It’s shocking that maternal deaths in the U.S. are on the rise, even as they have declined nearly everywhere else in the world. One explanation for this disturbing trend is the increase in chronic conditions — especially hypertension, diabetes, and obesity. Women who die from pregnancy or childbirth complications have disproportionately high rates of chronic disease. These health conditions now afflict more than a quarter of all pregnant women in the U.S.

Enhancing Maternal Mortality Review Boards In The U.S.

Learning from an unexpected death is an effective way to prevent future loss. When a woman dies during pregnancy, childbirth, or the postpartum period, the cause of death reported on the death certificate does not tell the full story. These situations require an in depth review to understand what happened so we can help save other women’s lives.

Regrettably, only about half of states in the U.S. have a maternal mortality review board in place, and many of these states do not act on the findings from the deaths they examine.

Maternal mortality review boards (MMRBs)—composed of an interdisciplinary group of experts—have been successful in driving efforts to improve maternal care in countries as diverse as the United Kingdom, South Africa, Malaysia, and Sri Lanka. After a maternal death, best practice dictates that a review board conduct a confidential evaluation to identify the root cause of the tragedy. The team reviews case files and interviews family members and friends to understand what happened, rather than to place blame. These findings often help shed light on systemic problems that, if addressed, could prevent future deaths.

In 2013, with support from Merck for Mothers—a global initiative to end preventable maternal deaths—the Association of Maternal and Child Health Programs is strengthening review boards nationwide. The Every Mother Initiative is helping states build their capacity to routinely analyze deaths and apply the findings to change policies and practices that could save women’s lives.

State Review Boards Take Action

Over the past two years, 12 states were selected to participate in the Every Mother Initiative (Note 1). In addition to sharing best practices, each state developed a program to address a leading cause of maternal death among its population. Several review teams chose to focus on the increasing prevalence of chronic conditions among women of reproductive age, given that many of the women who died in their states had untreated chronic health problems. The states’ response to this problem has national implications for efforts to improve women’s health before, during, and after pregnancy. Here are some examples of new statewide initiatives underway to reduce maternal mortality:


The Georgia Maternal Mortality Review committee found that women who had chronic and complex medical conditions were not receiving the information and support they needed to avoid pregnancy until their health was well managed — placing them at increased risk of death due to pregnancy.

The state maternal mortality review team partnered with Grady Health System and the Georgia Department of Public Health to test a new toolkit to help health care providers working in clinics in low-income communities provide counseling to patients on reproductive life planning and contraception. The toolkit includes a video on pregnancy and chronic conditions that is shown regularly in clinic waiting rooms, patient flyers with conversation prompts about chronic disease management, and recorded provider lectures to support an effective family planning counseling and referral process.

North Carolina

The North Carolina Pregnancy-Related Mortality Review team learned that a disproportionate number of maternal deaths in the state were due to complications related to cardiovascular disease and hypertension, and that many women were unaware of how their heart health might affect pregnancy.

In response, the team partnered with state-wide programs to prevent chronic disease and improve preconception health, developing the Show Your Heart Some Love social marketing campaign. The campaign targets women of reproductive age, urging them to follow a healthy lifestyle to ensure that a healthy heart comes before pregnancy. Through a short self-assessment, women can determine specific areas to focus on, such as weight-loss, diet improvements, and stress reduction to optimize heart health before pregnancy and childbirth.


The Oklahoma Maternal Mortality Review Committee identified pregnancy-induced hypertension and hemorrhage as major contributors to maternal mortality and morbidity in the state. To prevent further deaths and disabilities from these causes, the Oklahoma Perinatal Quality Improvement Collaborative, in partnership with the Oklahoma State Department of Health and the Oklahoma Health Care Authority, designed and launched a hospital-based maternal safety quality improvement initiative.

This initiative is recruiting hospitals throughout the state to adopt a set of guidelines for identifying, treating, and responding to complications related to hypertension and hemorrhage during pregnancy. The guidelines are evidence-based, adapted from quality improvement efforts in California and New York, and endorsed by the Council on Patient Safety for Women’s Health Care.

Looking Forward

It’s encouraging to see the progress the 12 states are making to improve maternal health by learning about the circumstances of pregnancy and childbirth-related deaths. The potential impact is significant because these states account for over a quarter of the four million births in the U.S. each year. Their smart approach will hopefully lead to more effective maternal care for women in these states and beyond.

Each woman’s death is a tragedy. We should not compound such a loss by failing to understand what went wrong or failing to act on what we’ve learned. Likewise, it’s important to take advantage of the window of opportunity that pregnancy provides, especially for women with chronic health conditions. These nine months are an ideal time to help a woman develop a healthier lifestyle, strengthen the relationship with her health care team, and learn to manage her health for the long term. Care during pregnancy should link closely with primary care so that after a woman gives birth, she continues to attend to her own health, not just the health of her baby.

Note 1

The states include: Colorado, Delaware, Florida, Georgia, Illinois, Louisiana, Missouri, New York, North Carolina, Ohio, Oklahoma, and Utah.