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Maternal, Child and Adolescent Health Division

California Pregnancy-Associated Mortality Review ​(CA-PAMR)


The California Pregnancy-Associated Mortality Review (CA-PAMR) is a comprehensive statewide maternal mortality examination that aims to identify pregnancy-related deaths during pregnancy or within 1 year of the end of pregnancy, their causes, factors that contributed to the death, and improvement opportunities in maternity care and support, with the ultimate goal to reduce preventable deaths and associated health disparities. CA-PAMR is a collaborative effort between the Maternal, Child and Adolescent Health (MCAH) Division of the California Department of Public Health (CDPH) and its partners, Stanford University’s California Maternal Quality of Care Collaborative (CMQCC) and the Public Health Institute (PHI). Funding for CA-PAMR comes from the Federal Title V Maternal Child Health Block Grant.

About | Origins | Methods | Key Findings | Key Definitions


CA-PAMR was established in 2006 following a dramatic rise in maternal mortality in California from 7.7 deaths per 100,000 live births in 1999 to 16.9 deaths per 100,000 live births in 2006. In collaboration with Stanford University’s California Maternal Quality Care Collaborative (CMQCC) and the Public Health Institute (PHI), the California Department of Public Health developed a methodological approach to review maternal mortality cases.

Methods for Improving Maternal Mortality and Morbitiy

Since 2006, the CA-PAMR team has been identifying and reviewing cases of women who died while pregnant or with-in one year of the end of pregnancy (live birth, stillbirth, spontaneous or elective abortion, ectopic pregnancy etc.) from any cause. These are referred to as pregnancy-associated deaths. Identification of pregnancy-related deaths involves multiple steps.

  • First, hospital discharge data are linked to birth and death certificates to construct pregnancy-associated death cohorts for each birth year.
  • Second, potential pregnancy-related cases are selected, and additional data sources, including investigative reports (coroner, autopsy, toxicology) and medical records, are gathered and abstracted to provide more information about this subset of cases.
  • Next, an appointed CA-PAMR committee of health professionals reviews all potential pregnancy-related cases to determine cause of death, contributing factors, whether the death was pregnancy-related, and improvement opportunities in maternal care and support.
  • Finally, recommendations to prevent or reduce the risk of pregnancy-related deaths are developed and critically reviewed by key stakeholders.

Key Findings

  • 41% of pregnancy-related obstetric deaths had a good-to-strong chance of preventability
  • Cardiovascular disease is the leading cause of pregnancy-related death 
  • Racial and ethnic disparities persist: African-American women continue to experience 3- to 4-fold higher risk of a pregnancy-related death
  • Multiple patient, facility, and health care provider factors contributed to pregnancy-related deaths
  • Case reviews informed public health prevention programs and led to the development of maternity care quality improvement strategies, also known as California Toolkits to Transform Maternity Care
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