Preventing maternal mortality and morbidity from obstetric hemorrhage: A baseline assessment to guide public health and hospital-based quality improvement efforts

Obstetric hemorrhage is a leading cause of pregnancy-related mortality and morbidity worldwide and in California. Annually, about 2% of California's approximately 550,000 births involve hemorrhage. California's rise in maternal mortality (16.9 in 2006), is being analyzed by the Pregnancy-Associated Mortality Review (CA-PAMR), which includes enhanced surveillance and case review by a multi-disciplinary expert committee.

CA-PAMR reviews identified hemorrhage as primary cause of pregnancy-related deaths in 9.2% (n=98) of 2002-03 cases (occurring within one year and aggravated or caused by pregnancy). Among these deaths, 66.7% had good or strong chances to alter outcomes. This finding informed the 2008 online survey of obstetric practices in California hospitals with >50 deliveries/year (n=261; 536,233 births) with 173 (66%; 395,941 births) responding (2005 data). Key findings were lack of consistent definitions of hemorrhage; 66% lacked massive hemorrhage protocols and 66% did not perform on-site drills. Barriers to recognition and response were also identified: 1) lack of agreement on definitions, 2) difficulty in assessing amount of blood loss, 3) lack of coordinated team response, and 4) difficulty in obtaining needed personnel or supplies.

Postpartum hemorrhage is a leading cause of maternal death, yet the majority of California facilities lack standard practices. Maternal hemorrhage data-driven quality improvement projects are operational at three levels: 1) statewide open access tools; 2) a local community networking project led by a county public health department (n=10; 50,007 births), and; 3) a statewide multi-hospital (n=29; approximately 100,000 births) learning collaborative. An impact outcomes evaluation of these efforts is in progress.