Characterizing Preventable Maternal Morbidity & Mortality
Attempts to address preventability or opportunities to alter outcome in women with severe maternal morbidity have been modeled after maternal death reviews and have focused on provider, system and patient factors and asked the question would the morbidity have been less or outcome improved if some aspect of care had been different. Specific areas identified that potentially negatively affected outcomes included delayed diagnosis, delayed treatment, failure to identify high risk, incomplete/inappropriate treatment, system issues are communication, documentation, equipment, protocols and medication.[20,21] Although, the CDC has recommended since 2001 that all maternal deaths in the USA should be reviewed in order to evaluate medical and nonmedical causes, analyze and interpret findings and then act on the results still today not all states have maternal mortality committees.[22,23] In contrast, The United Kingdom has consistently reviewed all maternal deaths and, based on interpretation of their data, mandated routine thrombotic risk assessment of all pregnant women with recommendations that resulted in postpartum heparin prophylaxis for most women delivering by cesarean, to reduce thromboembolic deaths.[24–26]
Women's Health. 2015;11(2):193-199. © 2015 Future Medicine Ltd.