CA-PAMR (Maternal Mortality Review)

Begun in 2006, the California Pregnancy-Associated Mortality Review (CA-PAMR) (co-convened by the Maternal, Child and Adolescent Health Division of the California Department of Public Health, Public Health Institute and CMQCCC) 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.  

In 2022, there are four 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.

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 reviewing deaths from 2020.

Findings up to 2019 from this review are available at the California pregnancy-related mortality dashboard from the California Department of Public Health, Maternal, Child and Adolescent Health Division. Here you will find state-level data for 2009-2019 at a glance, obtain more details for indicator subcategories, as well as download data for your own analyses.

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 and 2020. The project began reviewing cases in December 2020 and is piloting a new data collection tool which incorporates social determinants of health perspectives in the identification of quality improvement opportunities. Learn more about how the CDC supports maternal mortality review committees (MMRCs) at the Review to Action website.

Focused Statewide Review of Obstetric Hemorrhages Deaths, 2014-2018

This review examines cause of death and identifies quality improvement opportunities among the cases of women who died from hemorrhage. We aim to asess changes since this time period covers the CMQCC statewide introduction and implementation of hemorrhage bundles in > 200 hospitals in California. As of 5/13/2022, the committee reviews are complete and data analysis is underway.

Focused Statewide Review of Maternal Deaths due to COVID-19, 2020-2021

This review will look specifically at maternal deaths from COVID which occurred in 2020 and 2021. We are in the process of finalizing committee appointments and will commence the review in July 2022.

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.