Maternal mortality is a current and important issue for obstetrics. The challenge is to structure case reviews so that they develop real data that can inform and direct quality improvement activities. In this article, we describe a series of decisions we have made in California to organize and run our maternal mortality review committee. These include defining the goal of the reviews, selection of cases, composition of the committee, basic review issues, and the definitions used for analysis (eg, cause of death, contributing factors, role of cesarean delivery, preventability, identifying quality improvement opportunities). It is expected that each maternal mortality review committee will have somewhat different approaches based on local resources and case mix.
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