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California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings

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Abstract

After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999–2001 to a high of 14.0 deaths per 100,000 live births in 2006–2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20 %), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40 % of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

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References

  1. Kuklina, E., Meikle, S., Jamieson, D., Whiteman, M., Barfield, W., Hillis, S., et al. (2009). Severe obstetric morbidity in the United States: 1998–2005. Obstetrics and Gynecology, 113(2 Pt 1), 293–299.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Danel, I., Berg, C., Johnson, C. H., & Atrash, H. (2003). Magnitude of maternal morbidity during labor and delivery: United States, 1993–1997. American Journal of Public Health, 93(4), 631–634.

    Article  PubMed Central  PubMed  Google Scholar 

  3. Fridman, M., Korst, L., Lu, M., Shah, S., Chow, J., Boumediene, S., & Gregory, K. D. Trends in maternal morbidities in California, 1999–2005. 2010. Available at: http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf. Accessed January 21, 2013.

  4. Berg, C., Danel, I., Atrash, H., Zane, S., & Bartlett, L. (2001). Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta: Centers for Disease Control and Prevention.

    Google Scholar 

  5. Berg, C., Callaghan, W., Henderson, Z., & Syverson, C. (2010). Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology, 116(6), 1302–1309.

    Article  PubMed  Google Scholar 

  6. Callaghan, W. M. (2012). Overview of maternal mortality in the United States. Seminars in Perinatology, 36(1), 2–6.

    Article  PubMed  Google Scholar 

  7. Hoyert, D. L. (2007). Maternal mortality and related concepts. NCHS Vital Health Statistics, 3(33).

  8. Danielsen, B. Probabilistic Record Linkages for Generating a Comprehensive Epidemiological Research File on Maternal and Infant Health. Health Information Solutions; 2000. Available at: http://www.health-info-solutions.com/Probabilistic%20Record%20Linkages%20may%202002.pdf. Accessed January 21, 2013.

  9. Phibbs, C. S., Baker, L. C., Caughey, A. B., Danielsen, B., Schmitt, S. K., & Phibbs, R. H. (2007). Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. New England Journal of Medicine, 356(21), 2165–2175.

    Article  CAS  PubMed  Google Scholar 

  10. Hernandez, L., Sappenfield, W., Burch, D. Florida’s pregnancy-associated mortality review 2008 update. Florida Department of Health 2010. Available at: http://www.doh.state.fl.us/family/mch/docs/2008_pamr_update.pdf. Accessed August 16, 2010.

  11. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). London: Sage Publications.

    Google Scholar 

  12. Geller, S. E., Cox, S. M., & Kilpatrick, S. J. (2006). A descriptive model of preventability in maternal morbidity and mortality. Journal of Perinatology, 26(2), 79–84.

    Article  CAS  PubMed  Google Scholar 

  13. Geller, S. E., Adams, M. G., Kominiarek, M. A., Hibbard, J. U., Endres, L. K., Cox, S. M., et al. (Jan 2007). Reliability of a preventability model in maternal death and morbidity. Am J Obstet Gynecol, 196(1):57 e1–6.

  14. Dedoose Web Application for managing, analyzing and presenting qualitative and mixed method data. Los Angeles Sociocultural Research Consultants, LLC; 2012.

  15. Centre for Maternal and Child Enquiries (CMACE). (2011). Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer: 2006–08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG, 118(Suppl. 1), 1–203.

  16. Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., et al. (2005). Preventability of pregnancy-related deaths: Results of a state-wide review. Obstetrics and Gynecology, 106(6), 1228–1234.

    Article  PubMed  Google Scholar 

  17. Horon, I. L. (2005). Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. American Journal of Public Health, 95(3), 478–482.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Main, E. K. (2012). Decisions required for operating a maternal mortality review committee: the California experience. Seminars in Perinatology, 36(1), 37–41.

    Article  PubMed  Google Scholar 

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Acknowledgments

Funding for the California Pregnancy-Associated Morality Review was provided from the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Title V MCH Block Grant. We gratefully acknowledge leadership of Catherine Camacho, Deputy Director, Center for Family Health, and Dr. Shabbir Ahmad, California MCAH Title V Director. We also acknowledge Amy Godecker, Ph.D., for her work in the early development of CA-PAMR, as well as the generous volunteer contribution of the CA-PAMR Committee members. Finally, we appreciate the advice and consultation of Drs. Cynthia Berg and William Callaghan at the Centers for Disease Control and Prevention, Division of Reproductive Health.

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Correspondence to Elizabeth Lawton.

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Mitchell, C., Lawton, E., Morton, C. et al. California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings. Matern Child Health J 18, 518–526 (2014). https://doi.org/10.1007/s10995-013-1267-0

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