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 Understanding Why Maternal Mortality is on the Rise in America: The Case for Learning from Every Maternal Death

Priya Agrawal Headshot.jpgBy Priya Agrawal, BMBCh, MA, MPH, DFSRH
Executive Director, Merck for Mothers

In 2013 alone, approximately 1200 women died from pregnancy and childbirth related complications in the United States.  This number has risen sharply over the last two decades. In addition, since 1990, the rate of maternal deaths in this country has more than doubled. The question we must ask ourselves is "why?"

Why in a country that spends $111 billion on childbirth-related health care is maternal mortality on the rise?

Each maternal death is an unacceptable tragedy, and also an opportunity to learn how to prevent future deaths. Maternal mortality review boards have been used as an effective mechanism for finding out what led to maternal deaths in countries as diverse as the United Kingdom, South Africa, Malaysia and Sri Lanka.

The review board interdisciplinary group of experts conducts an evaluation to determine the root cause of the death, including reviewing case files and interviewing family members and friends of the woman who died.  The benefit of reviewing cases together, rather than in isolation, is the ability to identify trends and address problems at the population level. When a review board is operating optimally, the lessons it learns can inform changes to the health care system.

It is important to emphasize that the focus of reviews is learning, which is why they are confidential and blame free – a space for providers and others to discover system problems and develop recommendations that can be used to prevent future deaths.

When we act on the lessons learned from a strong maternal mortality review process, we can save the lives of women.  As an OB/GYN from the United Kingdom, I saw the direct impact of a strong maternal mortality review process firsthand. Throughout the early 2000s, the U.K. national maternal mortality review, referred to as the Confidential Enquiry into Maternal Deaths, found that there was a rise in mortality due to pulmonary embolism, a blood clot in the lung, which was not known to be a leading cause of maternal death. 

Because pulmonary embolism is often preventable, the Confidential Enquiry recommended that the national health system develop guidelines for prevention, especially after caesarian delivery (e.g., placement of compression socks on the legs after surgery, use of blood thinners).  After these new protocols were implemented, the number of deaths from pulmonary embolism dropped by 50 percent.

Here in the United States, we also have the opportunity to learn from maternal mortality reviews. Yet only about half of states in this country have a functioning maternal mortality review board. Our vision is that someday all 50 states will have maternal mortality review boards – and that they will examine every maternal death, with the mechanisms and resources necessary to take action so that women in the United States receive better care.

To help realize this vision, Merck, through Merck for Mothers our 10-year global initiative to end preventable maternal deaths – provided funding for the AMCHP Every Mother Initiative.  AMCHP is now working with 12 states to ensure the lessons and recommendations from robust maternal mortality reviews are carried out. For example, the Ohio maternal mortality review board recently identified a need to improve hospital team response to manage obstetric emergencies and is now exploring pilot sites for a Simulation Training Center.

As a MCH professional, you can take steps to help reverse the trend of women dying during pregnancy and childbirth.  Reach out to your state maternal mortality review team to find out ways to get involved or, if your state does not have one, reach out to AMCHP, your district ACOG chapter and other organizations that care about women's health to learn how to establish one.  Connect with MCH professionals in other states to exchange best practices for maternal mortality review.  And finally, educate your elected officials on why every state health department should have a high functioning maternal mortality review program.​

When a woman dies giving life, her family, friends and broader community suffer a terrible tragedy. Let us not add to that tragedy by failing to learn from what went wrong.  Let us learn, and then do everything we can to ensure that every pregnant woman in this country gets the support and care she needs for a healthy and happy pregnancy and birth. 

Second Cohort of States Selected for the AMCHP Every Mother Initiative 
In early October, AMCHP announced the second cohort of six states that will participate in the AMCHP Every Mother Initiative Action Learning Collaborative (ALC), funded by Merck for Mothers. Over the next 15 months, the second cohort will collaborate to strengthen their state-based maternal mortality review process and ensure the efforts of their reviews to characterize the factors contributing to these tragic events lead to data-informed and effective population-based strategies to prevent their further occurrence.

The six teams selected for the second cohort, with MCH leaders at the helm, include: Florida, Illinois, Louisiana, Missouri, Oklahoma and Utah. The ALC will run from Oct. 1, 2014 through Dec. 31, 2015.

Each state team brings unique experiences, expertise, and interests in improving maternal health outcomes to the Every Mother Initiative. Through the formation of multidisciplinary teams and developing a detailed action plan, states will focus on priority recommendations from their maternal mortality reviews to build new or strengthen existing collaborations and implement a specific and focused strategy to reduce maternal deaths in their state. To support these efforts, each team will receive $40,000 in a translation sub-award, as well as virtual and in-person technical assistance from AMCHP and other national, state, and community leaders, including the CDC Division of Reproductive Health, the Association of Women's Health, Obstetric and Neonatal Nurses, the American Congress of Obstetricians and Gynecologists, the Every Woman Southeast Coalition, and the states that participated in the first cohort of the initiative. To learn more about state Every Mother projects, check on this month's Member to Member.

The Every Mother Initiative launched in 2013 to help states take specific and focused steps to reduce maternal mortality and maternal morbidity. The first cohort of the initiative, which runs from August 2013 through October 2014, includes Colorado, Delaware, Georgia, New York, North Carolina and Ohio. The second cohort of the Every Mother Initiative will build on the successes of the first cohort and engage them as mentors in their own translation efforts.

For more information about the Every Mother Initiative and maternal mortality resources, please visit