Maternal mortality continues to be a public health crisis, with 20 percent to 60 percent of deaths considered preventable after thorough case review.1,2 The World Health Organization defines maternal mortality as a death while pregnant or within 42 days of termination of pregnancy.3 The Centers for Disease Control and Prevention defines maternal mortality as a death while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by pregnancy.4,5
While the global maternal mortality ratio has decreased by 38 percent in the last two decades (2000-2017), from 342 deaths to 211 deaths per 100,000 live births,6 the United States is an exception among high-resource countries. In the United States, maternal mortality has continued to increase, from 7.2 deaths per 100,000 live births in 1987 to 17.3 deaths per 100,000 live births in 2017,5 with about 700 birthing people dying every year from pregnancy-related causes.7
One-third of maternal deaths occur during pregnancy, one-third during childbirth and up to a week postpartum, and one-third after a week to a year postpartum.4 The top causes of maternal death include hemorrhage, hypertensive disorders in pregnancy, sepsis, and cardiovascular conditions.1 The exploration of the contribution of delayed or missed diagnosis to maternal mortality is a nascent area of study.
Maternal mortality is thought of as the “tip of the iceberg,” as severe maternal morbidity has similar root causes, is much more common, and has a substantial impact on patients, families, and the healthcare system. Severe maternal morbidity (SMM) is defined as an unintended outcome of birth that results in significant short-term or long-term consequences.8 For every maternal death, 70 women are estimated to suffer from a severe complication.9 Birthing people who have a blood transfusion, sepsis, or pulmonary edema are more likely to have maternal morbidity.8,10
Similar to maternal mortality, multidisciplinary review shows that maternal morbidity is associated with a high rate of preventability.11 While no consensus has been reached on what extent maternal mortality and SMM are attributable to diagnostic error, emerging evidence suggests it is imperative to focus on diagnostic safety in obstetrics to prevent and mitigate diagnostic errors.2,12
This issue brief discusses what is known about the contribution of diagnostic error to maternal morbidity and mortality, explains the rationale for improvement methods, and outlines the research agenda needed to make progress in this emerging area of diagnostic safety. The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with maternal hemorrhage as a primary example due to its prevalence, high rate of preventability, and interprofessional effort needed for diagnosis and treatment.