title: Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.
abstract: OBJECTIVE
  The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data.
  
  
  METHODS
  We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data.
  
  
  RESULTS
  Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases.
  
  
  CONCLUSIONS
  Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.
authors.affiliation: Hospital Corporation of America, Nashville, TN.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Clark
authors.affiliation: Hospital Corporation of America, Nashville, TN.
authors.forename: James T
authors.initials: JT
authors.lastname: Christmas
authors.affiliation: Hospital Corporation of America, Nashville, TN.
authors.forename: Donna R
authors.initials: DR
authors.lastname: Frye
authors.affiliation: Hospital Corporation of America, Nashville, TN.
authors.forename: Janet A
authors.initials: JA
authors.lastname: Meyers
authors.affiliation: Hospital Corporation of America, Nashville, TN.
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Perlin
mesh_terms: D000293:Adolescent; D000328:Adult; D000959:Antihypertensive Agents / Q000627:therapeutic use; D002423:Cause of Death; D002585:Cesarean Section / Q000401:mortality*; D057189:Checklist; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D046110:Hypertension, Pregnancy-Induced / Q000188:drug therapy* / Q000401:mortality; D048228:Intermittent Pneumatic Compression Devices; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D008428:Maternal Mortality / Q000639:trends*; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D011655:Pulmonary Embolism / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D012189:Retrospective Studies; D014187:Transportation of Patients / Q000379:methods / Q000592:standards; D014218:Triage / Q000379:methods / Q000592:standards; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000959:Antihypertensive Agents
keywords: checklist; maternal mortality rate; patient safety