Background:
Pregnancy-related mortality rates have increased in California since 2000 and are four times higher than the Healthy People 2010 goal of 3.3/100,000 births. Each maternal death is a sentinel event, suggesting that serious morbidity is also increasing. The California Department of Public Health, Maternal, Child and Adolescent Health/Office of Family Planning (MCAH/OFP) Branch has begun the California Pregnancy-Associated Mortality Review (CA-PAMR), a quality improvement (QI) surveillance and medical record review project. CA-PAMR is linked to the California Maternal Quality Care Collaborative (CMQCC) which will develop, implement, and coordinate the QI initiatives.

Objectives:
To describe CA-PAMR's innovative methodology and present preliminary results from the 2002 cohort review, including preconception characteristics that contributed to pregnancy-related deaths.

Methods:
CA-PAMR identifies, through linked data bases of birth and death certificates, a cohort of cases that will be reviewed annually. Abstracted medical records, death certificates, coroner and autopsy reports are reviewed by medical and nursing leaders to determine cause of death and whether the death was pregnancy-related. Contributing factors are identified based on community, patient, health care facility, and health care professional domains. Public health recommendations and QI opportunities for hospitals and medical personnel are coordinated through the MCAH/OFP Branch and CMQCC.

Results:
In 2002, California's pregnancy-related mortality rate from vital records was 10.6 deaths per 100,000 live births. This rate increased to 13.6 by 2004. In the 2002 cohort, 194 women died within 365 days of a 2002 live birth or fetal death. The case selection process and the review process will be described. A summary of the preliminary results that have implications for pre-conceptual care will be presented, including the contribution of pre-conceptual obesity, morbidity, and short birth intervals.

Conclusion and implications for practice:
Due to the high volume of births in California, approximately 550,000 births a year, CA-PAMR is uniquely positioned to identify QI opportunities related to pre-conceptual care that may have implications for other states. Improving maternal health status and reducing morbidity prior to pregnancy would reduce pregnancy-related morbidity and mortality in California.