Written By:
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.
Resources:
Arizona Department of Health Services, Maternal Mortality Review Report (2012-2015)
Centers for Disease Control, Report from Nine Maternal Mortality Review Committees (2018)
Dr. Lisa Villarroel is Medical Director of the Division of Public Health Preparedness, Arizona Department of Health Services (ADHS).
This is an enlightening article. There are many reasons why a pregnant woman’s death should be looked at separately and I appreciate the work your office is doing and making us aware. I do not have statistics, but I also understand that a pregnant woman or a recently postpartum woman is significantly more vulnerable to physical abuse by her relationship partner than at other times.