OBSTETRICS Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital Lynn C. Sadler, MBChB, MPH; Diana M. Austin, MA; Vicki L. Masson, MPH; Colin J. McArthur, MBChB; Claire McLintock, MBChB; Sharon P. Rhodes, MBChB; Cindy M. Farquhar, MBChB, MD OBJECTIVE: The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review. STUDY DESIGN: All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contrib- utory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Peri- natal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group. RESULTS: Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings. CONCLUSION: Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary re- view team; priorities were identified for improvement of local maternity services. Key words: intensive care unit, maternity, multidisciplinary review, severe acute maternal morbidity Cite this article as: Sadler LC, Austin DM, Masson VL, et al. Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital. Am J Obstet Gynecol 2013;209:549.e1-7. T he maternal mortality ratio in New Zealand was 17.8 of 100,000 births in the 5 years of 2006-2010, ranging between 12.3 and 24.7 in individual years. 1 This compares with rates of 11.8 of 100,000 in the United States 2 and 11.4 of 100,000 in the United Kingdom. 3 However, in high-income countries, the rarity of maternal death limits its utility as a robust measure of the quality of a maternity system and provides limited information about risk factors for specific pregnancy complications. Severe acute maternal morbidity (SAMM) has been proposed as an alternative measure; in some countries, a review of SAMM cases has been used to identify quality improvement priorities. 4 Published reviews of SAMM from different countries and centers have used a variety of methods and tools, although most publications focus on system, provider, and patient contribu- tory factors. In New Zealand, a single center pilot review 5 of admissions to the intensive care unit (ICU) has been reported with the methods of Geller et al. 2 The LEMMoN study from the Netherlands 6 defined substandard care at each level of the maternity system as “care that deviated from national or local guidelines, local protocols, best available evidence or expert consensus, ” and substandard care was considered to be present in 79% of all cases. 6 However, this study did not further determine whether major morbidity was consid- ered preventable. Other models that have determined preventable provider and system factors have reported that as many as one-third of cases were preventable. 2 In Scotland, all maternity centers audit severe maternal morbidity and contribute the findings to an annual national audit. 7 The NZ Perinatal and Maternal Mortality Review Committee (PMMRC) has developed a tool for measuring contributory factors and potentially avoidable maternal death. 8 The tool includes subheadings for contributory factors under organizational and man- agement, personnel, technology and From Auckland District Health Board (Drs Sadler, McArthur, McLintock, and Rhodes and Ms Austin) and the Departments of Epidemiology and Biostatistics (Dr Sadler) and Obstetrics and Gynecology (Dr Farquhar and Ms Masson), Faculty of Medicine and Health Sciences, University of Auckland, Auckland, NZ. Received May 27, 2013; revised May 27, 2013; accepted July 27, 2013. Supported by a grant from the ADHB Charitable Trust. The authors report no conflict of interest. Presented at the 10th Australasian Conference on Safety and Quality in Health Care of the Australasian Association for Quality in Health Care, Cairns, QLD, Australia, Sept. 3-5, 2012. Reprints not available from the authors. 0002-9378/$36.00 ª 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.07.031 DECEMBER 2013 American Journal of Obstetrics & Gynecology 549.e1 Research www. AJOG.org