Case Selection

Case Selection Wheel

How do MMRCs select maternal death cases for review?

The criteria MMRCs use to select cases for abstraction and review (e.g. the scope of the review) should be documented in the committees’ policies and procedures, and followed consistently. To adhere to best practices in maternal mortality surveillance, MMRCs should consider all pregnancy-associated deaths when selecting which cases to review.

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A sample scope from the MMRC Facilitation Guide:

The scope of cases for committee review is all pregnancy-associated deaths or any deaths of women with indication of pregnancy up to 365 days, regardless of cause (i.e. motor vehicle accidents during pregnancy, motor vehicle accidents postpartum, suicide, homicide).  Deaths are identified from review of death certificates with a pregnancy checkbox selection and linkage of vital records by searching death certificates of women of reproductive age and matching them to birth or fetal death certificates in the year prior.

To determine which cases are within scope a " small committee" may be convened. The small committee is a subset of the full MMRC. It considers all the pregnancy-associated cases identified through the case identification process and determines which cases are within scope and should be referred for case abstraction. A preliminary case classification spreadsheet is available for download on the Model Case Identification pageClick here to download the spreadsheet. 

The most significant factor that influences a committee’s scope for abstraction and review is the time and effort required to abstract cases. In smaller, less populous states, MMRCs might have the capacity to abstract and subsequently review all or most pregnancy-associated deaths due to the relatively low number of cases. Larger, more populous states identify more pregnancy-associated deaths during the case identification process. These states are more likely to have specific criteria for sending deaths forward for case abstraction and review by the committee. Some of the compromises these states make include:

Limiting abstraction of cases to deaths most likely to be pregnancy-related: Some MMRCs in larger states choose to limit review of deaths to those where the cause of death is classified by one of the obstetric cause of death codes on the death certificate. These reviews tend to omit deaths due to injury-related causes (e.g. suicide, substance overdose, and intimate partner violence or homicide), though committees may still include these deaths in their report of all pregnancy-associated deaths identified by the review. One reason for limiting case selection in this way is that records required for a thorough review of injury-related deaths can be especially difficult to obtain for case abstractors, and the absence of those records from the case narrative makes it challenging to determine whether the case is indeed pregnancy-related.

*MMRCs have found that the underlying mental health conditions are a leading cause of pregnancy-related death. Suicides that are linked to mental health diagnosis that was aggravated by the pregnancy are deemed pregnancy-related. Overdoses with evidence that a trigger initiated in pregnancy or postpartum led to overdose could be deemed pregnancy-related. By the same token, intimate partner violence or homicide that was triggered by the pregnancy are deemed pregnancy-related.