Establishment of a national severe maternal morbidity preventability review in New Zealand

Int J Gynaecol Obstet. 2016 Oct;135(1):120-3. doi: 10.1016/j.ijgo.2016.03.034. Epub 2016 Jul 1.


Severe maternal morbidity (SMM) review is an accepted quality measure to evaluate maternity care standards. Assessment of the potential preventability of SMM enables identification of factors and themes to inform clinical training and policy to improve maternal outcomes. The present report outlines the introduction of a national/regional external case review system using multidisciplinary panels to assess potential preventability of SMM, to assist other health jurisdictions to establish similar processes. Implementation steps are outlined including ethics, engagement with health services, recruitment and training of panel clinicians, identifying and preparing cases, and structuring meetings. More than 100 clinicians from all District Health Boards in New Zealand were recruited to form six panels. From August 2013, each panel met quarterly to review. By August 2015, 374 anonymized cases had been reviewed for potential preventability and practice improvement themes. This process established a quality monitoring tool to quantitate potential preventability of SMM, and identify practice and policy themes that can be reported locally and nationally for quality improvement. To our knowledge, this is the first national SMM preventability review using an internationally validated tool enabling intercountry comparisons. On the basis of this research, the New Zealand Ministry of Health funded the translation of the process to ongoing SMM national preventability review.

Keywords: Preventability audit; Severe maternal morbidity.

MeSH terms

  • Epidemiological Monitoring
  • Female
  • Humans
  • Interdisciplinary Communication
  • Maternal Health Services / standards*
  • Maternal Mortality / trends*
  • Medical Audit
  • New Zealand
  • Pregnancy
  • Pregnancy Complications / epidemiology*
  • Pregnancy Complications / prevention & control*