• Beverley Lawton, Evelyn Jane MacDonald, Selina Ann Brown, Leona Wilson, James Stanley, John David Tait, Richard Alan Dinsdale, Carolyn Lee Coles, and Stacie E Geller.
• Women's Health Research Center, Department of Primary Care, University of Otago, Wellington, New Zealand. Electronic address: Bev.lawton@otago.ac.nz.
• Am. J. Obstet. Gynecol. 2014 Jun 1; 210 (6): 557.e1-6.

ObjectiveWe sought to assess potential preventability of severe acute maternal morbidity (SAMM) cases admitted to intensive-care units (ICUs) or high-dependency units (HDUs).Study DesignInclusion criteria were admissions to ICUs or HDUs of women who were pregnant or within 42 days of delivery in 4 District Health Board areas (accounting for a third of annual births in New Zealand) during a 17-month period. Cases were reviewed by external multidisciplinary panels using a validated model for assessing preventability.ResultsIn all, 98 SAMM cases were assessed; 38 (38.8%) cases were deemed potentially preventable, 36 (36.7%) not preventable but improvement in care was needed, and 24 (24.5%) not preventable. The most frequent preventable factors were clinician related: delay or failure in diagnosis or recognition of high-risk status (51%); and delay or inappropriate treatment (70%). The most common causes of preventable severe morbidity were blood loss and septicemia.ConclusionThe majority of SAMM cases were potentially preventable or required improvement in care. Themes around substandard care related to delay in diagnosis and treatment for postpartum hemorrhage and septicemia. These findings can inform clinical educational programs and policies to improve maternal outcomes. This study has now been expanded to a national New Zealand audit of all SAMM cases admitted to an ICU/HDU.Copyright © 2014 Mosby, Inc. All rights reserved.

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