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Reviewing Maternal Deaths is First Step in Preventing Them

Data from nine states’ Maternal Mortality Review Committees (MMRCs) has been collected and analyzed under the “Building U.S. Capacity to Review and Prevent Maternal Deaths” project. For the first time, this report includes recommendations for prevention and more detailed analysis of factors and themes associated with the leading causes of maternal death.

Over 60% of pregnancy-related deaths were deemed preventable, up from 59% in last year’s report. The most common factors identified as contributing to the death were patient/family factors (e.g., lack of knowledge on warning signs and need to seek care), followed by factors related to providers (e.g., misdiagnosis and ineffective treatments) and systems of care (e.g., lack of coordination between providers). While those factors reflect the report’s generalized findings, they also closely mirror what we hear at the Preeclampsia Foundation – both anecdotally and in our data collection.

As expected, preeclampsia/eclampsia (PE/E) figure prominently in the report, particularly as one of the leading underlying causes of death among non-Hispanic black women. It was one of the seven leading causes of pregnancy-related death. Interestingly, PE/E factored into a higher percentage of deaths amongst older mothers (ages 35-44) than most other causes of death, and was one of the leading causes of death that occurred within 42 days of the end of pregnancy (versus during pregnancy or up to a year after pregnancy).

This report also found a higher percentage of deaths to be preventable, suggesting a possible shift over the last decade toward increased opportunities for prevention. While alarming, the specific contributing factors to PE/E deaths were heavily weighted to provider (52%) and patient/family (23%) factors.

The two predominate classes of provider factors were knowledge at 20.7% and referral at 13.8%, followed by assessment and clinical skill at 10.3% each. Common themes included delayed diagnosis or treatment, misdiagnosis, use of ineffective treatments, and failure to seek consultation. While troubling, this suggests that changes in healthcare provider practices could make a noticeable difference in outcomes. It is for this reason that the Preeclampsia Foundation has invested so heavily in advocacy work with professional societies, state-level task forces, and federal policy improvements. Our goal is getting providers to do a better job, consistently (every woman, every pregnancy) with what we know is optimal health care for preeclampsia.

System of care factors comprised only 17.9% with 40% of those related to communication, mostly related to coordination of care between providers. It will be interesting to see how patient-reported communication factors line up against this report.

Finally, a section of the report that we contributed to and in which we are very interested is incorporating severe maternal morbidity into MMRC processes. We are working on a national task force to create an “Informant Interview” process that will allow for the woman’s personal story – her ‘narrative’ – to be included in case reviews of really bad outcomes. We strongly believe that incorporating severe maternal morbidity survivors’ voices will address gaps that no other source will fill. Engaging survivors directly in quality improvement initiatives is a big focus of our 2018 Preeclampsia Foundation Summit.

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