blood products (30%).

Researchers have created guidelines for developing obstetric emergency response teams to care for patients in five clinical situations: postpartum hemorrhage, shoulder dystocia, emergency cesarean delivery, eclamptic seizure, and maternal code.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2015;125:938-947.

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