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Pregnancy-Related Mortality in California Due to Obstetric Hemorrhage
Paula Krakowiak1, Christine H Morton, Christy McCain
1Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, the Public Health Institute, Santa Cruz, the Marian Perinatal Center, Pacific Central Coast Community Clinics, San Luis Obispo, the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, the California Maternal Quality Care Collaborative and Department of Obstetrics and Gynecology-Maternal-Fetal Medicine, Stanford University, Stanford, the Department of Anesthesia and Perioperative Care and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, and the Kaiser Permanente San Francisco Medical Center, San Francisco, the School of Nursing, California State University, Stanislaus, Turlock, the Amniotic Fluid Embolism Foundation, Vista, and the California Nurse-Midwives Association, Santa Rosa, California.
Insights
Pregnancy-related hemorrhage deaths are often preventable, with placenta accreta spectrum and uterine atony as leading causes. Improving system-based approaches for hemorrhage detection and management is critical to reduce mortality.
Area of Science:
- Obstetrics and Gynecology
- Maternal Mortality Research
- Public Health
Background:
- Pregnancy-related hemorrhage is a significant cause of maternal mortality.
- Identifying specific causes and contributing factors is crucial for prevention strategies.
Purpose of the Study:
- To identify underlying causes, contributing factors, and quality-improvement opportunities for pregnancy-related hemorrhage deaths in California.
- To analyze trends and risk factors associated with these deaths.
Main Methods:
- The California Pregnancy-Associated Mortality Review analyzed data from 2014-2018.
- Data sources included vital records, hospital data, medical records, and coroner reports.
- A multidisciplinary expert panel reviewed case summaries to determine causes, preventability, and contributing factors.
Main Results:
- Placenta accreta spectrum, intra-abdominal bleeding, and uterine atony were leading causes of hemorrhage deaths.
- Higher risk was observed in older mothers, those with prior cesarean deliveries, and deliveries at lower-volume hospitals.
- A significant proportion (63.3%) of deaths were deemed highly preventable, with clinician, facility, and system factors contributing to 88.9% of cases.
Conclusions:
- Obstetric hemorrhage is a multifactorial issue with varying levels of preventability.
- Optimizing system-based approaches for hemorrhage preparedness, detection, and clinical management is essential to reduce preventable maternal deaths.
Objective:
To identify underlying causes, contributing factors, and quality-improvement opportunities of pregnancy-related hemorrhage deaths.
Methods:
The California Pregnancy-Associated Mortality Review examined pregnancy-related hemorrhage deaths in California that occurred in 2014-2018. Data were abstracted from multiple sources (vital records, hospital encounter data, medical records, and coroner or autopsy reports). A multidisciplinary expert panel reviewed all case summaries. Data from reviews were aggregated to determine underlying causes of death, preventability, contributing factors, and quality-improvement opportunities at the patient, clinician, facility, and system levels.
Results:
During the study period, there were 2,409,732 live births and 49 pregnancy-related hemorrhage deaths. Placenta accreta spectrum accounted for 16 (32.7%) of deaths; intra-abdominal bleeding and uterine atony each accounted for 10 deaths (20.4%). Compared with the California birth population, a significantly higher proportion of women who died were born in China (14.3% vs 3.9%); were 35 years of age or older (49.0% vs 21.9%); had two or more prior births (57.4% vs 29.1%); had cesarean deliveries (74.4% vs 31.8%); or delivered at hospitals with fewer than 1,200 births per year (33.3% vs 12.2%) (all P <.05). The committee determined that 63.3% of all hemorrhage deaths were highly preventable with substantial variation by cause. Clinician-, facility-, and system-level contributing factors were noted in 88.9% of cases and included delayed response or escalation (77.8%), delayed recognition (72.2%), and insufficient quantities of blood products used (52.8%). Corresponding quality-improvement opportunities included timely hemorrhage risk assessment; increased vigilance for identifying signs and symptoms of hemorrhage; escalation of care and aggressive management; preparation for hemorrhage complications and ongoing training for all hospitals, particularly low-resource facilities; and adherence to severe hemorrhage protocols.
Conclusion:
Obstetric hemorrhage remains a leading cause of pregnancy-related mortality and has multiple causes with various levels of preventability. Optimizing system-based approaches for hemorrhage preparedness, detection, and clinical management is critical to reduce preventable deaths from hemorrhage, especially among patients who do not respond to first-line treatment.
