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Maternal, Child and Adolescent Health Division

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

women consulting health care professional

Pregnancy-related mortality is a rare but tragic event for the families left behind and society as a whole. With the ultimate goal to eliminate preventable deaths related to or aggravated by pregnancy and associated racial/ethnic and health inequities, the California Pregnancy-Associated Mortality Review (CA-PAMR) was established to comprehensively review deaths among pregnant or recently pregnant Californians, up to one year after pregnancy. (For information on how these deaths are identified, visit CA-PMSS.)

Each death is examined through a health equity lens and discussions include how social determinants of health, discrimination and racism may have contributed to the death. Through detailed case reviews,  CA-PAMR's multidisciplinary committees of clinical and community experts identify the underlying causes of deaths related to physiologic changes of pregnancy or from causes aggravated by pregnancy or its management (pregnancy-related deaths); uncover contributing factors; determine quality improvement opportunities at the patient, provider, facility, system and community levels; and make actionable data-informed recommendations for preventing pregnancy-related deaths and optimizing maternal health outcomes and experiences equitably for all women and birthing people.

The Maternal, Child and Adolescent Health (MCAH) Division established CA-PAMR in 2006 following a dramatic rise in maternal mortality. CA-PAMR is a collaboration between MCAH and its contracting partners at Stanford University's California Maternal Quality Care Collaborative (CMQCC), the Public Health Institute (PHI) and Cedars-Sinai Medical Center.

Current Reviews

Statewide Review of Obstetric Hemorrhage Deaths, 2014-2018

This focused-topic review is examining deaths due to obstetric hemorrhage in 2014-2018.

Southern California Pregnancy-Associated Mortality Review, 2019-ongoing

This is a regional, population-based review of all deaths suspected to be medically related to pregnancy that occurred in Los Angeles, Orange, Riverside and San Bernardino counties beginning in 2019. This region was defined based on the annual number of pregnancy-related deaths, sociodemographic diversity, systems of care, and geographic proximity of the counties.

Planned Reviews

Statewide Review of Deaths from COVID-19, 2020-2021+

This focused review will examine deaths due to COVID-19 to provide insights for prevention of future deaths from novel infection during a pandemic.​​

Past Reviews


Hemorrhage PAMR is supported by the Health Resources and Services Administration (HRSA) Title V Maternal Child Health Block Grant. Southern CA PAMR is supported with grant funding from the Centers for Disease Control and Prevention (CDC)’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Program. Past reviews of obstetric/medical causes in 2002-2007 and pregnancy-associated suicide in 2002-2012 were supported by the HRSA Title V Maternal Child Health Block Grant.

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