Circumstances Contributing to Pregnancy-Related Deaths: Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019

Introduction

Maternal Mortality Review Committees (MMRCs) are multidisciplinary committees that convene at the state or local levels to review deaths during or within 1 year of the end of pregnancy (pregnancy-associated deaths). MMRCs have access to clinical and non-clinical information (for example, vital records, medical records, social service records) to better understand the circumstances that contributed to each death, determine whether the death was pregnancy-related, and develop recommendations for action to prevent similar deaths in the future.

Data on 1,018 pregnancy-related deaths among residents of 36 states from 2017 to 2019 were shared with the Centers for Disease Control and Prevention (CDC) through the Maternal Mortality Review Information Application (MMRIA, pronounced "Maria").

Circumstances surrounding a death

There are four "circumstances surrounding a pregnancy-related death" that can be documented by MMRCs using standard checkboxes. The four circumstances are:

• Obesity.
• Discrimination.
• Mental health conditions other than substance use disorder.
• Substance use disorder.

The options that an MMRC documents for each circumstance include Yes, No, Probably, or Unknown.

The MMRC determines if one of these four "circumstance surrounding a pregnancy-related death" was both present and contributed to the chain of events leading to a death but may not have been the underlying cause of death. The MMRC separately considers and documents each circumstance, so each pregnancy-related death may have multiple circumstances identified.

Obesity

MMRCs determine whether obesity contributed to the death, and not just whether the person was obese. The committee may determine that obesity contributed to the death when the condition directly compromised an individual's health or health care. For example, obesity complicated ventilation options for a pregnant person with the flu.

Committees determined that obesity is a circumstance that contributed (Yes or Probably) to 27% of deaths.

Figure 1. Committee Determination on Obesity as a Circumstance Contributing to the Death, Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019^a

	a	Deaths with missing values were not included in percent calculations.

This percentage is based on 1,016 (of 1,018) pregnancy-related deaths for which this determination was present.

Discrimination

MMRCs determine whether discrimination contributed to the death, and not just whether the individual was exposed to discrimination. Discrimination is defined as treating someone less or more favorably based on the group, class, or category they belong to resulting from biases, prejudices, and stereotyping.1 Discrimination can manifest as differences in care, clinical communication, and shared decision-making.1 For example, dismissing symptoms of abdominal pain described by a person with a history of substance use disorder that led to a delay in diagnosis and care for ruptured ectopic pregnancy. This determination was added as an option for MMRCs in MMRIA in May 2020. We report only on the 663 deaths that occurred between 2017 and 2019 and were reviewed after May 29, 2020.

Committees determined that discrimination is a circumstance that contributed (Yes or Probably) to 30% of deaths.

Figure 2. Committee Determination on Discrimination as a Circumstance Contributing to the Death, Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019^a

	a	Deaths with missing values were not included in percent calculations.

This percentage is based on 602 (of 663) pregnancy-related deaths for which this determination was present.

Mental health conditions other than substance use disorder

MMRCs determine whether a mental health condition other than substance use disorder contributed to the death, and not just whether the person had a mental health condition. Mental health conditions are defined as present when the individual had a documented diagnosis of a psychiatric disorder. This includes depressive, anxiety, psychotic, and bipolar disorders.

If a documented diagnosis is not available, the committee will consult with the review committee subject matter experts, such as a psychiatrist, psychologist, licensed counselor, to determine whether the criteria for a diagnosis of a mental health condition are met. The committee may determine that a mental health condition is a circumstance that contributed to the death when the condition directly compromised an individual's health or health care. For example, a mental health condition impacted the person’s ability to manage type 2 diabetes.

Committees determined that a mental health condition is a circumstance that contributed (Yes or Probably) to 28% of deaths.

Figure 3. Committee Determination on Mental Health Conditions Other Than Substance Use Disorder as a Circumstance Contributing to the Death, Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019^a

	a	Deaths with missing values were not included in percent calculations.

This percentage is based on 1,014 (of 1,018) pregnancy-related deaths for which this determination was present. If a documented diagnosis is not available, the committee will consult with their review committee subject matter experts, such as a psychiatrist, psychologist, licensed counselor, to determine whether the criteria for a diagnosis of a mental health condition are met based.

Substance use disorder

MMRCs determine whether substance use disorder contributed to the death, and not just whether the individual had a substance use disorder. Substance use disorder is characterized by recurrent use of alcohol and/or drugs causing clinically and functionally significant impairment, such as health problems or disability.

Substance use disorder is documented separately from other mental health conditions as a circumstance surrounding a death. The committee may determine that substance use disorder is a circumstance that contributed to the death when the disorder directly compromised an individual's health or health care. For instance, acute methamphetamine intoxication made preeclampsia worse, or the person was more vulnerable to infections or medical conditions.

Committees determined that substance use disorder is a circumstance that contributed (Yes or Probably) to 25% of deaths.

Figure 4. Committee Determination on Substance Use Disorder as a Circumstance Contributing to the Death, Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019^a

	a	Deaths with missing values were not included in percent calculations.

This percentage is based on 1,013 (of 1,018) pregnancy-related deaths for which this determination was present.

Data sources and methods

Data were shared for aggregate analysis by jurisdictional MMRCs through MMRIA. MMRIA supports standardized record abstraction, case summary development, documentation of committee decisions, and analysis.

Data analyzed included information on pregnancy-related deaths that occurred during 2017–2019 among residents of 36 states: Alabama (2017–2018), Alaska (2019), Arizona (2017–2019), Arkansas (2018–2019), California (2019), Colorado (2017–2019), Connecticut (2017–2019), Delaware (2017–2019), Florida (2017–2019), Georgia (2017–2018), Hawaii (2017–2018), Illinois (2017–2019), Indiana (2017–2019), Kansas (2017–2019), Louisiana (2017–2019), Massachusetts (2017), Minnesota (2017–2018), Mississippi (2017–2019), Missouri (2017–2019), North Carolina (2018–2019), Nebraska (2017–2019), New Hampshire (2017–2019), New Jersey (2017–2019), New Mexico (2017–2019), New York (2018–2019; 2019 excludes NYC), Ohio (2017–2018), Oklahoma (2017–2019), Oregon (2018–2019), Pennsylvania (2018), Tennessee (2017–2019), Texas (2019), Virginia (2018), Washington (2017–2019), West Virginia (2017–2019), Wisconsin (2017), and Wyoming (2018–2019).

In some states, only partial years of data were shared. Some states group review deaths by cause of death and may have reviewed only some causes before sharing data with CDC. Sensitivity analysis did not indicate any major differences in underlying causes of death when data for those states were excluded.

Definitions

Pregnancy-related: A death during pregnancy or within 1 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. In addition to having a temporal relationship to pregnancy, these deaths are causally related to pregnancy or its management.