Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006–2009

Abstract

Objective We sought to describe a new classification system for contributory factors in, and potential avoidability of, maternal deaths and to determine the contributory factors and potential avoidability among 4 years of maternal deaths in New Zealand. Study Design A new classification system for reporting contributory factors in all maternal deaths was developed from previous tools and applied to all maternal deaths in New Zealand from 2006 through 2009. Results There were 49 deaths and the maternal mortality ratio was 19.2/100,000 maternities. Contributory factors were identified in 55% of cases. An expert panel identified 35% of maternal deaths as potentially avoidable. In cases where potential avoidability was determined, there were nearly always 2 or 3 domains where contributory factors were identified. Conclusion Almost one third of maternal deaths in New Zealand can be considered to be potentially avoidable. This methodology has the potential to identify areas for improvement in the quality of maternity care.