Lisa Villarroel, MD, MPH
When a pregnant woman has a fatal seizure, her death is reviewed.
When a woman hemorrhages during childbirth, her death is reviewed.
When a postpartum woman hangs herself, her death is reviewed.
Arizona has a Maternal Mortality Review Committee that investigates the deaths of pregnant women and those twelve months post-pregnancy. This Committee, required under ARS 36-3501, reviews cases and makes recommendations for prevention. The Board is made up of health department staff and community providers (OB-GYNs, neonatologists, family physicians, and toxicologists – all on donated time).
Before the committee meets, the Arizona Department of Health Services compiles a list of deaths and requests the relevant medical, legal and social service records. Combined with findings from the news and social media (no contact with family is permitted), a case file is created, which the committee then reviews to answer the following questions:
- Was this death pregnancy-related? (i.e., from a cause related to or aggravated by the pregnancy)
- Was this death preventable?
- What are the recommendations for the future?
The discussions can get tricky. A pregnant woman overdosed on opioids. Is that pregnancy-related? A man with PTSD shot his pregnant wife. Is that preventable? While crossing the street a new mother was struck by a car. Is there an impactful prevention recommendation to be made?
Between 2012-2015, Arizona’s review board assessed 141 cases (the full report is linked below). The findings are striking – not just because suicide was the cause of 10% of the maternal deaths, the number of drug intoxications is increasing or that there are disparities in hemorrhages and mental health diagnoses — but because 89% of pregnancy-related deaths were considered preventable.
The high percentage of preventable maternal deaths is both tragic and hopeful. There are steps we can take — an intervention, a systems change, a policy shift — to prevent maternal deaths in the future. The Board makes ten principal recommendations in its report, which span from access to care to clinical coordination. Examples include:
- Recommendation # 6: Increase and streamline access to behavioral services statewide, including training and education for advanced practice nurses in behavioral health services.
- Recommendation # 10: Educate providers on the availability of maternal postpartum resources such as home-visiting programs.
The ultimate goal of the Review Committee is to reduce maternal deaths. Other, more established mortality review programs suggest that outcomes are staged: short-term outcomes include increasing awareness of the existence and recommendations of the Committee; intermediate-outcomes include widespread adoption of patient safety bundles or policies; a long-term outcome is the reduction of maternal mortality.
Could the Maternal Mortality Review Committee make that kind of impact? It’s possible. Looking at the Childhood Fatality Review Team in Arizona – over twenty years, its data have supported some of the early Back to Sleep campaigns and local pool-fencing rules. This Maternal Mortality Review Committee just started in 2012 — the first outcome must be the increased awareness that this group exists and that local recommendations are being made.
A layperson in Arizona once asked in disbelief, “You’re telling me, there are workers in a government building, reviewing cases and trying to prevent deaths?” Yes, but it is not just public health – it’s your community providers in there, too. Spread the word.
Dr. Lisa Villarroel is Medical Director of the Division of Public Health Preparedness, Arizona Department of Health Services (ADHS).