Reducing Maternal Deaths Through State Maternal Mortality Review

Background: Illinois has one of the highest rates of maternal death in the United States, and in 2000, the Illinois Maternal Mortality Review Committee (MMRC) was created to address this high rate of maternal death. Methods: This is a detailed description of the development of the MMRC, its process of review, its impact on the state's attention to maternal mortality and its obstetric hospitals, and a summary of its initial findings. Results: The Illinois MMRC, specifically designed to be multidisciplinary, was created to provide secondary review of select maternal deaths. Between 2000 and 2010, 45 of the 93 deaths reviewed had complete analysis. Hemorrhage was the leading cause of death, and 69% of all cases were deemed potentially avoidable. Compared to the primary required review conducted by the State Perinatal Center, the secondary review by the MMRC changed the cause of death in 20% of cases and changed the determination of avoidability in 36% of cases. Based on these findings and advocacy by the MMRC, in 2008, Illinois mandated that every M.D. and R.N. provider working in the obstetric unit of every obstetric hospital must complete the maternal hemorrhage education program. Conclusions: The MMRC has had a positive impact on Illinois' approach to reducing maternal deaths by being instrumental in getting the state to mandate that every obstetric hospital must comply with the Obstetric Hemorrhage Education Project to maintain its credentials. Further, the high rates at which cause of death and potential avoidability of death were changed by the MMRC underscore the need for multidisciplinary independent review of maternal deaths to achieve more accurate data and, hence, ultimately institute focused interventions to decrease preventable deaths.