Implement

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Actions recommended by the maternal mortality review committee (MMRC) can take many forms. Below are just a few examples of different MMRC success stories of putting recommendations into action. After reviewing these success stories, visit the Review to Action Resource Center by clicking the button below. There, you will find state and national partner resources that can be adapted, replicated, or tailored by states and jurisdictions to take evidence-based action to prevent maternal deaths.

The implementation of solutions and interventions identified by the MMRC is the ultimate goal of the review process – data collection and analysis alone do not have a purpose. Further, examples of population-based or targeted action taken or informed by the MMRC and an evaluation plan to demonstrate improved outcomes is the best way to ensure MMRC sustainability.

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Success Stories

The Florida Pregnancy Associated Mortality Review (PAMR) committee issued an Urgent Maternal Mortality Message about placental disorders in December 2015. The team decided to focus on hemorrhage as related to placenta accreta since Florida’s PAMR data showed hemorrhage as the leading cause of pregnancy-related death in Florida and is considered to be the most preventable cause of maternal mortality. The one-page electronic message summarized clinical guidelines and PAMR recommendations to improve clinical recognition and management, as well as provider awareness, of placenta accreta and subsequent risk of hemorrhage.

The New Jersey Maternal Mortality Review Team received at least two cases where young women were struck by a motor vehicle while crossing a busy county road. Pertinent documents described a common location of death, that the women both lived in a low-income dwelling and had young families, and that a store across the street was the closest place to buy food. The Department of Health contacted the Department of Highway and Traffic Safety who responded by placing a traffic light and crosswalk at this point in the road, preventing future deaths in the community.

The Georgia Maternal Mortality Review Committee (MMRC) is working closely with the Georgia Department of Public Health to improve the reporting and quality of data found in the pregnancy checkbox on the death certificate. The MMRC brought this issue forward after they found approximately 1 in 4 cases where the pregnancy check box was marked mistakenly, and incorrectly indicated that a woman had been pregnant at the time of her death or pregnant within a year of the time of her death, when that was not the case. This success story is an example of a quality improvement project focused on improving the process of case identification, spearheaded by the MMRC.

The Michigan Maternal Mortality Surveillance (MMMS) Injury Committee identified Substance Use Disorders (SUD) as the direct cause of death in more than one-third of the injury-related maternal deaths that occurred from 2010-2014. As a result, the MMMS Injury Committee has successfully undertaken steps to increase knowledge of maternal mortality due to SUDs and has begun to address gaps in services regarding women’s health programs, state policies, and systems of care. Medical provider education was developed that focused on both the coordination of care with mental health outpatient services and also enrollment of pregnant women in the Maternal Infant Health Program (MIHP). MIHP is the largest statewide home visiting program for Medicaid beneficiaries and utilizes evidence-based screening tools and risk identification for substance use disorders.

Based on the volume of cases reviewed related to obstetric emergencies, the Ohio Pregnancy Associated Mortality Review (PAMR) surveyed maternity units across the state to uncover training needs and preferences. Based on the results, the Ohio Department of Health contracted with Ohio State University to provide simulation training for obstetric providers in three rural Ohio communities. Three clinical simulations on postpartum hemorrhage, cardiomyopathy, and preeclampsia were developed based on PAMR cases and designed to educate staff within labor and delivery and postpartum units. Since the original implementation of the program in 2014, a total of 122 health care professionals across 14 Ohio hospitals have participated in the training, with evaluation results indicating improved knowledge of obstetric complications and confidence in managing obstetric emergencies.