BackgroundMaternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).Severe maternal morbidity in high-income countriesSince the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.Severe maternal morbidity in low and middle income countriesThe highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.Effects of SMM on delivery outcomes and infantsSevere maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.ConclusionIncreasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

OBJECTIVE To address rising rates of severe maternal morbidity and persistent racial disparities, Illinois established severe maternal morbidity review in all obstetric hospitals. The purpose of this study is to describe the findings from the statewide severe maternal morbidity review in 2018. METHODS This is a retrospective analysis of a hospital-level severe maternal morbidity review that occurred in 2018 (n=408) compared with all 2018 Illinois live births (n=141,595), inclusive of any severe maternal morbidity cases resulting in a live birth before hospital discharge. Cases were chosen for review based on completeness of records, complexity of the case, or an assessment that cases presented opportunities for learning and quality improvement; ie, not all severe maternal morbidity cases were reviewed. We present descriptive characteristics that contributed to the severe maternal morbidity event, and health care professional, system, and patient opportunities to alter the severe maternal morbidity outcome. RESULTS A total of 408 severe maternal morbidity cases were reviewed. Women with severe maternal morbidity were more likely to be non-Hispanic Black, multiparous, aged 35 years or older, have public insurance, and receive inadequate prenatal care. The most common causes of severe maternal morbidity were hemorrhage (48%), and preeclampsia and eclampsia (20%). Overall, 42% of severe maternal morbidity cases had opportunities to improve care. Non-Hispanic Black women had a disproportionately high burden of severe maternal morbidity due to preeclampsia and eclampsia (31% vs 18.1%) and were more likely to need improvement in care compared with non-Hispanic White women (53% vs 39.0%). The most common opportunities to alter the severe maternal morbidity outcome were health care professional factors during the intrapartum (9%) and postpartum (10%) periods. CONCLUSION Standardized severe maternal morbidity review gives a fuller view of the state of maternal health and highlights opportunities to improve quality of care.

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Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.