Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

Objective: We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. Study Design: This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. Results: Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. Conclusion: Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.