Maternal Mortality Review Committee Research Articles

Enhancing Maternal Population Health Training Through Maternal Mortality Review Committees: Innovative Models and Impact

Enhancing Maternal Population Health Training Through Maternal Mortality Review Committees: Innovative Models and Impact

Addressing Perinatal Substance Use: A Triad Approach Led by the Colorado Perinatal Care Quality Collaborative.

Unintentional overdose is a leading driver of maternal death in Colorado. The high volume of maternal deaths from preventable causes lends questions to failures in our clinical and community-based care for pregnant and postpartum people. The Colorado Maternal Mortality Review Committee identified 3 main contributors including stigma in the community and health care system, fragmentation of the health care system, and the need for more clinician training. The Colorado Perinatal Care Quality Collaborative led a 3-pronged intervention to address these challenges and improve perinatal care. The first intervention, the Colorado Alliance for Innovation on Maternal Health Substance Use Disorder quality improvement initiative, partnered with birthing hospitals statewide to institute universal screening and timely referral for individuals at risk of substance use disorder (SUD) and perinatal mood and anxiety disorders. The second intervention, the Improve Perinatal Access, Coordination, and Treatment for Behavioral Health initiative, established a perinatal support network within communities. This program assists individuals with SUD, perinatal mood and anxiety disorders, or social needs to navigate the perinatal period. The third intervention, the Colorado Maternal Overdose Matters Plus program, has enhanced in-hospital access to pharmacotherapy for pregnant and postpartum individuals with SUD through training and technical support. These collaborative initiatives aim to minimize barriers to care by integrating inpatient screening, treatment referrals, pharmacotherapy access, and community care support to mitigate maternal mortality in Colorado.

Policies, Leadership, and Funding - Oh, My! How we are working together to improve perinatal care access & integration in Arizona, U.S.

The United States has the highest maternal mortality rate of any high resource country, and it is the only country outside of Afghanistan and Sudan where the rate is rising. The rate of pregnancy-related mortality in the US increased from 7.2 pregnancy-related deaths per 100,000 live births per year in 1987 to 17.2 in 2017. In Arizona, almost half of all pregnancy-associated deaths in 2016-2018 or three out of five deaths were related to mental health conditions or substance use disorder, and 98% of those deaths were deemed preventable with 48.5% of deaths having a good chance to prevent the death. Over 40% of these deaths were accidents or unintentional overdoses. Social determinants of health, system, and community factors have increasingly been acknowledged as contributing factors to the increasing rate of poor maternal health outcomes nationally, yet few states have been able to comprehensively address these issues due to fragmented health and public health systems of care, as well as severe workforce shortages. 
 The State of Arizona launched a series of initiatives beginning or enhanced in 2019 to improve maternal health outcomes for persons of reproductive age in the State, including a grant-funded initiative to strengthen Arizona’s Maternal Mortality Review Committee and to fund prevention efforts. In 2020, maternal mental health was spotlighted by stakeholders as a crisis related to the COVID-19 pandemic. A maternal mental health task force was appointed by the state legislature and funded through a federal grant to bring statewide stakeholders together to identify gaps in care for the perinatal population, improve statewide data on maternal mortality, and to form a statewide action plan to promote and execute innovation in maternal health service delivery including recommendations to the state government for providers and facilities, regulatory and state policy, payers, law enforcement, other systems, public health, and communities.
 While the effort to improve perinatal care statewide has legislative and grant-funded support, the input from individuals with lived experience, healthcare professionals specializing in serving this population, and our community health workers such as peer support professionals, patient advocates, and BIPOC advocacy organizations have been the key to our momentum and successes. Ultimately, a legion of volunteers (primarily mothers) across the state have co-designed improvements that truly meet the needs in close partnership with the state department of health and state medicaid agency. 
 
 Through community and provider participation, workforce development initiatives, compassionate and informed leadership, change management, and policy making, we have developed a comprehensive strategy to expand access to better care across the continuum of providers and facilities involved in perinatal care outcomes in our state. 
 What we’ve learned and achieved through our evolving statewide efforts will contribute to the efforts of others in communities globally who are working to reduce adverse maternal health outcomes. Lessons learned and best practices in capacity building and sustainability will be shared. 

Consensus pregnancy-related criteria for suicide and unintentional overdoses using a Delphi process.

Suicide and unintentional overdose are leading manners of preventable death during and within a year of pregnancy. Recently, the Utah Maternal Mortality Review Committee (MMRC) developed 10 criteria to guide pregnancy-related classification of these deaths. Our objective was to (1) evaluate if consensus could be reached across experts in maternal mortality review when applying criteria to the determination of pregnancy-relatedness in mock MMRC case evaluation and (2) assess how additional case information shifted participants' determination of pregnancy-relatedness in these mock cases. We used a modified Delphi process to evaluate criteria for pregnancy-related suicides and unintentional overdose. The study team developed base case scenarios to reflect the 10 proposed criteria. Base scenarios varied in timing of death (prenatal or delivery, early postpartum (<6 months), late postpartum (6-12 months)) and level of additional information available (e.g., informant interviews, social media posts). Consensus in favor of a criterion was met when ≥75% of participants identified a case as pregnancy-related in at least 1 scenario. Fifty-eight participants, representing 48 MMRCs, reviewed scenarios. Of 10 proposed criteria, 8 reached consensus. Overall, participants classified 19.4% of base case scenarios as pregnancy-related, which increased to 56.8% with additional information. Pregnancy-related classification changed across timing of death and with availability of additional information (prenatal or delivery 27.7% versus 84.6%; early postpartum 30.0% versus 58.3%; late postpartum 0.0% versus 25.0%, respectively). We identified consensus supporting the application of 8 standardized criteria in MMRC determinations of pregnancy-relatedness among suicide and unintentional overdose deaths.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

An in-depth analysis of perinatal related mortality among women of South Asian ethnicity in Aotearoa New Zealand

BackgroundInternational and national New Zealand (NZ) research has identified women of South Asian ethnicity at increased risk of perinatal mortality, in particular stillbirth, with calls for increased perinatal research among this ethnic group. We aimed to analyse differences in pregnancy outcomes and associated risk factors between South Asian, Māori, Pacific and NZ European women in Aotearoa NZ, with a focus on women of South Asian ethnicity, to ultimately understand the distinctive pathways leading to adverse events.MethodsClinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, while national maternity and neonatal data, and singleton birth records from the same decade, were linked using the Statistics NZ Integrated Data Infrastructure for all births. Pregnancy outcomes and risk factors for stillbirth and neonatal death were compared between ethnicities with adjustment for pre-specified risk factors.ResultsWomen of South Asian ethnicity were at increased risk of stillbirth (aOR 1.51, 95%CI 1.29–1.77), and neonatal death (aOR 1.51, 95%CI 1.17–1.92), compared with NZ European. The highest perinatal related mortality rates among South Asian women were between 20–23 weeks gestation (between 0.8 and 1.3/1,000 ongoing pregnancies; p < 0.01 compared with NZ European) and at term, although differences by ethnicity at term were not apparent until ≥ 41 weeks (p < 0.01). No major differences in commonly described risk factors for stillbirth and neonatal death were observed between ethnicities. Among perinatal deaths, South Asian women were overrepresented in a range of metabolic-related disorders, such as gestational diabetes, pre-existing thyroid disease, or maternal red blood cell disorders (all p < 0.05 compared with NZ European).ConclusionsConsistent with previous reports, women of South Asian ethnicity in Aotearoa NZ were at increased risk of stillbirth and neonatal death compared with NZ European women, although only at extremely preterm (< 24 weeks) and post-term (≥ 41 weeks) gestations. While there were no major differences in established risk factors for stillbirth and neonatal death by ethnicity, metabolic-related factors were more common among South Asian women, which may contribute to adverse pregnancy outcomes in this ethnic group.

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Time to pay attention: an underrecognized casualty of the opioid epidemic.

Maternal mortality and overdose deaths have both been on the rise in the USA, but the relationship between the two is unclear. Recent reports have pointed toward accidental overdoses and suicides as leading causes of maternal mortality. This short communication collected data on psychiatric-related deaths, suicide and drug overdose, from each state's Maternal Mortality Review Committee to better conceptualize the rate at which these deaths are occurring. Data was collected from each state's most recent online MMRC legislative report and met inclusion criteria if the reports included the number of deaths due to suicide and accidental overdoses during each review period, as well if the report encompassed data from 2017. Fourteen reports met inclusion criteria, cumulatively reviewing 1929 maternal deaths. Of these deaths, 603 (31.3%) were due to accidental overdose, while 111 (5.7%) were due to suicide. These findings highlight the need for increased psychiatric care in the pregnant and postpartum period, specifically for substance use disorders. Increasing screening for depression and substance use, decriminalizing substance use during pregnancy, and extending Medicaid coverage to 12 months postpartum on a national level are all interventions that could significantly reduce maternal deaths.

Placental pathology findings in perinatal deaths from 28 weeks gestation in Aotearoa New Zealand

IntroductionWomen of South Asian ethnicity are overrepresented in adverse pregnancy outcome across high-income countries, including those related to placental dysfunction. It has been hypothesised that placental aging occurs at earlier gestation in South Asian pregnancies. We aimed to identify differences in placental pathology among perinatal deaths ≥28 weeks gestation, between South Asian, Māori and New Zealand (NZ) European women in Aotearoa NZ, with a focus on women of South Asian ethnicity. MethodsPlacental pathology reports and clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, blinded, and analysed by an experienced perinatal pathologist using the Amsterdam Placental Workshop Group Consensus Statement criteria. Results790 of 1161 placental pathology reports, 346 preterm (28+0 to 36+6 weeks) and 444 term (≥37+0 weeks) deaths, met the inclusion criteria. Among preterm deaths, South Asian women had higher rates of maternal vascular malperfusion compared with Māori (aOR 4.16, 95%CI 1.55–11.15) and NZ European (aOR 2.60, 95%CI 1.10–6.16). Among term deaths, South Asian women had higher rates of abnormal villous morphology compared with Māori (aOR 2.19, 95%CI 1.04–4.62) and NZ European (aOR 2.12, 95%CI 1.14–3.94), mostly due to increased rates of chorangiosis (36.7%, compared to 23.3% and 21.7%, respectively). DiscussionDifferences in placental pathology by ethnicity were observed among preterm and term perinatal deaths. While we suspect differing underlying causal pathways, these deaths may be associated with maternal diabetic and red blood cell disorders among South Asian women, leading to a hypoxic state in-utero.

Placental pathology findings amongst extremely preterm perinatal deaths in Aotearoa New Zealand

IntroductionWomen of South Asian ethnicity are overrepresented in adverse pregnancy outcomes across high-income countries, including placental dysfunction and antepartum haemorrhage. As the burden of mortality is highest for extremely preterm infants, we aimed to identify any differences in placental pathology among perinatal deaths from 20+0 to 27+6 weeks gestation between South Asian, Māori and New Zealand (NZ) European women in Aotearoa NZ, with a focus on women of South Asian ethnicity. MethodsPlacental pathology reports and clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, blinded and analysed by an experienced perinatal pathologist using the Amsterdam Placental Workshop Group Consensus Statement criteria. South Asian ethnicity was classified as Indian, Fijian Indian, South African Indian, Sri Lankan, Pakistani and Bangladeshi. Results886 of 1571 placental pathology reports met the inclusion criteria. Women of South Asian ethnicity were significantly more likely to show features of histologic chorioamnionitis (aOR 1.87, 95%CI 1.19–2.94) and chorionic vasculitis (aOR 1.92, 95%CI 1.13–3.29), than NZ European and Māori women respectively. 13 of 15 (87%) of South Asian mothers with a diabetic disorder were identified with chorioamnionitis, compared to 1 in 5 (20%) of Māori and 5 in 12 (41%) of NZ European women. Cord hyper-coiling was also more common among South Asian pregnancies, compared to NZ European (aOR 1.98, 95%CI 1.10–3.56). DiscussionDifferences in placental pathology by ethnicity were observed among extremely preterm perinatal deaths. Underlying metabolic disorders and an associated pro-inflammatory environment may play an important role in the causal pathway leading to these deaths in women of South Asian ethnicity.

Preventing Maternal Mortality—Supporting Maternal Mortality Review Committees (CDC)

Federal Grants & ContractsVolume 47, Issue 6 p. 7-7 Grants Alerts Preventing Maternal Mortality—Supporting Maternal Mortality Review Committees (CDC) First published: 14 February 2023 https://doi.org/10.1002/fgc.32874Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume47, Issue616 February 2023Pages 7-7 RelatedInformation

Focused cardiac ultrasound in pregnancy.

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care.

Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

Supporting Success: ASTHO's Strategies for Reducing Maternal Mortality and Morbidity.

Supporting Success: ASTHO's Strategies for Reducing Maternal Mortality and Morbidity.

The role of the maternal death review

Maternal mortality review committees are statutory authorities involved in data collection and research. They undertake reviews of all cases of maternal mortality and increasingly examine instances of significant maternal morbidity. Their bailiwick includes all maternal deaths occurring during pregnancy and within a year of birth. Cases of significant morbidity are identified based on intensive care admissions during pregnancy and the 42 days of the puerperium. The committees classify deaths as direct (relating to the pregnancy or birth, e.g., amniotic fluid embolism), indirect (relating to pre-existing medical conditions, e.g., valvular heart disease), incidental (unrelated to the pregnancy or birth, e.g., motor vehicle collisions) or late (deaths occurring between 42 days and 1 year).

Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group.

The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Assessing Perinatal Insurance Coverage at Time of Death: A National Survey of Maternal Mortality Review Committees.

Background: The objective of this study is to understand the proportion of Maternal Mortality Review Committees (MMRCs) that investigate insurance status at the time of maternal deaths occurring during three time periods: pregnancy, childbirth, and up to 12 months postpartum. Materials and Methods: We conducted a national survey of MMRCs between July and September of 2020. Jurisdictions were e-mailed a 17-item questionnaire that addressed whether the MMRCs document insurance status for each of the three time periods as well as facilitators and barriers to doing so. Descriptive statistics were performed. Follow-up interviews were conducted with five MMRCs between November and December of 2020 to assess unique strategies and challenges discovered in their survey responses. Results: Among 46 eligible jurisdictions, 37 completed the survey (80.4%). The vast majority of MMRCs reported documenting insurance status during pregnancy (97.3%, 36/37) and childbirth (88.4%, 30/34). Fewer MMRCs reported documenting insurance status at the time of death for deaths that occur postpartum (59.4%, 19/32). Barriers to doing so included limited access to postpartum insurance data and a historic focus on deaths occurring during pregnancy and in association with childbirth. Conclusions: MMRCs primarily focus on identifying insurance status during pregnancy and at childbirth. Information on insurance status in the postpartum period is more difficult to ascertain and less often determined. The findings from this work should inform efforts for MMRCs to improve data collection on insurance status and ultimately improve the capacity of MMRCs to identify targeted insurance policy reforms that could help reduce maternal mortality.

Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008-17.

Each year approximately 700 people die in the United States from pregnancy-related complications. We describe the characteristics of pregnancy-related deaths due to mental health conditions, including substance use disorders, and identify opportunities for prevention based on recommendations from fourteen state Maternal Mortality Review Committees (MMRCs) from the period 2008-17. Among 421 pregnancy-related deaths with an MMRC-determined underlying cause of death, 11percent were due to mental health conditions. Pregnancy-related mental health deaths were more likely than deaths from other causes to be determined by an MMRC to be preventable (100percent versus 64percent), to occur among non-Hispanic White people (86percent versus 45percent), and to occur 43-365 days postpartum (63percent versus 18percent). Sixty-three percent of pregnancy-related mental health deaths were by suicide. Nearly three-quarters of people with a pregnancy-related mental health cause of death had a history of depression, and more than two-thirds had past or current substance use. MMRC recommendations can be used to prioritize interventions and can inform strategies to enable screening, care coordination, and continuation of care throughout pregnancy and the year postpartum.

Integrating National Violent Death Reporting System Data into Maternal Mortality Review Committees.

Background: With the Maternal Mortality Review Information Application (MMRIA) data system, the Centers for Disease Control and Prevention (CDC), alongside Maternal Mortality Review Committees (MMRCs), are developing comprehensive and uniform data collection to eradicate preventable maternal deaths. However, MMRIA is primarily focused on pregnancy-related deaths, and not pregnancy-associated deaths. Currently, the National Violent Death Reporting System Restricted Access Data (NVDRS-RAD) on pregnancy-associated homicides and suicides are not included in MMRIA and by extension the work of most MMRCs. This study examined the NVDRS-RAD data from 2014 to 2017 and argues that the data for pregnancy-associated maternal deaths should be integrated into the work of MMRCs. Methods: A secondary data analysis of the NVDRS-RAD from 2014 to 2017 was conducted. Pregnancy-associated mortality was identified using data available within the NVDRS-RAD and categorized according to period of pregnancy and manner of death. Descriptive statistics and risk ratios were calculated. Chi-square tests were also calculated. Results: The results indicate that pregnancy and the postpartum period show increased risk for homicide and suicide. Pregnant women were found to be five times more likely to die by homicide than their nonpregnant peers who died by violent means. The relationships between periods of pregnancy and manner of death were all found to be significantly associated although the association was weak. Conclusions: Integrating National Violent Death Reporting System data on pregnancy-associated deaths into MMRIA would improve the efficacy of MMRCs and address the intertwined risk factors driving the racial disparities of the United States' maternal mortality rate.

Enhancing Reviews and Surveillance to Eliminate Maternal Mortality.

Multisectoral investments over the past decade have accelerated the growth of Maternal Mortality Review Committee (MMRC) programs across the United States. The U.S. Centers for Disease Control and Prevention (CDC) launched the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Initiative in 2019. Under ERASE MM, CDC directly funds 24 U.S. jurisdictions supporting MMRCs in 25 states. With increased investment in programs nationally, the CDC has designed a performance management framework to identify areas for improvement or sustained achievement and standardize measurement of key process benchmarks across programs. This article presents a report on the baseline measures collected through this performance management approach and suggests key partnerships required to continue to accelerate progress toward the elimination of preventable maternal mortality in the United States.