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Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois
Stacie E Geller1, Abigail R Koch2, Nancy J Martin3
1Department of Obstetrics and Gynecology, Center for Research on Women and Gender, College of Medicine, University of Illinois at Chicago, 820 S. Wood St., Chicago, IL, 60612, USA. sgeller@uic.edu.
Objectives:
To compare the results of two maternal death review processes conducted from 2002 to 2012 by Illinois regionalized perinatal centers with those conducted by the Illinois Department of Public Health's (IDPH's) statewide multidisciplinary external Maternal Mortality Review Committee (MMRC).
Methods:
This is a retrospective record review linking MMRC case assessment forms to the IDPH's Maternal Mortality Review Form database to compare causes of death and potential preventability as determined by both review processes.
Results:
MMRC records for 76 maternal death reviews were linked to the IDPH maternal mortality review form database. Most deaths reviewed by the statewide MMRC were due to pregnancy-related causes. The statewide MMRC differed from the regional perinatal centers on cause of death in 55.3% (n = 42) of cases and on the disposition of potential preventability in 48.7% (n = 37) of cases. The statewide MMRC judged 69.7% (n = 53) of cases potentially preventable, compared with 40.8% (n = 31) for the regional perinatal centers. The MMRC identified more preventable provider and systems factors for potentially preventable deaths compared with regional perinatal centers which identified more preventable patient factors.
Conclusions For Practice:
The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews.
Insights
The Illinois statewide Maternal Mortality Review Committee (MMRC) identified more preventable maternal deaths than regional centers, often citing provider and system factors. Multidisciplinary expert panels are recommended alongside local reviews.
Area of Science:
- Public Health
- Maternal Health
- Healthcare Quality Improvement
Background:
- Maternal death reviews are crucial for identifying preventable deaths and improving care.
- Illinois has utilized both regionalized perinatal centers and a statewide committee for maternal mortality reviews.
Purpose of the Study:
- To compare the findings of maternal death reviews conducted by Illinois regional perinatal centers and the statewide Maternal Mortality Review Committee (MMRC).
- To analyze discrepancies in determining causes of death and preventability between the two review processes.
Main Methods:
- A retrospective record review linking MMRC case assessment forms with the Illinois Department of Public Health's (IDPH) Maternal Mortality Review Form database.
- Comparison of causes of death and potential preventability assessments between the two review bodies for 76 maternal deaths (2002-2012).
Main Results:
- The statewide MMRC identified more potentially preventable maternal deaths (69.7%) compared to regional centers (40.8%).
- Discrepancies in cause of death (55.3%) and preventability (48.7%) were noted between the review processes.
- The MMRC highlighted preventable provider and systems factors, whereas regional centers focused more on patient factors.
Conclusions:
- The statewide MMRC's findings suggest a greater potential for preventability, linked to provider and system-level issues.
- Differences in review outcomes may stem from case complexity, review team composition, and data de-identification.
- Implementing multidisciplinary statewide expert panels in conjunction with local reviews is recommended to enhance maternal mortality reviews.
