CA-PAMR (Maternal Mortality Review)

The California Pregnancy-Associated Mortality Review (CA-PAMR) (co-convened by CDPH/MCAH; CMQCC and PHI) is in its 15th year. This work has produced three reports, several peer-reviewed journal articles and provided the rationale for maternal quality toolkits that transformed the improvement opportunities into implementation efforts to better care for women who experience obstetric hemorrhage, hypertensive disorders of pregnancy, venous thromboembolism, sepsis and cardiovascular disease.  

Beginning in 2020, there are 3 separate reviews in process, with volunteer committees composed of clinicians and community members selected for their expertise, representativeness, and commitment to eliminating preventable maternal mortality and racial inequities.

  1. Pregnancy-Associated Mortality Surveillance System (PMSS), 2008-current

A small subset of reviewers from the 2002-2007 CA-PAMR report reviewed > 500 cases of deaths occurring to women within one year of pregnancy to determine pregnancy-relatedness and cause of death. The project produced a report on pregnancy-related deaths that occurred between 2008-2016. The CA-PMSS committee team is rapidly catching up to current data, and in April 2021 it began reviewing deaths from 2020.

  1. Statewide Review of Obstetric Hemorrhage Deaths, 2014-2019

This review examines cause of death and identifies quality improvement opportunities among the cases of women who died from hemorrhage.  We can assess whether there are changes over time since this period covers the CMQCC statewide implementation of hemorrhage bundles in > 200 hospitals. 

  1. Southern California Pregnancy-Associated Mortality Review, 2019-2020

Funded by a grant from the CDC-ERASE program, this review covers maternal deaths which occurred in Los Angeles, Orange, Riverside and San Bernardino counties in 2019.  The project is piloting a new data collection tool and incorporating social determinants of health perspectives in the identification of quality improvement opportunities. 

Funding Acknowledgement 

CA-PAMR is supported by federal Title V Maternal and Child Health block grant from the California Maternal, Child and Adolescent Health Division of the California Department of Public Health.