E3 - Maternal Mortality Surveillance: Different Methods Inform Different Actions

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Full Description: Death while pregnant or recently pregnant should be a rare event. As maternal deaths increased in the early 2000s, public health and health care professionals investigated cases and improved the data collection process itself. California acted similarly and now relies on three methods for gathering information about maternal deaths, each with its own advantages, limitations, and implementation costs, contributing data that informs a particular action.
We describe three methods currently in use and their relevance to policy and practice changes that have been implemented to improve maternal health: 1) Vital Statistics Maternal Mortality Ratios (VS-MMR); 2) Pregnancy Mortality Surveillance System (PMSS); and 3) Pregnancy-Associated Mortality Review (PAMR).
VS-MMR is based on vital statistics (VS) and thus is readily available but misses deaths in early pregnancy and excludes deaths later than 42 days postpartum. Its principal advantage is to allow crude comparisons by state, which can lead to shared learning regarding effective policies and practices. Most births/deaths are registered electronically in real time, but final VS files take more than one year to compile, requiring three to four months of data cleaning before transmission to the national database.
PMSS relies on data linkage of vital records and medical care administrative data to identify deaths within one year of pregnancy. Supplemented with coroner reports, these data usually provide adequate information for a committee to determine causes of death and relationship to pregnancy. PMSS reveals differences in the causes of death when the postpartum window is expanded and wider Black:White disparities that increased most for causes related to cardiovascular disease and hypertensive disorders. Case identification links multiple data sources and takes 12-16 months to identify and verify all pregnancy-associated deaths. Each “case” requires about four hours of preparation and review time.
PAMR relies upon the same data linkage process as PMSS to identify deaths, but PAMR’s reviews are more in-depth and identify contributing factors and prevention opportunities at the patient, provider, facility, system, and community levels. PAMR is resource intensive but can offer insights that convert data into action for prevention. PAMR’s scope can be narrowed to a single cause of death using a committee with focused expertise. This strategy led to the first ever California study of pregnancy-associated suicide. The resources needed to prepare for and conduct PAMR investigations are almost four times those of PMSS. PAMR findings helped to inform toolkits to guide hospital obstetric quality improvement efforts and may have led to improved rescue care and declines in California’s MMR.
We will provide greater detail to describe each method, implementations costs, and how the data have informed or could inform maternal mortality prevention policies and practices.

Abbreviated Description: Death while pregnant or recently pregnant should be a rare event. As maternal deaths increased in the early 2000s, public health and health care professionals investigated cases and improved the data collection process itself. California acted similarly and now relies on three methods for gathering information about maternal deaths, each with its own advantages, limitations, and implementation costs, contributing data that informs a particular action. We describe three methods currently in use and their relevance to policy and practice changes that have been implemented to improve maternal health: 1) Vital Statistics Maternal Mortality Ratios (VS-MMR); 2) Pregnancy Mortality Surveillance System (PMSS); and 3) Pregnancy-Associated Mortality Review (PAMR).