Review to Action

Case Evaluation Wheel

It can be difficult to evaluate and monitor maternal mortality trends over time because pregnancy-related deaths in the United States are relatively rare events. If the number of pregnancy-related deaths in a state or jurisdiction is small, statistics may fluctuate from year to year, which causes variation in the pregnancy-related mortality ratio (PRMR) or maternal mortality ratio (MMR). Maternal mortality review committees (MMRCs) interpret data using two methods: quantitative and qualitative analysis. Both methods are valuable, and conducting them in tandem provides MMRCs with more insight and a deeper understanding of the circumstances surrounding maternal mortality trends. Both quantitative and qualitative data are used in reports and other publications created by the MMRC to share findings with external stakeholders.

MMRCs use race, socioeconomic status, geographic location, education, age, and the number of previous pregnancies and births to develop quantitative analyses. To conduct reliable quantitative analyses of maternal deaths in a state or jurisdiction, committees often must consider multiple years of data to make sound conclusions. To conduct rigorous qualitative analyses, committees should keep in mind that the reasons for deaths may vary even when many of the medical cause of pregnancy-related deaths may be the same. Additionally, the health care the deceased mother received, the health care system as it relates to her care, and any state or local policies as they affected her also need to be examined. An epidemiologist, administrative coordinator, or partner with analytic expertise conducts the analysis. MMRCs should also summarize their recommendations and themes from their discussions across cases.

The analysis usually includes:

  • demographic information
  • characteristics of the cases that may indicate increased risk of death.
  • a summary or identification of the most common causes of death or problems identified as factors leading to the deaths.

The MMRIA project includes numerous resources and tools to assist states in conducting analyses and fully understanding maternal mortality through a health equity lens.

In addition to summarizing data across cases, the MMRC must regularly evaluate its processes and outcomes and identify opportunities for improvement. From a process standpoint, this may include improving methods of case identification, checking in with committee members on the productivity and efficiency of case discussions, or expanding the expertise on the committee. Each year that the committee convenes, it should consider if and how the major causes of death or factors contributing to deaths are changing over time, with respect to outcomes. This approach could include looking at other surveillance systems that are not mortality-related to understand changes in morbidity or improvements in the overall health status of women before, during, and after pregnancy since the committee was established.

As a part of improving internal processes, MMRCs could consider the following:

  • Request technical assistance from the Building U.S. Capacity to Review and Prevent Maternal Deaths project team, which conducts site visits with MMRCs to address specific areas of improvement.
  • Reach out to states in the same region or with a similar population to get new ideas on tackling problems or challenges. Contact information is available in the interactive state map on this site, and you can pose specific questions in the Discussion Board.

Finally, MMRCs should make specific plans for disseminating their reports and activities to external stakeholders to communicate the value of the MMRC and ensure widespread support. Such plans may include presenting the MMRC and its findings at professional conferences within the state or at a national level, traveling to hospitals or community centers across the state to raise awareness of the MMRC and its findings, coordinating with partners to gain media attention by developing a press release about a committee report, publishing manuscripts in scholarly journals, or writing articles in professional newsletters of the disciplines and organizations reflected in the review committee. Further, prior to the release of a report or public dissemination of findings, MMRCs should partner early and often with representatives of the disciplines or organizations that are the targets of recommendations in order to plan together the implementation of the findings.

A key way to ensure the success of the MMRC is to collaborate and share project experiences with other states, national organizations, and stakeholders. MMRCs can also share suggestions, discoveries, and lessons learned from meetings to help others address pitfalls they may have encountered.

Recommendations for Action

During the case review process, the committee decides whether or not the death was preventable and may also characterize the chance to alter the outcome. The discussion facilitator will need to take special care to push the committee to subsequently answer the following questions:

  • If there was at least some chance that the death could have been averted, were there specific and feasible actions which, if implemented, might have changed the course of events?
  • If there was at least some chance that the death could have been averted, were there specific actions in the course of events which, if altered, might have changed the outcome?

This discussion can be tailored for each critical factor identified during the review process. When committee members offer recommendations, the discussion facilitator should emphasize that recommendations should be specific and feasible, answering the questions of who is responsible to act, by when, and how. For example, committees should avoid recommendations such as “Improve substance use disorder screening” and rather consider the following: “Prenatal care providers should screen all patients for substance use disorder at their first prenatal visit.” The unique strength of identifying “who” also assists the committee in thinking early about whether there is an individual on the committee who may have authority or responsibility to bring the recommendation to fruition (e.g. an OB/GYN leader active in his or her ACOG district or divison).

For each recommendation, the committee should determine the expected level of impact if the recommendation were implemented.

Ohio PAMR Fact Sheet

The Ohio Pregnancy Associated Mortality Review
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This document gives a description of the Ohio PAMR, baseline information, and a summary of initiatives.

Georgia 2012 Maternal Mortality Report

Georgia Department of Public Health
Year of publication or last update: 
A complete review of all case findings and lessons learned with Georgia’s 2012 maternal mortality review cases.

Best Practice Submission on Project ECHO in Utah

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In deciding on a priority for moving PMR findings into population action, we compared published data on Utah maternal deaths from 1995-2002 to deaths between 2005 and 2012. The top five causes of maternal death in Utah were embolism, overdose/drug toxicity, hemorrhage, cardiac conditions and infection. We evaluated evidence-based interventions for these top causes and ultimately focused on implementing the recommendations from the Obstetric Hemorrhage Safety Bundle from the National Partnership for Maternal Safety.