Maternal, Child & Adolescent Health Division

CA-PARC • Obstetric Hemorrhage PAMR CommitteePrevention of Obstetric Hemorrhage Deaths:Recommendations for Agencies, Organizations, and Institutions

The California Pregnancy-Associated Review Committee (CA-PARC) was established to review and report on California’s maternal deaths (HSC 123636). While the California Department of Public Health (CDPH) provides administrative and scientific support to CA-PARC, recommendations for preventing maternal deaths are made solely by the members of CA-PARC.

The Obstetric Hemorrhage Pregnancy-Associated Mortality Review Committee, part of CA-PARC, looked at obstetric hemorrhage deaths in California between 2014 and 2018. Obstetric hemorrhage refers to excessive bleeding during pregnancy, childbirth, or postpartum. During this time, there were 2,409,732 live births and 49 deaths from obstetric hemorrhage. The committee identified several causes of hemorrhage, and some were more preventable than others. Improving preconception health and using system-based strategies for hemorrhage preparedness, detection, and clinical management are key to reducing deaths from hemorrhage.

Key findings from reviews of 49 obstetric hemorrhage deaths:

After cardiovascular disease, hemorrhage was the second leading cause of pregnancy-related deaths in California from 2014 to 2018

Top causes of hemorrhage*:

*Total doesn’t add up to 100% due to rounding

Placenta accreta spectrum is a group ofplacental disorders caused by the placentaattaching abnormally to the uterus (womb) which can lead to serious pregnancycomplications such as severe hemorrhage.
Intra-abdominal bleeding/laceration is bleeding in the space between abdominal muscles and internal organs as a result of a pregnancy complication or complications of surgery.
Uterine atony refers to uterus muscles failing to contract (tighten) after childbirth, which is needed to close off blood vessels.
Ruptured ectopic pregnancy is when the fertilized egg attaches and grows outside the uterus and bursts causing life-threatening bleeding.

Characteristics of the individuals who died:

58% had two or more births prior to death compared to 29% of the birthing population
75% had a first-time or repeat cesarean delivery compared to 32% of the birthing population
33% gave birth at hospitals with fewer than 1,200 annual births (low birth volume) compared to 12% of the birthing population

Preventability:

63% of all hemorrhage deaths likely could have been avoided, withsome causes—such as uterine atony and intra-abdominal bleeding/lacerations—more preventable than others

Health Care Contributing Factors:

89% of the deaths were linked to clinician, facility, or healthcare system factors that happened during or after labor in hospitals
78% delays in acting quickly or getting more advanced care
72% delays in recognizing the signs and symptoms of hemorrhage
53% not giving enough blood products when it was needed

Patient-level Contributing Factors:

55% of deaths were related to patient-level factors
20% Anemia (low iron)
18% Chronic conditions like heart disease or obesity

These findings were adapted from Krakowiak P, Morton CH, et al. Pregnancy-Related Mortality in California Due to Obstetric Hemorrhage. Obstet Gynecol. 2025 Feb 13. doi: 10.1097/AOG.0000000000005847. Reprinted with permission from Wolters Kluwer Health, Inc., copyright #6290470073999.

CA-PARC Prevention Recommendations for Agencies, Organizations, and Institutions:

Encourage sexual and reproductive health education in schools, clinics, and other community settings.
Raise awareness via an educational media campaign about menstrual cycles and warning signs of ectopic pregnancy among individuals who can get pregnant.
Raise awareness via educational campaigns about the importance of having good iron stores prior to and during pregnancy.
Develop wrap-around, person-centered, accessible support services for pregnant and postpartum individuals with complex social needs and barriers to accessing quality care.
Educate families to not delay calling 911 or going to the Emergency Department in emergent situations for pregnant or postpartum individuals.
Decriminalize consequences for pregnant or postpartum persons with substance use disorder to encourage all to access care early and often.

The findings and recommendations in this document are those of CA-PARC and do not necessarily represent the views or opinions of the California Department of Public Health (CDPH) or the California Health and Human Services Agency. While CDPH provides administrative and scientific support to CA-PARC, recommendations for preventing maternal deaths are made solely by the members of CA-PARC.

CDPH/MCAH acknowledges the invaluable contributions of the CA-Pregnancy-Associated Mortality Review Committee (Obstetric Hemorrhage) in generating essential data for this factsheet from their reviews of maternal deaths.

Resources:

Identifying and Managing Obstetric Emergencies in Nonobstetric Settings: Developed by The American College of Obstetrics and Gynecology and the Centers for Disease Control and Prevention (CDC).
Improving Health Care Response to Obstetric Hemorrhage Toolkit, Version 3.0: A toolkit for clinicians and healthcare facilities outlining best practices to manage obstetric hemorrhage using the 4-R Framework: Readiness, Recognition & Prevention, Response, and Reporting/Systems Learning.
CDC HEAR HER Campaign: A resource for women who are pregnant to raise awareness of urgent maternal warning signs during and after pregnancy.

Also see Recommendations for Clinicians, Facilities and Healthcare Systems.