Have you ever wondered what happens during a maternal mortality review committee meeting? Maybe you are in the early phases of assembling a committee in your local jurisdiction, and you aren’t quite sure who should be involved or how to describe the process to potential committee members. Or maybe you have been invited to serve on a review committee, but you don’t know what to expect when you arrive.
This interactive website was designed to offer people a peek inside a review committee meeting. We convened a group of experts who agreed to share their insights and participate in a mock panel review. As you navigate through the website, you will meet the committee members and follow the flow of their process as they review and discuss a fictitious case before reaching consensus about the underlying cause of death, pregnancy-relatedness, preventability, contributing factors to the death, and recommendations for action that address those contributing factors.
Before you begin, watch this short video that explains key considerations for maternal mortality review committees.
The purpose of this maternal mortality review committee is to conduct a full examination of all pregnancy-associated deaths in our jurisdiction and to utilize our findings to inform actions for prevention. In order to fulfill this purpose, we as a committee have set ground rules for how we will function.
START AND END ON TIME
everyone serving on the committee is busy; everyone’s time is valuable and shouldn’t be wasted.
STICK TO TASK AND TOPIC
it can be easy to drift into tangential discussions about similar cases or to wonder about information not included in the records available to the committee; everyone should make a concerted effort to limit discussions to the tasks and topics directly relevant.
SHARE THE AIR
everyone on the committee has valuable insights and a unique perspective; everyone should be allowed to speak and no one should attempt to dominate the conversation.
after reviewing and discussing each case, the committee should seek to reach consensus and make decisions as a group; a single committee member should not be charged with making a final decision on behalf of the group.
AGREE TO CONFIDENTIALITY
everyone should review and sign the pledge of confidentiality at the start of each meeting.
Before reviewing information about any cases, the Committee Chair should review the mission and vision of the committee. This is also a good time to review definitions.
The vision of the maternal mortality review committee is to eliminate preventable maternal deaths in our jurisdiction, reduce maternal morbidities, and improve population health for women of reproductive age.
The mission of our maternal mortality review committee is to increase awareness of the issues surrounding maternal deaths and to identify interventions and promote change among individuals, health care systems, and communities in order to prevent maternal deaths, reduce maternal morbidities, and improve population health of women of reproductive age.
Our committee currently identifies and reviews all pregnancy-associated deaths in our jurisdiction within a defined time period in hopes of developing interventions to prevent and reduce future deaths. We revisit our scope yearly to ensure it aligns with our resources.
The core definitions that every maternal mortality review committee member should be familiar with
are the definitions for pregnancy-associated death, pregnancy-associated, but not related death, and
The death of a woman while pregnant or within one year of the end of pregnancy, regardless of the cause. This is the umbrella term that indicates a relation in time only, not a causal relation.
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 while pregnant or within one year of termination of pregnancy, due to a cause that is not related to pregnancy. One example of this might be a pregnant woman who dies in an earthquake.
Sometimes we find that we are unable to determine whether a death is pregnancy-related or pregnancy-associated but not -related, and that’s okay. In those cases, we label the case “unable to be determined” and we proceed to discuss the contributing factors and recommendations for action.
MORE INFO > reviewtoaction.org
We are now ready to review the first case. The Committee Chair will present the case narrative to the committee. Take time now to read the full case narrative, and then listen to our committee discuss important issues related to the case.
She died with cause of death listed on the death certificate as cardiogenic shock secondary to peripartum cardiomyopathy due to non-ST elevated myocardial infarction (NSTEMI), six weeks after delivery. Medical history was significant for developing heart failure and asthma after her delivery in 2005. Pre-pregnancy body mass index (BMI) was 33.8. Her family medical history was significant for having a brother who passed away from cardiac disease at age 19.
Entry into prenatal care was at 36 weeks with four visits at a hospital clinic with an obstetrician (OB). Prenatal history was significant for late entry into care and anemia. There were no referrals made during the prenatal period. This sentinel pregnancy was her 6th pregnancy. She had a past OB history of 4 preterm births and one first trimester termination of pregnancy. There were no noted health events prior to delivery. She presented to hospital at 38.3 weeks’ gestation for induction/augmentation of labor. On admission, she requested that her sister adopt infant and a social service consult was made.
Delivery was by an OB, method was spontaneous vaginal delivery (SVD) with epidural anesthesia. No obstetric complications noted. Infant was 38 weeks’ gestation and weighed 7 lbs., 2 oz., Apgar scores were 9 and 9. Day after delivery, she developed dry cough, chest x-ray (CXR) was negative. Social service consult completed for adoption request but due to potential for lengthy paternity legal issues, adoption plans were to be formalized after discharge. Mother and infant were discharged to home.
She had scheduled early postpartum visit at 2 weeks. At visit, she complained of (c/o) being tired and still having pain. Edema noted in lower extremities, and she was encouraged to ambulate more and quit smoking. Advised to continue with Motrin every 6 hours for pain and to call if pain does not go away.
Two days later, she presented to emergency department (ED) (same as delivery facility) with complaints of right-sided chest pain and shortness of breath x 2 hours. Studies negative for pulmonary embolus. CXR and computed tomography (CT) scan noted cardiomegaly consistent with postpartum state. EKG noted sinus tachycardia. Pain relieved with narcotics, and she was discharged home with instructions to follow up with her primary care physician (PCP).
Three weeks later, she presented to a different ED c/o shortness of breath (SOB) and chest pain. She was diagnosed with NSTEMI and cardiogenic shock and admitted to intensive care unit (ICU). Seven hours after admission, she was transferred out to higher level cardiac care. Cardiac catheterization was completed. Cardiac support given but she died seven days after admission. The case was not referred to the medical examiner (ME) and no autopsy was performed.
The discussion is the meat of the committee review process. Explore the section below to hear important considerations raised by our committee members as they seek to reach consensus about the underlying cause of death, pregnancy-relatedness, preventability, contributing factors to the death, and recommendations for action that address those contributing factors.
After discussion, our committee must answer a series of questions to complete the Committee Decisions form.
Watch the video below to gain more insight into how a committee reaches consensus on these important points.
This brings us to the end of our case review. There are still some unanswered questions, as there will be any time a case is reviewed. Skillful facilitation is an essential component of a maternal mortality review committee’s success. A skilled facilitator knows when to say, “We have to close the case at some point. We have to make decisions so we can make recommendations.” Sometimes discussions will go on longer or shorter than planned, but when people start repeating things, it’s time to move on. Before the committee adjourns, we recap the accomplishments of the meeting, identify how many cases were reviewed and the pregnancy-relatedness and preventability determinations for each one, and review the recommendations made.
The quality of a case review is dependent on the expertise and commitment of the members serving on the review committee. The work of a dedicated and focused committee has the potential to eliminate preventable maternal deaths, reduce maternal morbidities, and improve population health for women of reproductive age in the local jurisdiction and beyond. It is challenging work, but it is critically important.
We would like to acknowledge the following individuals who contributed to the content of this mock review experience:
Bette Begleiter, MSW
Deborah Burch, MSN, RN
Andria Cornell, MSPH
Julie Cristol, CNM
Robyn D'Oria, MA, RNC, APN
Jane E. Ellis, MD, PhD
Toby Goldsmith, MD
Dave Goodman, PhD
Jan Gorniak, DO
Afshan Hameed, MD
Roy Hoffman, MD, MPH
Torri Metz, MD, MS
Jill Mhyre, MD
Angela Rohan, PhD, MA
Cynthia Shellhaas, MD
Amy St. Pierre, MBA
Keila Torres, JD, DrNP(c)
Julie Zaharatos, MPH