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Case Selection

Case Selection Wheel

How do MMRCs select maternal death cases for review?

The criteria MMRCs use to select cases for abstraction and review (e.g. the scope of the review) should be documented in the committees’ policies and procedures, and followed consistently. To adhere to best practices in maternal mortality surveillance, MMRCs should consider all pregnancy-associated deaths when selecting which cases to review.

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The most significant factor that influences a committee’s scope for abstraction and review is the time and effort required to abstract cases. In smaller, less populous states, MMRCs might have the capacity to abstract and subsequently review all or most pregnancy-associated deaths due to the relatively low number of cases. Larger, more populous states identify more pregnancy-associated deaths during the case identification process. These states are more likely to have specific criteria for sending deaths forward for case abstraction and review by the committee. Some of the compromises these states make include:

  • Limiting abstraction of cases to obstetric causes of death: Some MMRCs in larger states choose to limit review of deaths to those where the cause of death is classified by one of the obstetric cause of death codes on the death certificate. These reviews tend to omit deaths due to injury-related causes (e.g. suicide, substance overdose, and intimate partner violence or homicide), though committees may still include these deaths in their report of all pregnancy-associated deaths identified by the review. One reason for limiting case selection in this way is that records required for a thorough review of injury-related deaths can be especially difficult to obtain for case abstractors, and the absence of those records from the case narrative makes it challenging to determine whether the case is indeed pregnancy-related.
  • Selecting a sample of cases or a specific type of case for in-depth study: Due to a high volume of pregnancy-associated deaths identified, some MMRCs in more populous states might send forward a sample, preferably representative, of the cases identified for abstraction and presentation to the full committee. Other MMRCs may determine that for a limited period of time, the abstraction and review of cases will be limited to a particular cause of death that is of high priority or concern to the committee or state public health leaders.

One effective strategy that is preferable to those described above yet still ensures a comprehensive review is to convene a “small committee.” The small committee is a subset of the full MMRC. It considers all the pregnancy-associated cases identified through the case identification process and determines whether the case should be recommended for case abstraction.