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After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

Little is known about people's willingness to engage in sex without protection from unwanted pregnancy. This study surveyed 1,497 women and men at 75 clinics and physician offices across California after their reproductive health care visits in late 2007 and early 2008. When asked if they would have sex without contraception, 30% said definitively that yes, they would have unprotected sex, and 20% indicated they would "sometimes" or "maybe" engage in unprotected sex. In multivariate models, compared to non-Latino White respondents, Latinos who responded to the survey in English were 52% more likely and African Americans were 75% more likely to report willingness to have unprotected intercourse. Wanting a child within the next three years was associated with increased willingness to have unprotected sex. Age, gender, parity, and relationship status were not significant in multivariate models. A considerable proportion of women and men may be willing to have unprotected sex, even with access to subsidized contraceptive services and even when recently counseled about birth control. The dominant behavioral models of contraceptive use need to acknowledge the widespread likelihood of occasional unprotected sex, even among people motivated to usually use contraceptives. Findings underscore the need to make contraceptive methods accessible, easy to use, and even pleasurable.