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MMR Resource Portal for States: Building Capacity for Maternal Mortality Review

Why Establish a State Maternal Mortality Review?

Maternal mortality surveillance is needed to identify and address the factors contributing to poor pregnancy outcomes for women. Though it requires an investment of time and resources, a structured death review process can be a powerful facilitator of state systems change to improve the health of women before, during and after pregnancy.

Resources Available to States

With support from Merck for Mothers, the AMCHP Every Mother Initiative launched in 2013 to help states improve maternal mortality surveillance. This site provides a central location for the sharing of national and state resources. The number of resources available will increase rapidly as content is submitted by new states, so check back regularly for additional tools and publications!

Note: This is a beta version of the website. It will migrate to a more robust, external site later this year. We are excited to launch this interim space for immediate peer sharing.

Borrow freely and be a resource to others.

New and existing reviews can benefit from the tools and examples shared here. Click on the map, below, to find resources shared by specific states. Or browse resources by type of activity (e.g., case identification, data collection, action) using the tabs under the map.

If your state is not represented on the map, below, but you have a mortality review for pregnancy-related or pregnancy-associated deaths, please complete this form and return it to Andria Cornell, Senior Program Manager for Women's Health, at acornell@amchp.org or call (202) 266-3043.

Partner organizations: We know our members appreciate your tools and publications, too. Please complete and send us this form, and we will gladly review your resources for inclusion in the resource portal.

 State-Specific Resources

  • DC
    District of Columbia
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  • KS
    Kansas
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  • WY
    Wyoming
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  • WI
    Wisconsin
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  • WV
    West Virginia
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  • WA
    Washington
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  • VA
    Virginia
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  • VT
    Vermont
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  • UT
    Utah
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  • TX
    Texas
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    The Texas Maternal Mortality and Morbidity Task Force first convened in 2014. It has 15 members, meets quarterly, and reviews maternal deaths by natural and non-natural causes. The state had 382,438 live births in 2012; deaths are currently in review.
  • TN
    Tennessee
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  • SD
    South Dakota
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  • SC
    South Carolina
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  • RI
    Rhode Island
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  • PA
    Pennsylvania
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  • OR
    Oregon
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  • OK
    Oklahoma
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  • OH
    Ohio
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    Ohio’s current Pregnancy Associated Mortality Review Committee convened in 2010. The committee has 30 members, meets quarterly, and reviews all pregnancy-associated cases. In 2012, Ohio had 138,284 live births and 21 pregnancy-related deaths.
  • ND
    North Dakota
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  • NC
    North Carolina
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  • NY
    New York
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  • NM
    New Mexico
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  • NJ
    New Jersey
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  • NH
    New Hampshire
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  • NV
    Nevada
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  • NE
    Nebraska
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  • MT
    Montana
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    Montana’s MMR Workgroup was established in November 2013.
  • MO
    Missouri
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  • MS
    Mississippi
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  • MN
    Minnesota
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  • MI
    Michigan
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  • MA
    Massachusetts
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    The Massachusetts Maternal Mortality & Morbidity Review Committee (MMMRC) convened in 1998. The committee has 16 members, meets twice annually, and reviews all pregnancy associated and pregnancy related deaths. In 2013, Massachusetts had 72,188 live bir
  • MD
    Maryland
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    The Maryland MMR Program was established in 2000. Reviews of all pregnancy-associated cases are conducted monthly by a work group from the approximately 30-member committee. In 2012, Maryland had 72,751 live births and 14 pregnancy-related deaths.
  • ME
    Maine
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  • KY
    Kentucky
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  • LA
    Louisiana
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  • IA
    Iowa
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  • IN
    Indiana
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  • IL
    Illinois
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  • ID
    Idaho
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  • HI
    Hawaii
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  • GA
    Georgia
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    Georgia’s Maternal Mortality Review Committee convened in 2012. The committee has 40 members, meets quarterly, and reviews pre-screened cases that are likely pregnancy-related. In 2012, Georgia had 130,112 live births and 25 pregnancy-related deaths.
  • FL
    Florida
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    Florida’s Pregnancy Associated Mortality Review began in 1996. The committee now has 21 members, meets quarterly, and reviews pre-screened cases that are likely pregnancy-related. In 2013, Florida had 215,194 live births and 54 pregnancy-related deaths.
  • DE
    Delaware
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    Delaware’s Maternal Mortality Review Program first convened in 2013. The committee has 25 members, meets twice a year, and reviews all pregnancy-associated cases. In 2013, there were 10,831 live births and four pregnancy-related deaths in Delaware.
  • CT
    Connecticut
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  • CO
    Colorado
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    Colorado’s Maternal Mortality Review Committee (MMRC) first convened in 1998. The committee has 26 members, meets quarterly, and reviews all pregnancy-associated cases. In 2012, Colorado had 65,188 live births and six pregnancy-related deaths.
  • CA
    California
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  • AR
    Arkansas
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  • AZ
    Arizona
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  • AK
    Alaska
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  • AL
    Alabama
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 Statutes

  • New or expanded laws can protect many aspects of the maternal mortality review (MMR) process and lay the foundation for sustainability. Among other benefits, legislative statutes can facilitate access to medical records, ensure confidentiality and protection of case information, and protect committee members, review proceedings, and findings from subpoena and legal action. The following resources illustrate possible legislative considerations and language.

    Maryland MMR Program Legislation

    Source: General Assembly of Maryland, §13-1201 to §13-1207
    Year of publication or last update: 2000
    A statute providing for the establishment of a maternal mortality review program in the state of Maryland, including definitions, purpose, access to death and medical records, reporting requirements, and provider, facility and committee member protections from legal discovery and action.
  • Delaware Policy and Procedure for the Review of Maternal Deaths

    Source: Delaware Child Death Review Commission
    Year of publication or last update: 2013
    A document describing policies and procedures for the review of maternal deaths in Delaware, including purpose, scope, legislative authority, definitions, and standard actions taken during the review process.
  • Georgia Senate Bill 273

    Source: Georgia General Assembly
    Year of publication or last update: 2014
    An act that requires the Department of Public Health to establish the Maternal Mortality Review Committee to review maternal deaths; to provide for legislative findings; to provide for data; to provide for confidentiality; to provide for limited liability; and to provide for reports, among other purposes.
  • ACOG State Legislative Toolkit: Improving Pregnancy Outcomes: Maternal Mortality Reviews and Standardized Reporting

    Source: American Congress of Obstetricians and Gynecologists
    Year of publication or last update: 2011
    This toolkit includes an ACOG legislative position statement on maternal mortality review (MMR) and standard reporting, legislative considerations for drafting a state MMR bill, and a model bill for standardized state vital records reporting.

 Case Identification

  • Pregnancy-associated deaths may occur at any point in pregnancy, while a woman is in labor, or up to one year after delivery. They may occur in a facility or a woman’s home. In order to identify all deaths, multiple case finding strategies may be needed. The following resources may aid states seeking to improve their capacity to identify cases and select from them the cases to be abstracted and reviewed.

    Medical Examiners' and Coroners' Handbook on Death Registration and Fetal Death Reporting

    Source: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics
    Year of publication or last update: 2003
    This handbook contains instructions for medical examiners and coroners on the registration of deaths and the reporting of fetal deaths. It is intended to serve as a model that can be adapted by any vital statistics registration area.
  • Identifying Pregnancy-Associated Deaths in Florida

    Source: Florida Department of Health
    Year of publication or last update: 2010
    In 2001, Florida developed seven SQL query programs to identify pregnancy-associated deaths. The process was reviewed and updated in 2010, and an additional query was included as a result of changes to the fetal death certificate.

 Case Data Collection

  • After deaths are selected for review, medical records and other files must be located, requested, and abstracted into detailed case summaries, which support a more directed discussion of the death and its causal relationship to pregnancy. Included below are potential data sources, record request templates, and sample abstraction and case summary forms used by states to compile this important information.

    Montana Maternal Mortality Case Review Report

    Source:
    Year of publication or last update:
    Document completed by the local FICMMR Teams for a maternal death review.
  • Delaware Home Interview Consent Form

    Source: Delaware Child Death Review Commission
    Year of publication or last update: 2011
    A form developed for use during family interviews. During interviews, information is gathered about a woman who has died during or within one year of pregnancy that may be helpful to a review committee (e.g., health history, use of health care and social services).
  • Ohio PAMR Record Request Letter Templates

    Source: Ohio Department of Health
    Year of publication or last update: 2014
    Template letters developed for the request of case records from county coroners, medical providers, and law enforcement.
  • Texas Facility Learning Module: Responding to Data Requests

    Source: Texas Department of State Health Services
    Year of publication or last update: 2014
    Texas Health and Safety Code gives the Department of State Health Services authority to access health and medical records relevant to cases of pregnancy-associated death and severe morbidity. This learning module provides facilities with an overview of Task Force authority and their role in the record request process.
  • Florida PAMR Combined Abstraction Tool

    Source: Florida Department of Health
    Year of publication or last update: 2015
    A form used for the abstraction of maternal deaths in Florida. Data is obtained from a variety of sources, such as primary care records; risk assessment screenings; prenatal, labor and delivery, transport, hospitalization, and postpartum care records; or documentation of social services received and referrals made. Also includes an obstetric hemorrhage abstraction form. The reference numbers on the abstraction tool correspond to the reference numbers on the case summary template.

 Case Review

  • A multidisciplinary committee convenes to discuss a set of cases. For each case, the committee makes determinations about the cause of death, its relationship to pregnancy, and opportunities to alter the outcome. These determinations and related recommendations are recorded on case discussion forms and entered into a database to support aggregate analysis. Related resources are shared below for state use.

    Maryland MMR Case Discussion Guide

    Source: Maryland Department of Health and Mental Hygiene
    Year of publication or last update: 2013
    A form completed during the review of pregnancy-associated deaths, used to document individual, provider and institutional issues present; determinations made by the review committee; and recommendations for systems change in response to identified issues.
  • Massachusetts Maternal Mortality and Morbidity Review Case Summary Form

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    Year of publication or last update: 2014
    A primary and a secondary reviewer from the MMMMRC analyze all available documents on pregnancy associated and pregnancy related deaths. The reviewers use the MMMMRC Case Summary Form to summarize each case for the entire Committee without identifying patients, clinicians, or institutions.
  • Ohio PAMR Associated Factors Form

    Source: Ohio Department of Health
    Year of publication or last update: 2014
    Form used by the Ohio Pregnancy Associated Mortality Review (PAMR) Committee to facilitate case discussion and determinations regarding cause and manner of death, opportunity to alter the outcome, case recommendations, and associated individual, clinical, and system factors.
  • Delaware MMR Case Review Discussion Form

    Source: Delaware Child Death Review Commission
    Year of publication or last update: 2014
    A form used by the Delaware Maternal Mortality Review Panel to facilitate case discussion and determinations regarding cause and classification of the death, issues and gaps identified, and related recommendations for improved quality of care and systems change.
  • Colorado Maternal Mortality Review Policies and Procedures

    Source: Colorado Department of Public Health and Environment
    Year of publication or last update: 2014
    This document describes statutory authority, committee structure, committee member responsibilities and protections, and other procedures governing the functioning of the Colorado Maternal Mortality Review Committee.
  • Colorado Maternal Mortality Review Committee Confidentiality Statement

    Source: Colorado Department of Public Health and Environment
    Year of publication or last update: 2014
    The Colorado Maternal Mortality Review Committee reviews pertinent information on each death from de-identified autopsy reports, coroner’s reports, law enforcement reports, hospital and prenatal care records, and other sensitive sources. This form is completed by members of the committee at the start of each meeting to acknowledge applicable confidentiality protections.
  • Florida Case Summary Template

    Source: Florida Department of Health
    Year of publication or last update: 2015
    A form used to prepare the abstracted information from the maternal deaths in Florida into an organized case summary for the PAMR team to review. Data is obtained from a variety of sources, such as primary care records; risk assessment screenings; prenatal, labor and delivery, transport, hospitalization, and postpartum care records; or documentation of social services received and referrals made. The reference numbers throughout the template correspond to the reference numbers on the abstraction tool.
  • Florida Cause of Death Classification

    Source: Florida Department of Health
    Year of publication or last update: 2011
    Florida’s classification of pregnancy-related deaths is based on guidance from the Centers for Disease Control and Prevention (CDC), last revised in July 2004. Florida’s version attempts to clarify and define the CDC classification to assure consistency and does not intend to alter the numbering system or categorization process.
  • Colorado Maternal Mortality Review Committee Application

    Source: Colorado Department of Public Health and Environment
    Year of publication or last update: 2014
    An application form completed by prospective members of the Colorado Maternal Mortality Review Committee to facilitate member selection and on-boarding. The form assesses availability, areas of expertise, affiliations, self-rated level of influence, and motivation for the desire to serve.
  • Colorado CFPS Meeting Facilitation Guidance

    Source: Colorado Department of Public Health and Environment
    Year of publication or last update: 2014
    Developed to serve as a guide for the facilitation of local Child Fatality Review meetings, this resource also may be adapted to support the facilitation of meetings convened by other types of Review Boards, such as Pregnancy-Associated Mortality Review and Maternal Mortality Review.

 Action

  • Once reviewed, findings from a specific period of time are aggregated, synthesized, and analyzed to inform action. Methods of analysis vary and may be based on number of deaths or the types of cases reviewed. Once key findings are compiled and presented, the process of translation begins. The below examples reflect statewide efforts to synthesize and translate maternal mortality review (MMR) findings into action.

    Improving Health Care Response to Obstetric Hemorrhage 2.0

    Source: California Maternal Quality Care Collaborative
    Year of publication or last update: 2015
    This toolkit is designed to assist birth facilities in demonstrating adoption of the National Partnership for Maternal Safety Hemorrhage Bundle by developing systems that promote readiness, recognition, and response to obstetric hemorrhage.
  • Controlling Chronic Conditions Before Pregnancy PSA

    Source: Georgia Department of Public Health
    Year of publication or last update: 2014
    A powerful, silent video produced in English and Spanish for use in clinic waiting rooms to motivate chronic disease management prior to pregnancy. The video is accompanied by flyers with tear-off tabs to prompt patient-provider conversations about disease management and family planning options.

 Cross-Cutting

  • Institutions and individuals have developed resources that address multiple aspects of the maternal mortality review (MMR) action cycle. These general resources offer an overview of MMR methodology, cross-cutting considerations for new reviews, and recommendations for system improvements over time.

    Strategies to Reduce Pregnancy-Related Deaths: From Identification and Review to Action

    Source: Centers for Disease Control and Prevention
    Year of publication or last update: 2001
    This manual describes strategies for conducting pregnancy-related mortality surveillance in the United States. It addresses considerations made throughout the review process and issues relevant to health departments, policymakers and clinicians.
  • State Maternal Mortality Review: Accomplishments of Nine States

    Source: Centers for Disease Control and Prevention
    Year of publication or last update: 2006
    This publication provides background on reviews in Florida, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Utah and Virginia. It also includes guidelines for starting an MMR and appendices of supporting and sample documents.
  • Assessment of Maternal Mortality Review Processes in the United States

    Source: Centers for Disease Control and Prevention; Association of Maternal and Child Health Programs
    Year of publication or last update: 2012
    This publication highlights results from a capacity assessment of 20 state and two local maternal death reviews in the United States. The 33-item, online assessment covered staffing and funding; legislation; case identification, abstraction and review; challenges; and translation activities.