Maternal Mortality Definitions
In 1993, the Minnesota Department of Health (MDH) adopted the Center for Disease Control and Prevention (CDC) definition of maternal mortality:
- Pregnancy-associated maternal death
The death of a woman while pregnant or within one year of the termination of pregnancy, regardless of the cause.
The following are subsets of pregnancy-associated maternal deaths:
- Pregnancy-related death
The death of a woman during pregnancy or within one year of the end of pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.
- Pregnancy-associated, but not related death
The death of a woman during pregnancy or within one year of the end of pregnancy, from a cause that is not related to a pregnancy.
Maternal Mortality in Minnesota
The MMMRP continues to review maternal deaths, to provide surveillance and lead to recommendations for change in practice, systems of support, and patient education. Based on preliminary data from 2011-2017, the maternal mortality rate for non-Hispanic African-American women is 2.3 times higher when compared to white mothers. The American Indian maternal mortality rate is approximately 4 times higher than that for white mothers. This data suggests that almost half (47%) of maternal deaths occur in greater Minnesota.
- Historically in Minnesota, maternal deaths have been caused by reasons such as hemorrhage, infections and complications from delivery. However, in recent years, we have seen more deaths attributed to motor vehicle accidents and chronic health conditions such as hypertension and diabetes. Similar to the broader U.S. population, we have also seen an increase in maternal deaths involving substance use, depression and suicides, and gun violence.
Recommendations from Review of Cases
The following recommendations were developed from the Minnesota Maternal Mortality Review Committee (MMMRC), which convened in the fall of 2019. These recommendations are based on maternal mortality cases from 2017 case narratives, and will be updated as new recommendations are determined.
Maternal Mortality Nationally
In the United States from 2000-2015, maternal death rates increased, while globally rates fell by more than one third. As an industrialized nation, the U.S. is the only nation to see rising maternal mortality rates. Many of these death are likely preventable. Maternal mortality has devastating effects on families and communities, and rates continue to increase across the United States.
Changes in medical coding for maternal deaths could attribute to some of the rise in deaths. Improvements in surveillance and identification of cases can also be attributed to the rise in maternal death cases. Reducing maternal mortality is an achievable goal and many maternal deaths can be prevented through activities such as education, early prenatal care, reproductive life planning and social supports.
The following reports from the CDC in May 2019 provide an overview of national maternal mortality data from 2011-2015.
- Pregnancy-related deaths: Saving women's lives before, during and after delivery
- Las muertes relacionadas con el embarazo ocurren antes, durante y hasta un año después del parto
This report is a focused evaluation of 13 states’ pregnancy mortality surveillance systems from 2011-2015, analyzing preventability and factors contributing to pregnancy-related deaths.
Minnesota Maternal Mortality Review Project (MMMRP)
Per Minnesota Statute 145.901, “the commissioner of health may conduct maternal death studies to assist the planning, implementation, and evaluation of medical, health, and welfare service systems and to reduce the numbers of preventable maternal deaths in Minnesota.” To that end, the Minnesota Maternal Mortality Review Project was reinstituted in 2012 to review maternal deaths in order to examine the circumstances surrounding maternal deaths, identify risk factors for maternal mortality and make recommendations and interventions for reducing or eliminating future deaths in women of reproductive age.
The Minnesota Maternal Mortality Review Project Process
Step 1: Case findings
The Minnesota Department of Health (MDH) conducts surveillance of maternal deaths through standard and enhanced surveillance methods.
- Physician and hospital reporting
- Pregnancy status check box on death certificate
- ICD-10 codes
- Matching death certificates from any female death between the ages of 5-70 with birth certificates and/or fetal death certificates.
For more information on reporting deaths, see the Maternal Death Reporting Form (PDF).
Step 2: Assemble Available Medical Records and Information
Minnesota Statute 145.901 allows for the collection maternal medical records in accordance to the statute purpose. Decedent information is requested from multiple sources. Death certificates, birth certificates, medical records, autopsy reports, police reports and obituaries are some sources of information that are requested and collected. All available relevant medical records from a woman’s pregnancy, labor, birth, postpartum and other medical care are gathered to review the circumstances leading up to her death. The investigation of the maternal case is to gain insight into the various factors - social, geographic, cultural, spiritual, psychological, environmental, economic, or circumstances that lead to the maternal death and factors that may be preventable. This information is abstracted and developed into a case narrative, which is then reviewed by the Minnesota Maternal Mortality Review Project committee.
Step 3: Minnesota Maternal Mortality Review/Review Committee
The maternal mortality review convenes at least twice a year or more frequently if needed. It is conducted by a multi-disciplinary committee of expert professionals who meet to investigate the causes of maternal deaths in Minnesota and make recommendations. Professions represented include but are not limited to: Obstetrics/Gynecology, Maternal Fetal Medicine, Family Medicine, Midwifery, Nursing (Labor & Delivery, Neonatal, Perinatal, Public Health), Psychiatry, Medical Examiners/Forensics, Social Work, Tribal Liaison, law enforcement, social workers, doulas, and community advocates. This diverse group ensures that the case reviews are approached from many different professional perspectives.
The committee deconstructs the case narrative and determines if the death is classified as pregnancy related, pregnancy associated or unknown. Immediate, contributing, and underlying causes of death are evaluated and summary of recommendations are drafted for dissemination to professional groups and health systems involved in the care of pregnant and postpartum women to heighten their awareness of the causes of maternal mortality and ways they might be prevented.
Step 4: Analysis
Maternal information is abstracted and analyzed in the Maternal Mortality Review Information Application. This application developed by the CDC, provides for a standardization of surveillance, information collection, and monitoring of maternal mortality rates, allowing states to detect similar trends.
Step 5: Use of recommendations
The recommendations from the Minnesota Maternal Mortality Review Project are to:
- Identify themes or trends in maternal mortality in Minnesota over time
- Inform maternity care providers and clinical practice and community stakeholders
- Offer relevant public health interventions for women of reproductive age
- Provide opportunities for quality improvement
- Determine where resources should be allocated in the State
- Influence policy at the state and local level
The following are national resources focused on maternal mortality:
- World Health Organization - Maternal Mortality
- Centers for Disease Control and Prevention - Pregnancy- Related Deaths
- Building U.S. Capacity to Review and Prevent Maternal Deaths
- National Network of Perinatal Quality Collaborative
- Merck for Mothers
- Review to Action: Working Together to Prevent Maternal Mortality
- Association of Maternal & Child Health Programs - Maternal Health
- March of Dimes - Maternal Death and Pregnancy - Related Death
- Alliance for Innovation on Maternal Health Program