Audit of Severe Acute Maternal Morbidity Describing Reasons for Transfer and Potential Preventability of Admissions to ICU

Background: Maternal mortality is a rare event in the developed world. Assessment of severe acute maternal morbidity (SAMM) is therefore an appropriate measure of the quality of maternity care.

Aims: The aim of the study was to conduct a retrospective audit of SAMM cases (pregnant women admitted to a New Zealand Intensive Care Unit) to describe clinical, socio-demographic characteristics, pregnancy outcomes and preventability.

Methods: Severe acute maternal morbidity cases were reviewed by a multidisciplinary panel to determine reasons for admission to ICU, to classify organ-system dysfunction and to determine whether the SAMM case was preventable or not. Inclusion criteria were: admission to ICU between 2005 and 2007 during pregnancy or within 42 days of delivery.

Results: Twenty-nine SAMM cases were reviewed, of which 10 (35%) were deemed preventable. The most common reasons for transfer to ICU were: the need for invasive vascular monitoring, hypotension and disseminated intravascular coagulation. The most frequent types of preventable events were: inadequate diagnosis/recognition of high-risk status, inappropriate treatment, communication problems and inadequate documentation. All five SAMM cases of septicaemia were deemed preventable. Of the ten preventable cases, three were Maori (50% of the Maori in total audit), four were Pacific (67% of the Pacific in total audit) and three were women of 'other' ethnicities (17.6%, 3 of 17 in the audit).

Conclusions: An audit of SAMM cases describing reasons for transfer to ICU and preventability is feasible. We recommend that a prospective national SAMM audit process be introduced in New Zealand as a quality of care measure.