Definitions & Terminology

• Maternal Mortality is defined as the death of a woman while pregnant or within one year of the end of a pregnancy—regardless of the outcome, duration, or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. While researchers will use other terminology to further categorize a maternal death (i.e. pregnancy-associated death and pregnancy-related death), the phrase maternal mortality is more encompassing and covers the topic of deaths during pregnancy, childbirth, and the postpartum period.

• Maternal Mortality Rate represents the number of maternal deaths per 100,000 live births.

• Maternal Morbidity describes those instances where a mother did not die, but “unexpected outcomes of labor and delivery resulted in significant short-or long-term consequences to a woman’s health.”

• Preventable Deaths are deaths which could likely have been avoided  if “there was at least some chance of the death being averted by one or more reasonable changes to patient, community, provider, facility, and/or system factors.”

• Maternal Mortality Review (MMR) is a process by which a multi-disciplinary Committee (MMRC) identifies and reviews cases of maternal death within one year of pregnancy to understand the health, economic, educational, and environmental factors associated with the deaths.

United States

• According to the Alliance for Innovation on Maternal Health (AIM), the U.S. is one of only three countries in the world where the rate of maternal deaths is on the rise (Sudan and Afghanistan being the others).

• In 2018, a total of 658 women died of maternal causes in the United States. The maternal mortality rate for 2018 was 17.4 deaths per 100,000 live births. 

• For every maternal death, there are also over 80 women who suffer from maternal morbidity, totaling over 55,000 severe complications in 2014.

• Pre-existing conditions, rather than complications with delivery, have now become the leading cause of maternal mortality and morbidity, with cardiovascular conditions being responsible for 33.6% of pregnancy-related deaths.

• Nationally, over 60% of maternal deaths could have been prevented. A Tennessee report issued this year found an overwhelming 85% of its maternal deaths could have been prevented.

Alabama

• In 2017, 41 women died from pregnancy or childbirth complications, the second-worst maternal death of any state in the nation that year.

• From 2011-2015, the maternal mortality rate for White women was 5.6%, while the rate for Black women was 27.6%. However, due to newly available statistics and reporting, these numbers are projected to be much higher today.

• Alabama’s maternal death rate is increasing, with only 12 deaths in 2015, then 35 in 2016, to 41 in 2017.

• Around 60% of maternal deaths in Alabama occur after delivery, not before.

• Nearly 65% of Alabama mothers reported having some kind of medical problem during pregnancy.

• Alabama ranks 46th in women’s and children’s health, and Alabama’s hospitals rank 47th in maternity care and infant feeding.

• Fewer than 50% of Alabama counties now have a hospital with obstetrical services.

Black Women

• In 2018, the maternal mortality rate for black women (37.1 deaths per 100,000 live births) was 2.5 times the rate for white women (14.7) and 3.1 times the rate for Hispanic women (11.8).

• On average, Black women are 3-4x more likely to die from pregnancy-related issues than White women.

• Even Black women with more education and higher incomes still die at a higher rate. Among all women with a college education, Black women are 5.2x more likely to die than their White counterparts.

• Black women experience severe maternal morbidity at a 79% higher rate than white women.

• In 2010, 32% of Black women did not receive the recommended number of prenatal visits, an increase in 7% of the national average.

• In 2016, the preterm birth rate for Black women was 50% higher than White women.

Rural Health Challenges 

• Safe maternity care requires access to hospitals with quality obstetric units and appropriately staffed medical teams led by trained physicians.

• A lack of access to high-quality maternal health services in rural communities is the result of many factors including hospital and obstetric department closures, workforce shortages, and access to care challenges arising from the social determinants of health which have contributed to disparities in

  maternal health care for rural women and their babies.

• Between 2004 and 2014, 179 rural counties lost or closed their hospital obstetric services. Consequentially, fewer than 50% of rural women have access to perinatal services within a 30-mile drive from their home and more than 10% of rural women drive 100 miles or more for these services.

• In Dallas County, Alabama, where many obstetrical care providers have closed, and there is no meaningful public transit infrastructure. Because of this, a recent report describes how some Selma residents have no other choice than to pay friends or family to drive them to a clinic.

Rural Health Statistics

• Approximately 500,000 women deliver in rural hospitals each year.

• Maternal mortality rates are significantly higher in rural areas than in urban areas. For 2015, the maternal mortality rate for rural women was 29.4%, whereas in large metropolitan areas it was 18.2%.

• One in five Americans live in a rural community, including approximately 18 million women of reproductive age.

• Women who are required to drive 45 minutes or more to their delivery location are 1.5x more likely to have a premature delivery than women who drive 15 minutes or less.

Overview of MMRCs

• MMRCs bring together local experts—ob-gyns, nurses, social workers, patient advocates, and other health care professionals—to review individual maternal deaths and recommend specific ways to prevent them in the future.

• Today, at least 35 states have an established committee and process to review maternal deaths.

• Slightly more than half the states have maternal mortality review committees that have been operating for at least a year. Many receive little or no funding and rely on volunteers to take on case analyses.

• Review committees draw not only from vital records, but from a variety of sources, from obituaries to social media, to identify and compile facts about maternal deaths. For each case, they typically extract demographic data such as a woman’s age and race, then use medical records, notes from care providers and other resources to look at what happened, determining whether the catastrophic outcome was related to pregnancy or childbirth and whether it was preventable.

Alabama’s MMRC

• In 2018, a coalition of Alabama doctors, nurses, public health leaders and others began forming a Maternal Mortality Review Committee under the umbrella of the Alabama Department of Public Health. The committee met to review its first cases in February of 2019. 

• Alabama funds programs to review infant deaths, but its MMRC currently receives no funding. As a result, ADPH must rely on staff and volunteers from other programs and professions in order to compile data and review maternal deaths.

Racial Disparities

• Reducing disparities in maternal mortality requires addressing multifaceted contributors. Ensuring robust comprehensive data collection and analysis through maternal mortality review committees offers the best opportunity for identifying priority strategies to reduce disparities in pregnancy-related deaths.

Rural Disparities

• Recent attention to the rural hospital supply has focused on hospital closures; however, we continue to

  see a substantial decline in the provision of obstetric services, even among surviving rural hospitals. Greater attention to obstetric care services is needed, especially in rural areas, to ensure that prenatal care is provided based on the best medical evidence and that pregnant patients can access quality care, when needed, within a reasonable travel distance.

 MMRC Success

• Since creating its MMRC and implementing new policy and system strategies, California reduced its maternal mortality rate by half to an average of 7 deaths per 100,000 births.

• Not only has California’s MMRC reduced maternal mortality overall, but the most significant reduction in deaths was among Black women.

• North Carolina’s MMRC has contributed to improved outcomes and a reduced maternal mortality rate among Black women, so much so that its racial disparity has become non-existent. 

Alabama Healthcare

• “When a mom dies, it is such a tragic event that impacts not only the baby but a whole family. It’s a reflection on the quality of healthcare here in our state. It’s a failure of our healthcare system when that happens. We’ve got to do better.” – Dr. Grace Thomas, OB-GYN, Health Officer for Family Services at ADPH

Racial Disparities

• “We know that black women are much more likely to die in childbirth. We know black babies are more likely to die than white babies. But we don’t understand the why, and I don’t think we’ve done enough to address the issue adequately.” – Dr. Sara Mazzoni, Associate Professor, Dept. of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine

Funding the MMRC

• “As an organization of physicians, we feel compelled to take the lead in tackling this issue. Each and every maternal death is devastating to families, and leaves everyone asking ‘why?’.  Alabama’s maternal mortality stats are unnerving. As physicians, we feel like our state has got to do better, can do better, and must do better, and our coalition partners feel the same way.  But until we have a thorough review of the maternal death data, we can’t answer the all-important question of ‘why?’ when a mother dies and take steps to stop maternal death.  Alabama has made major strides in reducing infant mortality in large part due to action steps identified through the state’s infant-death review process.  But Alabama currently doesn’t fund maternal mortality review, and until we appropriately do so and dig down into the root causes of maternal death in this state, we can’t expect to be able to make informed health policy decisions as a state to move forward in eradicating maternal deaths.” – Dr. John Meigs, President of the Medical Association of the State of Alabama

• “We cannot solve the crisis of maternal mortality without truly understanding the causes. Fully funding the costs associated with sustaining a robust maternal mortality investigation process and review committee will result in an increased understanding of the medical and social causes of maternal death, in order to find solutions. We owe this to our moms and all families here in Alabama.” – Britta Cedergren, MPH, MPA, Director of Maternal Child Health & Government Affairs

• Comprehensive analysis is essential in order to focus resources on successful interventions-and to revise and rescind policies that are having unintended consequences. – American Medical Association

Articles

• Alabama to spend nearly half a million to investigate maternal deaths (al.com)
• Alabama has third-highest death rate of mothers in the nation, new federal report says (al.com)
• Rural healthcare isn’t easy. Here’s how one Alabama woman bridges gaps in the Black Belt (al.com)
• 7 things I learned from spending a year reporting on mothers in Alabama (al.com)
• Alabama medical experts ask for $478,000 to investigate pregnancy-related deaths (al.com)
• Deaths from pregnancy and child birth are often preventable; Alabama finally starts to take notice (al.com)
• 7 things I learned from spending a year reporting on mothers in Alabama (al.com)
• In Alabama, Eyeing Better Pregnancies for Black Women (usnews.com)
• How America Is Combating Maternal Mortality (usnews.com)
• We finally have a new US maternal mortality estimate. It’s still terrible. (vox.com)
• Women dying from pregnancy and childbirth is still a problem in the United States, CDC report shows (cnn.com)
• Maternal death rate among black women 2.5 times higher than white women, new report finds (gma.com)
• The U.S. finally has better maternal mortality data. Black mothers still fare the worst. (nbcnews.com)
• How Many American Women Die From Causes Related to Pregnancy or Childbirth? No One Knows. (propublica.org)
• Black Mothers Get Less Treatment For Postpartum Depression Than Other Moms (khn.org)
• Maternal deaths among black women focus attention on the need for policy and payment reform (healthjournalism.org)
• As a Doctor and Mother, Here’s What I Wish People Knew About the Maternal Mortality Crisis (self.com)
• How ACOG is Combating Maternal Mortality (acog.org)
• The Extraordinary Danger of Being Pregnant and Uninsured in Texas (propublica.org)
• There’s so much Nevada doesn’t know about maternal mortality (nevadacurrent.com)
• Ga. Lawmakers Release Recommendations To Reduce State’s High Maternal Mortality Rate (wabe.org)
• Lawmakers target maternal mortality (valdastadailytimes.com)

Reports

• 2019 March of Dimes Report Card – Alabama (marchofdimes.org)
• 2018 Health of Women and Children Report – Alabama (americashealthrankings.org)
• 2019 CDC Evaluation of the Pregnancy Status Checkbox on the Identification of Maternal Deaths (cdc.gov)
• 2019 CDC Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release (cdc.gov)
• 2019 CDC The Impact of the Pregnancy Checkbox and Misclassification on Maternal Mortality Trends in the United States, 1999–2017 (cdc.gov)
• 2019 Georgia House of Representatives Study Committee on Maternal Mortality (house.ga.gov)
• Report from Nine MMRCs (reviewtoaction.org)
• Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017 (cdc.gov)
• Mississippi Maternal Mortality Review Report (msdh.ms.gov)
• Vital Signs: Pregnancy-related deaths (cdc.gov)
• Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007–2016 (cdc.gov/mmwr)
• AAF Insights: Maternal Mortality in the United States (americanactionforum.org)
• Maternal Mortality Review Committees – Issue Brief (networkforphl.org)
• Improving Access to Maternal Health Care in Rural Communities (cms.gov)
• NRHA Policy Paper: Access to Rural Maternity Care (ruralhealthweb.org)
• State Approaches to Reducing Health Disparities (ncsl.org)
• Beyond The Preventing Maternal Deaths Act: Implementation And Further Policy Change (healthaffairs.org)