Maternal Mortality Review (MMR) and Pregnancy Associated Mortality Review (PAMR) are surveillance systems that help states identify opportunities to improve maternal health. This month, we asked members, "How have findings from your maternal mortality review informed your state efforts to prevent poor maternal outcomes due to chronic health conditions, violence or injury?" Below, we are pleased to feature some of the exciting work taking place in Virginia, Colorado, Alaska, Louisiana and North Carolina to address these important issues.
By Victoria Kavanaugh, RN, PhD
Maternal Mortality Review Team Coordinator, Office of the Chief Medical Examiner, Virginia Department of Health
The Virginia Maternal Mortality Review Team is a multidisciplinary team whose mission is to review all pregnancy-associated deaths. The team represents a public health partnership between the Virginia Department of Health Division of Family Health Services and Office of the Chief Medical Examiner. Our purpose is to recommend improvements and interventions to reduce the numbers of preventable deaths, including deaths due to violence and injury.
Over the course of nine years of continuous case review, the team has made a number of recommendations to address identified gaps in services and interventions that have been successfully implemented. Examples of accomplishments include:
- A recommendation for improved screening for substance abuse, behavioral health, and domestic violence led to the development of the Virginia Behavioral Health Risks Screening Tool, which is a one-page screening tool for depression, substance abuse and domestic violence for use with pregnant women
- A recommendation for practitioners to have ready access to resources to address patient needs led to the development of a partnership between the Virginia Departments of Health and Social Services to update, expand, and disseminate referral sources to practitioners
- A recommendation for education on proper placement and use of seat belts during pregnancy led to a campaign through the Virginia Department of Motor Vehicles Occupant Protection Program Committee to encourage pregnant women to always wear seat belts
By Krista Beckwith, MSPH
Maternal Health Specialist, Children, Youth and Families Branch, Colorado Department of Public Health & Environment
The most recent Colorado Title V Needs Assessment for 2011-2015 identified depression during pregnancy and postpartum both as a top need within the state and a leading complication of pregnancy. The state's robust linkage process for maternal mortality also reflected an increasing number of maternal deaths related to suicide or accidental overdose. This data, combined with the review findings of the Colorado Maternal Mortality Review Committee, was used to support the selection of pregnancy-related depression as one of the 10 state MCH priorities for 2011-2015.
As a recipient of the AMCHP Every Mother Initiative, Colorado received funding to focus on translating data to action. Given the recent data findings on maternal mortality and focus of the state Title V funds, Colorado chose to allocate funding toward addressing maternal mental and behavioral health systems. A review of maternal mortality cases highlighted the need to understand what worked for women experienced a "near miss" related to suicide or overdose but were able to obtain the support they needed – as mortality data was only able to identify what did not work. Through focus groups and interviews with providers, women and family members, the department identified themes and recommendations on what worked for women who made it through these experiences. These findings will be incorporated into Title V work focused on improving systems of care across Colorado and made available to external advocates.
By Margaret Young, MPH
MCH Epidemiology Unit, Women's, Children's and Family Health Section, Alaska Division of Public Health
In spring 2013, the Alaska Maternal-Infant Mortality Review (MIMR) committee completed reviews of pregnancy-associated deaths that occurred in Alaska during 2000-2011. The committee identified 13 deaths that occurred during this time due to causes related to or aggravated by pregnancy or its management, of which five were definitely or probably preventable. The findings were published and presented around the state, including to the Alaska Native Tribal Health clinical directors and hospital administrators at their quarterly meeting in August 2013.
One of the recommendations made by the MIMR committee was that reviewing near misses could help identify additional points of intervention for improving care. This was in recognition of the understanding that near misses, experiences of severe maternal morbidity, were increasing nationwide yet we did not know the extent of this problem in Alaska, and also because the small number of actual deaths in Alaska made identifying patterns or systematic issues difficult. As a result of the MIMR recommendation, the Alaska Native Medical Center has recently begun a pilot program reviewing maternal near misses within their health system. The MIMR program manager also is working with ANMC and other Alaska hospitals to begin assessing the potential of ongoing statewide surveillance of severe maternal morbidity.
By Amy Zapata, MPH
Title V MCH Director
Denver Dinsick, MPH
Mortality Surveillance Epidemiologist, Bureau of Family Health, Louisiana Department of Health & Hospitals
The Louisiana PAMR examination of 2008-2010 maternal deaths highlighted a need for enhanced screening and connection to care among women experiencing postpartum depression, domestic violence, and substance abuse. With the help of the AMCHP Every Mother Initiative, Louisiana plans to identify new approaches to integrate screening for high risk women. Title V and the state Birth Outcomes Initiative have supported statewide efforts in the past, but various transitions within the health care system have resulted in a gap in a sustained cohesive approach. Screening will be piloted in select health care settings in order to test for effectiveness and sustainability.
In addition to supporting screening to connect women with preventive care, Louisiana plans to analyze severe maternal morbidity (near fatality) events from maternal complications. After analyzing near-miss data, a multidisciplinary team will select prevention measures that will be implemented to improve health outcomes. A mortality risk profile instrument will be piloted in selected hospitals, acting as a clinical early warning system for severe maternal mortality events and ultimately leading to the implementation of preventive measures during antenatal care.
By Belinda Pettiford, MPH
Women's Health Branch Head, Division of Public Health, North Carolina Department of Health & Human Services
The State of North Carolina has a long-standing commitment to maternal mortality review, which began in 1945. In 1988, the State Center for Health Statistics within the Division of Public Health, Department of Health and Human Services initiated an enhanced, statewide, population-based system for identifying pregnancy-related deaths within the state. This multisource system has increased the number of pregnancy-related deaths identified by as much as 30 percent.
The leading contributor to pregnancy-related deaths in our state is cardiovascular disease. As part of the Every Mother Initiative, two translational activities are underway. In partnership with Community Care of North Carolina, we are conducting a pilot initiative, utilizing International Classification of Diseases (ICD) codes to identify women with potential risk factors for cardiovascular disease and connect them to a care manager. The care manager provides comprehensive counseling to the woman with a focus on reproductive life planning, including contraception use. In addition, we also are developing specific educational materials that can be utilized by providers to counsel and educate women of reproductive age who have potential risk factors. Current materials tend to focus on women beyond childbearing age. This work is linked to our statewide focus on preconception and interconception health.