The United States is one of few industrialized countries where maternal death rates are rising.1 Rates of maternal mortality in the United States are also higher among certain groups than others, including African-American women, who are three to four times more likely to die during pregnancy or childbirth than are White women.2 Sadly, the vast majority of these deaths are preventable.
Efforts to reduce stagnant maternal death rates and to address racial disparities began in the mid-1980s, when the Centers for Disease Control and Prevention (CDC) formed the Maternal Mortality Study Group in collaboration with the American Congress of Obstetricians and Gynecologists (ACOG). The Study Group called for state-based maternal mortality review teams to identify and review all pregnancy-associated deaths in order to identify problems and possible solutions.3
“Pregnancy-associated” deaths are deaths that occurred either during pregnancy or within one year of pregnancy — regardless of the cause of death or the pregnancy outcome (i.e., abortion, miscarriage, still birth, birth). The Study Group used this broad definition in order to better identify deaths not due to the specific reasons reflected in the “cause of death” codes. These case reviews are more critical today than ever before to improve our understanding of the events leading to maternal deaths and the formulation of corrective strategies.4 Hopefully, these reviews can help accelerate reductions in the U.S. maternal mortality rates.
Teams composed of experts from a variety of disciplines work together to identify what happened, and why. Strengths, gaps, and the need for additional resources can be identified by those most knowledgeable about policies and practices associated with their specific discipline. State-based maternal death reviews are anonymous, confidential, and nonjudgmental. Team members do not know the names of decedents, health care providers, or the facilities where care was received.
These teams review psychosocial, clinical, and medical factors associated with each case. For each case, the team answers several questions: Which agencies met this woman in the days or years before her pregnancy? Which agencies or providers might have gathered more information, provided additional resources, and/or sought alternatives to address an identified need? Had someone known of an existing condition, might they have referred her for additional evaluations or treatment? Were appropriate services available and accessible to the woman who died? How and where could changes be made to reduce the likelihood of a similar death occurring in the future?
Review teams then make recommendations for interventions and prevention strategies to prevent future deaths. These recommendations apply to a wide array of fields, including prenatal health care, social work, psychiatry, emergency care, dietary services, health care, and advocacy.
Virginia’s multidisciplinary Maternal Mortality Review Team has reviewed nearly 400 cases of pregnancy-associated death occurring between 1999 and 2007. The Team has identified several risk factors, including substance abuse, obesity, heart disease, and other chronic conditions, which are major contributors to these deaths. These women often had chronic conditions such as hypertension and obesity, highlighting the need to improve women’s overall health before they reach childbearing age. Virginia’s findings mirror national reports of disparity, which show that African-American women are more likely to die during or near pregnancy when compared to White women. For example, African-American women died from heart disease and related conditions within one year of pregnancy at a rate more than three times that of White women. As a result of its reviews, the Team developed recommendations to address these risk factors throughout the state.
Currently, about two-thirds of states have maternal mortality review teams either in operation or development.5 Several national initiatives are also attempting to increase the number of state maternal mortality reviews, including efforts by ACOG and the Association of Maternal and Child Health Programs.6,7 In 2012, the CDC launched the Maternal Mortality Initiative, through which 15 active review teams and multiple national partners are assessing capacities for conducting maternal death reviews. As a result, national guidelines and standardized methods for data collection are being developed. On the Federal level, the Maternal Health Accountability Act was introduced in both 2011 and 2014, but was not passed by the House of Representatives. The Act would provide grants to states for mandatory reporting of pregnancy-related deaths; establish state maternal mortality review committees; and organize the study of maternal morbidity.8
Maternal mortality and morbidity reviews offer our best opportunity for reversing our dismal trend and improving maternal outcomes in the United States. We encourage you to find out what is being done in your state and/or facility! If your state lacks a review committee, propose that one be formed; if it has one, consider participating as a member of the established team.
This article was written by: Victoria Kavanaugh, RN, PhD
Victoria Kavanaugh, RN, PhD, is the Coordinator of the Virginia Maternal Mortality Review in the Virginia Department of Health’s Office of the Chief Medical Examiner.
1. Hogan MC, Foreman KJ, Naghavi M, et al. “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5,” Lancet 2010; 375:1609-23.
2. Amnesty International, Deadly Delivery: The Maternal Health Care Crisis in the USA, London: Amnesty International, 2010.
3. Berg C, Danel I, Atrash H, et al. (Editors), Strategies to Reduce Pregnancy-related Deaths: From Identification and Review to Action, Atlanta: Centers for Disease Control and Prevention; 2001.
4. D’Alton ME, “Where is the “M” in maternal-fetal medicine,” Obstet Gynecol 2010; 6(116): 1401-1404.
5. American College of Obstetricians and Gynecologists, Maternal Mortality Review, Retrieved on October 21, 2014 from: http://www.acog.org/About-ACOG/ACOG-Departments/Public-Health-and-Social-Issues/Maternal-Mortality-Review.
6. American College of Obstetricians and Gynecologists, Council on Patient Safety in Women’s Healthcare. 2011. Retrieved on October 21, 2014 from: http://www.acog.org/About-ACOG/ACOG-Departments/Patient-Safety-and-Quality-Improvement/Council-on-Patient-Safety-in-Womens-Health-Care
7. Association of Maternal and Child Health Programs, Maternal Mortality, Retrieved on October 21, 2014 from: http://www.amchp.org/programsandtopics/womens-health/Focus%20Areas/MaternalMortality/Pages/default.aspx
8. American College of Obstetricians and Gynecologists, Council on Patient Safety in Women’s Healthcare. 2011. Retrieved on October 21, 2014 from: http://www.acog.org/About-ACOG/ACOG-Departments/Patient-Safety-and-Quality-Improvement/Council-on-Patient-Safety-in-Womens-Health-Care