Bejanchong Foretia, et al
AMCHP Program Analyst, Women’s & Infant Health

Maternal mortality review is a standard and comprehensive system that primarily operates at the state level to identify, review, and analyze maternal deaths, disseminate findings, and act on the results. Maternal mortality review committees (MMRCs) have existed in the United States for more than a century. Although these committees were initially comprised primarily of medical professionals, MMRCs have expanded their membership to include a vast array of professionals and partners who engage with and serve people during pregnancy and the postpartum period. The goal of maternal mortality review is not merely to prevent maternal death, but to put in place recommendations that support health and wellness during pregnancy, childbirth, and postpartum. For more information on the review process, please visit www.ReviewtoAction.org. To learn more about these committees, visit their state profiles.

Significant changes and advancements for MMRCs have occurred over the past decade.  Thus, AMCHP asked the leaders and members of established, long-standing MMRCs from various states for their personal reflections on how the review process evolved, as well as their hopes for the future of review committees.

1. Reflecting on the history of MMRCs over the past decade, what do you feel have been “game-changers” in the way MMRCs function, or are supported?
   

   “The shift to multidisciplinary MMRCs has changed the function and output of the MMRC for the better. The review of a maternal death is no longer only clinical in nature; we are able to ask questions about a pregnant or postpartum person’s social environment, access to care, and lived experience. Colorado’s MMRC now includes representatives from addiction medicine, anesthesiology, behavioral health, epidemiology, family medicine, forensic nursing, forensic pathology, health systems, home visiting, labor and delivery lived experience, etc. This multidisciplinary nature is crucial, particularly as we better understand the ways in which systemic racism and implicit or explicit bias affect maternal health outcomes. – Shivani Bhatia, M.P.H. (Colorado)

   “I believe the most important event that has happened is the creation of the maternal mortality review information application (MMRIA). Having a centralized database that can be used by states to streamline chart audits and to have a consistent set of variables that are looked at, evaluated, and used to determine pregnancy relatedness for maternal deaths is essentially a “game changer.” It supports objective comparison across states while providing a mechanism to identify ways to prevent maternal death.  Although this is still a challenging discussion among our MMRC committee members, the guidance that MMRIA provides is enormous and has helped us tremendously in this aspect of maternal mortality review.” – Robyn D’Oria M.A., RNC, APN (New Jersey)

2. What is one (maybe two) major accomplishments you want to celebrate from the past decade (or since your MMRC was established)?
   

   “Successful data analysis and release of our multi-year report; secondly, being awarded the recent Centers for Disease Control and Prevention/Health Resources and Services Administration grants to implement our recommendations.” – Cynthia S. Shellhaas, M.D., M.P.H (Ohio)

   “Colorado’s MMRC was first founded in 1993, and we have records of an entity that reviewed maternal deaths in the 1950s through the 1970s. In May 2019, however, Colorado passed bipartisan legislation to put our MMRC in statute and fund the program for the first time. The legislation also supported us in a successful application to CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant program, which started in October 2019. The state and federal funding means we can collect better data, analyze and publish data more frequently, and implement recommendations to prevent deaths and improve maternal health equity.” – Shivani Bhatia, M.P.H (Colorado) 

3. How has the mission, scope, or structure of your review changed since it was established to meet an evolving understanding of preventing maternal deaths?
   

   “Over the last several years, the Department of Public Health has instituted a formal process for recruiting new members who reflect a more diverse and multi-sectoral membership. The new process includes a formal application that clearly defines member roles and includes term limits. The membership is representative of diverse geographic areas, all levels of care, and both urban and rural hospitals. In addition, the adoption of MMRIA has enabled standardization of data collection to allow for comparison across states.”  – Karin Downs, R.N., M.P.H., on behalf of the MMRC (Massachusetts)

   “Since the Virginia Team was established in 2002, the Team has successfully incorporated a reproductive justice framework into its case review process as a result of the significant racial disparities in pregnancy-associated deaths in Virginia.” – Melanie Rouse, Ph.D. (Virginia)

4. Are there any overlooked trends in the maternal mortality data that you believe haven’t gotten enough attention?
   

   “One issue that could use more attention is the shift in causes of death over time. In Illinois, we found that for 2015-2016, mental health conditions were the most common underlying cause of pregnancy-related death. The second most common cause was a tie between maternal hemorrhage and pre-existing chronic medical conditions that were exacerbated by pregnancy. Because most people think about direct pregnancy complications such as hemorrhage and pre-eclampsia when they think about maternal deaths, I think our data showing the contribution of chronic physical and mental health conditions is striking.” – Amanda Bennett, Ph.D., M.P.H.  and Shannon Lightner, M.P.A., M.S.W. (Illinois) 

   I believe that the lack of care coordination, including lack of appropriate referrals, consultations, and continued management throughout the pregnancy, among pregnant and postpartum women with chronic conditions, is a trend that has been overlooked. – Melanie Rouse, Ph.D. (Virginia)

5. What are some persisting barriers your MMRC faces in curbing maternal mortality?
   

   “Our greatest challenge is developing recommendations that address the social determinants of health (SDoH). It is often much easier to develop “clinical” recommendations that target hospitals and providers, but this is only one piece of the puzzle for reducing maternal mortality. We know that addressing the SDOH would have the greatest impact on reducing maternal mortality, but identifying concrete, realistic, actionable SDOH recommendations is very challenging.” –  Amanda Bennett, Ph.D., M.P.H. and Shannon Lightner, M.P.A., M.S.W. (Illinois) 

   “In Massachusetts, the main barriers to implementing MMRC more effectively are limited staff capacity and lack of funding. Additionally, to date, the MMRC has remained a process implemented within the health care system and maintains a strong clinical focus on improving care in pregnancy, during delivery, and in the postpartum period.  While providers are increasingly aware of SDoH, and factors outside the health care system that affect poor birth outcomes, there are continued barriers in reaching across sectors and from hospitals to communities to strengthen comprehensive strategies to improve the health of women, their families. and communities.” –  Karin Downs, R.N., M.P.H., on behalf of the MMRC (Massachusetts) 

6. What do you want the public to know about the work and relevance of MMRCs in preventing maternal deaths and improving maternal health? What is the next frontier for improvement in MMRCs? Please describe your hope for their future and their impact on maternal health equity and maternal mortality.

“Understanding that prevention is not just making sure health care providers/facilities do the right thing. Sometimes prevention is community wide and far upstream from the actual event. It is everyone’s responsibility, not just the clinicians. It’s much broader in scope than the general public and media realize.” – Cynthia S. Shellhaas, M.D., M.P.H. (Ohio)

“The greatest strength of MMRCs is their ability to develop recommendations to address maternal mortality that are rooted in the themes identified from specific cases of maternal deaths. MMRCs are looking at the specific factors that caused a death and talking about what actions could have been done to prevent that death. Each individual death provides powerful lessons, but then being able to aggregate the findings across multiple deaths validates MMRC recommendations. One important next step is to get an MMRC up and running in every state so that we can aggregate data at the national level.”  – Amanda Bennett, Ph.D., M.P.H. and Shannon Lightner, M.P.A., M.S.W. (Illinois)

“Maternal death is a sentinel event, the tip of the iceberg that highlights the underlying issue of rising severe maternal morbidity in Massachusetts. Morbidity can lead to a lifetime of chronic illness for women and their families and can significantly impact quality of family life.  It is also an increasing burden on the health care system. Our hope for the MMRC is to expand its focus to address improving maternal health more broadly, and to more actively engage in hearing from women and their families about their experiences of oppression within the health care system, including practices that have harmed them and strategies that have supported their voices in their own health care.  We recognize that reducing maternal mortality and morbidity without addressing inequities may not reduce the disparities in outcomes. It is critical to eliminate racial inequities in maternal health to improve birth outcomes for women and their families.” – Karin Downs, RN, M.P.H., on behalf of the MMRC (Massachusetts)

“The ethic of the maternal mortality review is one of reflection, respect, grief, and improvement. It is an opportunity for us as a society to reflect on how we can do better by pregnant and postpartum people and our communities, and to grieve the person who has died, to recognize and honor the trauma experienced by their children, their families, their provider care teams, and their communities. It is also an opportunity to grieve that these are inequities that exist in our society, and to build a fire for change—not just to ensure that we prevent deaths, but also to ensure that we support health and well-being.” – Shivani Bhatia, M.P.H. (Colorado)

“I would want the public to know that MMRCs are important not only for preventing maternal deaths, but also in preventing severe maternal morbidity and improving women’s health outcomes in general. MMRCs review the worst case scenarios with the benefit of 20/20 hindsight. This places them in a unique position to better understand the contributors to pregnancy-associated deaths and to develop recommendations to improve maternal outcomes. The next frontier for the improvement of MMRCs is the continued improvement in the data we are able to collect. As we collect better data, we will be able to develop better recommendations that will more adequately address the wide variety of factors that contribute to these deaths. My hope is that MMRCs will lead the way in the fight for health equity and the reduction in maternal mortality.”  – Melanie Rouse, Ph.D. (Virginia)

“I believe MMRCs are in a unique position to identify what is needed to improve maternal health in the United States, but more importantly in their own state. All states need to have their own MMRC.  As they say, all politics are local. I believe this is true and in addition to politics, other issues impacting our health care system are often specific to that particular community. It is imperative that each MMRC has representation from a variety of stakeholders. Their familiarity with the state, the system, the community, the issues surrounding maternal mortality is what makes our MMRC relevant and essential to the women of New Jersey.” – Robyn D’Oria MA, RNC, APN (New Jersey)

In the past year alone, the public health community, including AMCHP members, have been recipients of unprecedented investments designed to reduce maternal mortality and improving maternal health. Examples of these investments include the following:

• The launch of the CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program that now supports agencies and organizations in 25 states that coordinate and manage MMRCs
• The Health Resources and Services Administration’s State Maternal Health Innovation (State MHI) program, which assists nine states in addressing disparities in maternal health and improving maternal health outcomes.

In conclusion, new funding has changed the game for MMRCs. The adoption of MMRIA makes it possible to standardize data collection and analysis for MMRCs across the nation. Since we now understand more fully the need to make the MMRC process more multidisciplinary in nature and to engage the leadership of communities and the organizations that serve them, this new decade is poised for transformation. As we continue to learn more with these innovations for MMRCs, we can contribute to a future where we no longer must fear maternal deaths.