Appendix 1a. Severe Maternal Morbidity Review Form
Reprinted with permission from the Alliance for Innovation on Maternal Health (AIM). Copyright American College of Obstetricians and Gynecologists.
Appendix 1b. Primary Causes of Severe Maternal Morbidity, Used in Standardized Review Form, With Definitions
Etiology Definition
Obstetric hemorrhage*
Excessive blood loss that occurred during or as a result of the delivery and was not related to placental pathology including but not limited to cases of uterine atony, obstetric laceration of the cervix and vagina, excessive blood loss during the cesarean section and intraabdominal bleeding as a complication of a cesarean section.
Placental hemorrhage*
Excessive blood loss that occurred due to abnormal placentation including placenta previa, placental abruption, retained products of conception and placenta accreta spectrum
Hypertensive disorder
Any complication related to hypertensive disease (chronic or gestational) in pregnancy
Uterine infection Intraamniotic infection and endometritis
Other infection Any infection other than uterine, including but not limited to post-operative soft tissue infections, pneumonias, complicated urinary tract infections, sepsis of non-uterine etiology
Cardiovascular disease
Any cardiovascular disease with the exception of hypertensive disorders, including congenital and acquired heart disease and vascular pathology Other medical or
surgical disease
Serious illness that is not primary obstetric in etiology (e.g. asthma exacerbation, diabetic ketoacidosis, bowel perforation spontaneous or iatrogenic as a result of a non-obstetric procedure, etc)
Other obstetric disease
Any severe pregnancy-related complication not listed above (e.g. acute fatty liver of pregnancy)
Treatment complication
Any iatrogenic complication that resulted from a medical treatment (e.g.
accidental medication overdose, surgical injury, etc)
Thromboembolism Any venous or arterial obstruction by thrombus that originated elsewhere in the body
Amniotic Fluid Embolism
Presentation meeting defined criteria**
Trauma Any accidental or intentional injury
Drug use Use of illegal substances or use of non-prescribed medications Suicide attempt Any attempt of purposeful self-harm with intent to die
Other or unknown
* The authors acknowledge that hemorrhage is not typically categorized into obstetric and placental. This categorization was included in the standardized SMM review form that was adopted by the Committee.
** Based on the joint definition by SMFM and the Amniotic Fluid Embolism Foundation. Criteria for AFE (all 4 must be present): Sudden onset of cardiorespiratory arrest OR hypotension with evidence of respiratory compromise;
documentation of overt DIC; Clinical onset during labor or within 30 minutes of placental delivery; absence of fever (≥38oC) during labor
Appendix 1c. Patient, Health Care Professional, and System-Level Factors Included in the Standardized Form and Assessed During Each Severe Maternal Morbidity Case Review
Patient factors System and Health Care Professional factors Pre-pregnancy underlying significant medical
conditions
Previous significant obstetric condition Non-obstetric medical complications
Complications due to conditions of pregnancy Psychiatric/behavioral health
Barriers to seeking care
Point of entry to health care Referral to higher level of care Treatment
Management hierarchy Education
Team communication Policies and procedures Documentation
Equipment and environmental factors Discharge
Definitions: Patient factor - any factor that is unique and specific to the patient. System factor – any factor that could have been regulated within the institution but such regulation is missing. Health care professional factor – any factor that is related to a specific health care professional’s action or decision that did not follow institutional or professional society guidelines or recommendations.
Appendix 2. Contribution of Different Patient Factors to Morbidity and Their Association With Opportunity to Alter Outcome
Patient factors contributing to
morbidity
Opportunity to alter outcome
P
None Possible Strong
59 (37.8) 66 (42.3) 31 (19.9) Pre-pregnancy underlying significant medical conditions
None 26 (42.6) 23 (37.7) 12 (19.7)
0.3
Possible 13 (39.4) 11 (33.3) 9 (27.3)
Direct 20 (32.8) 32 (52.5) 9 (14.7)
Previous significant obstetric conditions
None 39 (35.1) 51 (46.0) 21 (18.9)
0.34
Possible 5 (33.3) 5 (33.3) 5 (33.3)
Direct 15 (51.7) 10 (34.5) 4 (13.8)
Non-obstetrical medical complications
None 37 (41.1) 33 (36.7) 20 (22.2)
0.44
Possible 1 (20.0) 3 (60.0) 1 (20.0)
Direct 21 (35.0) 30 (50.0) 9 (15.0)
Complications due to conditions of pregnancy
None 17 (47.2) 15 (41.7) 4 (11.1)
0.38
Possible 4 (25.0) 7 (43.8) 5 (31.2)
Direct 38 (36.5) 44 (42.3) 22 (21.2)
Psychiatric/behavioral health
None 52 (41.3) 48 (38.1) 26 (20.6)
0.26
Possible 5 (25.0) 11 (55.0) 4 (20.0)
Direct 2 (20.0) 7 (70.0) 1 (10.0)
Barriers to seeking care
None 52 (40.6) 53 (41.4) 23 (18.0)
Appendix 3. Contribution of Different System and Health Care Professional Factors to Morbidity and Their Association With Opportunity to Alter Outcome
System and health care professional factors contributing
to morbidity
Opportunity to alter outcome
P
None Possible Strong
59 (37.8) 66 (42.3) 31 (19.9) Point of entry
None 52 (43.0) 50 (41.3) 19 (15.7)
0.013
Possible 6 (25.0) 12 (50.0) 6 (25.0)
Direct 1 (10.0) 3 (30.0) 6 (60.0)
Referral to higher level of care
None 56 (41.2) 57 (41.9) 23 (16.9)
0.022
Possible 3 (21.4) 7 (50.0) 4 (28.6)
Direct 0 (0.0) 2 (33.3) 4 (66.7)
Treatment
None 47 (62.7) 20 (26.7) 8 (10.7)
<0.0001
Possible 9 (17.7) 32 (62.7) 10 (19.6)
Direct 3 (10.0) 14 (46.7) 13 (43.3)
Management hierarchy
None 57 (47.5) 48 (40.0) 15 (12.5)
<0.0001
Possible 2 (8.7) 12 (52.2) 9 (39.1)
Direct 0 (0.0) 3 (30.0) 7 (70.0)
Education
None 56 (56.0) 35 (35.0) 9 (9.0)
<0.0001
Possible 3 (7.7) 24 (61.5) 12 (30.8)
Direct 0 (0.0) 5 (33.3) 10 (66.7)
Team communication
None 56 (54.4) 35 (34.0) 12 (11.6)
<0.0001
Possible 2 (5.7) 24 (68.6) 9 (25.7)
Direct 1 (5.9) 6 (35.3) 10 (58.80
Policies and procedures
None 57 (55.9) 34 (33.3) 11 (10.8)
<0.0001
Possible 2 (4.8) 25 (59.5) 15 (35.7)
Direct 0 (0.0) 5 (55.6) 4 (44.4)
Documentation
None 58 (42.7) 55 (40.4) 23 (16.9)
<0.0001
Possible 1 (5.9) 11 (64.7) 5 (29.4)
Equipment and environmental factors
None 58 (42.6) 53 (39.0) 25 (18.4)
0.007
Possible 1 (6.7) 10 (66.7) 4 (26.7)
Direct 0 (0.0) 3 (60.0) 2 (40.0)
Discharge
None 58 (40.0) 59 (40.7) 28 (19.3)
Possible 0 (0.0) 4 (80.0) 1 (20.0) 0.2
Direct 1 (20.0) 2 (40.0) 2 (40.0)
Totals may not equal 156 due to missing observations. Chi-square or Fisher exact test used as appropriate.
