Making her way to her baby’s crib at the end of naptime, a 29-year-old, first-time mother falls to the ground unconscious. She never recovers.
Until that day, despite the exhaustion that inevitably accompanies life with a newborn, the young woman appeared to be recovering well from childbirth. Even though she’d battled hypertension throughout her pregnancy, after delivery, her blood pressure readings were normal and she was discharged.
Her family is bewildered and distraught. It will be several confusing and agonizing weeks before they learn what took the life of this young, vibrant mother.
While this may sound like the plot of a scripted medical drama, I’ve just described a real-life scenario. Each year in the United States, 700 women die during pregnancy, delivery, or soon after delivering, with causes ranging from cardiovascular conditions, to hemorrhage, to complications with anesthesia. Yet research shows that about half of those deaths may be preventable. A collaboration between the Centers for Disease Control and Prevention (CDC) staff and colleagues at the CDC Foundation and the Association of Maternal and Child Health Programs (AMCHP) is taking steps to strengthen state and local maternal mortality prevention efforts.
Maternal Mortality Review Committees
In the circumstance I described above, the death certificate would probably list hypertension as the underlying cause of death. However, that death certificate wouldn’t have captured the intersection of factors that likely contributed to her death — circumstances related to the patient, her providers, medical facilities, and community. It certainly wouldn’t offer clear recommendations for changes to prevent future deaths. For that level of investigation and action, we rely on the hard work of state and local maternal mortality review committees (MMRCs). These multidisciplinary groups of medical and public health professionals dig deep into individual cases of maternal death, examining medical records and any available social information for each woman to identify opportunities for prevention.
MMRCs have existed in various forms across the country for nearly 100 years, but largely work independently from each other, resulting in non-standard data collection that creates challenges for information-sharing between committees. The collaboration between our CDC team and our colleagues at the CDC Foundation and AMCHP is working to produce stronger data than ever before and foster collaboration that can lead to effective interventions. The collaboration is supported by funding from Merck, through “Merck for Mothers,” the company’s 10-year, $500 million initiative to help create a world where no woman dies giving birth. Merck for Mothers is known as “MSD for Mothers” outside the United States and Canada.
Stronger, More Detailed Data
In early February, CDC and our partners introduced the first, game-changing outcome of this collaboration to MMRC teams from across the nation. We debuted a data system—the Maternal Mortality Review Information Application (MMRIA)—that, when used, provides stronger, more detailed data across jurisdictions than previously available. MMRIA builds on lessons learned from implementing its precursor, the Maternal Mortality Review Data System (MMRDS). For example, as a result of feedback from MMRDS users, MMRIA was developed to capture increased detail on mental health conditions and substance use.
We also published a preliminary report of data from four states—Colorado, Delaware, Georgia, and Ohio—using this data-collection system. The report provides the first in-depth look at key factors contributing to maternal death and showcases opportunities for prevention from multiple states. For example, mental health conditions were found to be a leading cause of pregnancy-related death in these four states. More specifically, among postpartum women, suicide most commonly occurs 43 days to one year after delivery. This was something that previously available data hadn’t revealed. We also learned that causes of pregnancy-related death differ by age and whether a woman was pregnant, in delivery, or recently delivered. Finally, this report offers concrete evidence that a maternal death is most often the tragic result of a number of contributing factors, not just one singular event.
Currently, more than 30 states and cities have a MMRC and several are using MMRIA. As more states and cities participate, these data can help identify causes and contributing factors to maternal deaths and the prevention opportunities with the greatest potential impacts within and across jurisdictions.
To revisit our earlier scenario, an investigation by a MMRC may have determined that the young mother was released too early and recommended that in the future, hypertensive women remain in the hospital until their blood pressure readings are normal for a specified amount of time. Alternatively, concerned about her hypertension, perhaps the woman’s doctor asked to see her back within two weeks of delivery but she never showed. The MMRC investigation may have discovered that she missed her appointment because she lived in a rural area and her partner had their car, leaving her without transportation to an office an hour away. Other investigations might reveal this same scenario playing out for women across the region. In response, the MMRC could identify an urgent need for specialized care much closer to this community. MMRCs are uniquely positioned to consider all of the factors that are contributing to deaths and make recommendations that can make a difference.
The death of every mother leaves a hole — a child without a mother, parents without a daughter, and partners without their better half. However, we have an opportunity to prevent many of these deaths. The first step is strong, accurate data. We at the CDC are hopeful that our collaboration will give state-based MMRCs a tool they can use to collect the best data possible in their area — data which they can then translate into effective policies and programs that address all of the factors contributing to maternal deaths.
To learn more, please visit www.reviewtoaction.org. This new website promotes the maternal mortality review process as the best way to understand why maternal mortality in the United States is increasing and identify interventions to prevent maternal deaths. The site provides resources and tools to support standard review processes that enable a common language for review committees, including our new data-collection tool, MMRIA, and the data report, “Report from Maternal Mortality Review Committees: A View Into Their Critical Role.”