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Maternal, Child and Adolescent Health Division

The California Pregnancy Mortality Surveillance System (CA-PMSS)

Maternal mortality is a key indicator of population health. Deaths in pregnancy and postpartum should be rare events, so routine and accurate surveillance of pregnancy-related deaths is an essential public health responsibility. CA-PMSS is a statewide surveillance of deaths among Californians who were pregnant within the prior year. The Maternal, Child and Adolescent Health (MCAH) Division of the California Department of Public Health (CDPH) initiated CA-PMSS in 2018 to provide a timely and accurate accounting of deaths related to or aggravated by the pregnancy or its management. In CA-PMSS, deaths are identified by complex data linkage of vital statistics data and patient-level administrative data from hospitals, emergency departments and ambulatory surgery centers. Coroner and autopsy reports and medical records are used to verify pregnancy status and timing to death. A committee of experts conducts limited case reviews of the deaths to determine the underlying cause of death and whether it was related to pregnancy.

The goal of CA-PMSS is to monitor deaths related to pregnancy using the most accurate information available. While the commonly used maternal mortality ratio (MMR) remains a key indicator of the overall health of a population, it relies solely on death certificate data. CA-PMSS compiles the findings from its more complex data linkage and expert committee review to create a pregnancy-related mortality ratio (PRMR), allowing California to monitor deaths related to pregnancy using the most accurate information available .

Here are the major differences between the two maternal mortality measures:

Major differences

Pregnancy-Related Mortality Ratio (PRMR) as used in CA-PMSS and CA-PAMR and by CDC RDH*

Maternal Mortality Ratio (MMR) as used by the CDC NCHS**

Time frame

Deaths while pregnant and up to ONE YEAR after the end of a pregnancy.

Deaths while pregnant or up to 42 days after the end of the pregnancy.

Data sources

Cases are identified by complex data linkage of vital records (i.e., death, birth and fetal death files) and administrative data (i.e., patient discharge, emergency department and ambulatory surgery center data). These data are then supplemented with coroner and autopsy reports and medical records to confirm pregnancy status, verify timing to death and augment case information. (Note: CDC uses linked vital statistics data files but does not have access to state administrative data, coroner reports or medical records.)

Death certificate data

Relationship to pregnancy

Generated using cause-of-death and pregnancy-relatedness determinations made by expert committee review. (Note: At CDC, determinations are made by two medical epidemiologists.)

Defined only by obstetric ICD-10 codes from the death certificate data files.

* CDC's Division of Reproductive Health's Pregnancy Mortality Surveillance System (PMSS) reports the national pregnancy-related mortality ratio

** CDC's National Center for Health Statistics' National Vital Statistics System CDC's National Center for Health Statistics' National Vital Statistics System (NVSS) reports the national maternal mortality ratio

Funded by the federal Title V Maternal and Child Health Block Grant, CA-PMSS relies on a collaboration with three key partners: The Public Health Institute , Stanford University's California Maternal Quality Care Collaborative , and a volunteer review committee of experts.

Key Findings

What are the key report findings?

Published: September 7, 2021

Duration: 1:21

Audio (MP3) | Transcript (PDF)

Pregnancy-Related Mortality Ratio by Geographic Region, California 2008-2016

The highest pregnancy-related mortality ratio was in the Southern Central Valley region.

Pregnancy-Related Mortality Ratio in California, 2008-2016

California’s annual pregnancy-related mortality ratios (PRMRs) remained low and largely stable in 2008-2016, except for spike in 2009.

Pregnancy-Related Mortality Ratio by Race/Ethnicity, California 2008-2016

Racial/ethnic disparities in pregnancy-related mortality ratios widened between 2008 and 2016.

Methodology

Health Equity

On the Horizon

Meet the Team

CA-PMSS Project Team

CDPH MCAH Division

Paula Krakowiak, PhD, MS – Team Lead

Dan Sun, MA

Public Health Institute

Christy McCain, MPH

Delphina Alvarez

California Maternal Quality Care Collaborative

Elliott K. Main, MD

Christine H. Morton, PhD

Past team members:

David J. Reynen, DrPH, MA, MPPA, MPH, CPH

Diana E. Ramos, MD, MPH

CA-PMSS Review Committee

Elliott K. Main, MD – Committee Chair

California Maternal Quality Care Collaborative

(Maternal Fetal Medicine)

Maurice Druzin, MD

Stanford University

(Maternal Fetal Medicine)

Afshan Hameed, MD

University of California, Irvine

(Cardiology, Maternal Fetal Medicine)

Thomas Kelly, MD

University of California, San Diego

(Maternal Fetal Medicine)

Natalie Martina, CNM, MSN

Alta Bates Medical Center, Berkeley

(Nurse Midwifery)

Past committee members:

Kimberly Gregory, MD, MPH
Cedars-Sinai Medical Center
(Maternal Fetal Medicine)

Marla Seacrist, PhD, RNC
California State University, Stanislaus
(Obstetric and Neonatal Nursing)

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