Every family deserves to experience a happy and healthy pregnancy. However, approximately 700 pregnant women die each year in the U.S due to pregnancy and complications (CDC, 2018)1. Even more, it is reported that more than half of these deaths are due to preventable factors, such as having access to quality maternal health care (Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018)2. Severe disparities by race and socioeconomic status plague this public health problem. While maternal mortality can impact women of all backgrounds, women of color, mothers aged 30 years or older, immigrants, and women living in poverty, are populations that are disproportionately affected by this issue (Amnesty International, 2010)3. Why is the mortality rate increasing in various parts of the U.S., even as our advances in technology are rapidly improving? Solutions to this problem might exist both inside the birthing room in the form of safer precautions in hospitals, and may also be related to other factors, including financial barriers and limited knowledge on prenatal care. Mothers are often the center point of the family. But mothers are also the most undervalued and overworked members of our society. It is high time that we start prioritizing the lives of those who give life to us. As my main project at the Illinois Department of Public Health, Office of Women's Health & Family Services, here is a portion of my state-by-state analysis of maternal mortality prevention recommendations. 1. Pregnancy-related health outcomes are influences by a variety of factors, including healthy weight and diet, risk of cardiovascular disease, previous injuries and complications, and substance abuse. 2. Nine Maternal Mortality Review Committees (MMRC) were tasked to collaboratively collect data from states that together represent 92% of the country’s maternal deaths. These include Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah. 3. Addressing the structural barriers to receiving care, also known as the social determinants of health, are important components to preventing maternal deaths.

1. A SILENT CRISIS
MATERNAL MORTALITY
A STATE-BY-ANALYSIS ON MATERNAL MORTALITY RECOMMENDATIONS AND CONSIDERATIONS FOR
ILLINOIS’S MATERNAL MORTALITY REPORT
Chelsea Dade
Graduate Intern, Office of Women’s Health & Family Services
Illinois Department of Public Health
Master of Science Candidate, Health Communication, 2018
Northwestern University

2. WHAT DO YOU KNOW ABOUT THIS TOPIC?

3. WHAT WE KNOW ABOUT MATERNAL MORTALITY

4. WHAT WE KNOW ABOUT MATERNAL MORTALITY
PBS NewsHour. (2018, April 18). Why are black mothers and infants far more likely to die in U.S. from pregnancy-related
causes?
[Video File]. Retrieved from https://www.youtube.com/watch?v=AODAk-accVc&pbjreload=10

5. INTRODUCTION
 Approximately 700 pregnant women die each year in the U.S due to pregnancy and complications (CDC,
2018).
 Even more, it is reported that more than half of these deaths are due to preventable factors, such as
having access to quality maternal health care (Building U.S. Capacity to Review and Prevent Maternal
Deaths, 2018).
 Severe disparities by race and socioeconomic status plague this public health problem. While maternal
mortality can impact women of all backgrounds, women of color, mothers aged 30 years or older,
immigrants, and women living in poverty, are populations that are disproportionately affected by this
issue (Amnesty International, 2010).
 Pregnancy-related health outcomes are influences by a variety of factors, including healthy weight and
diet, risk of cardiovascular disease, previous injuries and complications, and substance abuse.
 Addressing the structural barriers to receiving care, also known as the social determinants of health, are
important components to preventing maternal deaths.

6. THE ISSUE IN ILLINOIS
 According to data from the Illinois Department of Public Health’s 2015 Needs Assessment, there were
256 deaths determined to be pregnancy related during 2002-2014 (Illinois Department of Public
Health, 2015, p. 21).
 Furthermore, during this same study period, there were 456 pregnancy associated deaths that were not
pregnancy related. The latter refers to maternal deaths that commonly occur due to vehicular crashes,
homicide and suicide.
 When considering risks for maternal mortality, maternal morbidity is an equally important consideration
to better understand the root of the mortality problem. In other words, the issues leading up to the birth,
including access to prenatal care, healthy food, surrounding crime and violence, and pre-existing
conditions, each may contribute to a mother’s risk of dying within one year of their pregnancy.

7. IMPORTANCE OF MATERNAL MORTALITY
Bennett, A. (2018, February). Illinois Maternal Mortality Review: Orientation for New Committee Members. Retrieved from
file:///C:/Users/CDADE/Desktop/IL%20MMR-Orientation%20for%20New%20Members-Amanda-Epi.pdf

8. HOW DO MATERNAL DEATHS IMPACT
SOCIETY?
 In a report on the consequences of maternal
morbidity and maternal mortality, findings
depicted in the table indicate that maternal
deaths have factual economic, social, and
political implications (Reed, Koblinsky, &
Mosley, 2000). Moreover, child and infant
health can be negatively impacted by
maternal deaths.
 Therefore, many researchers consistently
suggest the focus of reducing maternal/child
health disparities needs to be more equally
centered on both infants and mothers
(Martin & Montagne, 2017).

9. WHAT IS BEING DONE TO REDUCE THE INCIDENCE OF MATERNAL
MORTALITY?
 Nine Maternal Mortality Review Committees (MMRC) were tasked to collaboratively collect data from
states that together represent 92% of the country’s maternal deaths. The first of these included
Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, Ohio, South Carolina, and Utah.
 When lawmakers follow the recommendations of such commissions, they can be a useful vehicles for
reducing preventable maternal deaths (Grossman, 2018).
 The specifics for this information can be found at the MMRIA website: http://mmria.org/

10. COMMUNICATING THE IMPORTANCE OF MATERNAL MORTALITY
 My assignment was to analyze information on 26 states, including Illinois, and the District of
Columbia, for how they present their maternal mortality data and their state-specific recommendations,
in order to get a better sense of how to communicate Illinois’s maternal mortality data in the upcoming
report.
 For this presentation, I’ll include my findings on some of these states
 All states Maternal Mortality Review Committee information was not readily accessible online. In this
case, I would use existing reports on maternal mortality or peer reviewed literature

11. MATERNAL MORTALITY REVIEW
COMMITTEE STATUS & MATERNAL
MORTALITY RATIO (MMR) BY STATE
https://bit.ly/2JPTKq8

12. https://bit.ly/2JPTKq8
MATERNAL MORTALITY REVIEW
COMMITTEE STATUS & MATERNAL
MORTALITY RATIO (MMR) BY STATE

13. FLORIDA
 In 2015, FL experienced a severe spike in
pregnancy-related deaths for women ages 19
and younger, as opposed to this ratio from
2002-2014
 Similar to other states, a BMI representing
overweight or obese status is a severe risk
factor for maternal mortality in the state of
Florida
 In 2015, the main causes of pregnancy-
related deaths were hemorrhage (31.6%) and
infection (10.5%)
https://bit.ly/2IJT5Gr

14. FLORIDA
 Recommendations
 The Florida Perinatal
Quality Collaborative
(FPQC) Obstetric
Hemorrhage Tool Box
 Includes protocols for risk
screening, diagnosis and treatment
of hemorrhage
 Sepsis Alert Policy
 Development of a Thrombosis Risk
Scoring System
https://bit.ly/2IJT5Gr

15. ILLINOIS
• https://bit.ly/2xti6V5
• The data shows that while
the trend is remaining
neutral for Non-Hispanic
Whites and Hispanics, it is
increasing for Black
women

16. ILLINOIS
 According to the most recent IL Maternal and
Child Health Databook by the IDPH, of the
pregnancy-related deaths in 2002-2014, 34%
were determined by the death review
committee to be potentially preventable.
• https://bit.ly/2syllVL

17. LOUISIANA
 Louisiana ranks poorly (3rd worst) in maternal
and child health outcomes
 Considerable problems related to maternal
mortality rates are access to an OB/GYN, access
to health insurance, and access to
preconception counseling
 These are important factors to consider including
in the upcoming Maternal Mortality report
 Louisiana has only one OB/GYN physician per
13,136 women, ranking 43rd of 48 in the nation.
• https://bit.ly/2kWyaWs

18. LOUISIANA
 Access to pre and post conception
care
 Louisiana is one of 28 states to license
certified professional midwives in
addition to Advanced Practice Registered
Nurses in the nurse-midwife role.
 As of late 2015, LA Medicaid covers both
nurse-midwives and professional
midwives as recognized provider types
for vaginal delivery services rendered at
free standing birthing centers.
 However, the reimbursement rates for
mid-wives are substantially low.
Furthermore, doulas are not covered by
Medicaid in LA.
• https://bit.ly/2kWyaWs

19. LOUISIANA
 According to the Center for Reproductive
Rights, in Louisiana, most maternal deaths for
women occurred during or shortly after the
post-partum period (88%)
 There is a health communication gap surrounding
the existing information on when maternal
deaths occur.
• https://bit.ly/2kWyaWs

20. LOUISIANA
 Recommendations
 Proposed Legislation
 Two bills were proposed in the 2015-2016
session but did not advance:
 A bill authorizing extended maternity leave for
school employees
 A bill requiring mental health counseling
referrals, upon request, for pregnant Medicaid
recipients
 Every Mother Initiative
 The state is a member of the Every Mother
Initiative, a resource to help states create and
improve their maternal mortality review
surveillance and committee review processes
• https://bit.ly/2kWyaWs

21. MASSACHUSETTS
• The severity of Maternal Mortality is
difficult to communicate, but a
population impact model can help
articulate it:
• A similar model in the Illinois
Maternal Mortality Report would
help different stakeholders picture
where they can intervene on the
issue at various levels
• https://bit.ly/2t4pXTy

22. MASSACHUSETTS Recommendations
 A framework for public health for Maternal
Mortality (Bottom-up)
 Implement Policies in the environment
which promote healthy women and their
families
 Change the social/health context to make
women’s default decisions healthy during
her childbearing years
 Develop universal protocol for
preconception, prenatal, intrapartum,
postpartum care, including newborns
 Perinatal Clinical Interventions
 Maternal Counseling & Education
• https://bit.ly/2t4pXTy

23. MICHIGAN
 Recommendations and Ongoing
Activities (pg. 3)
 5. We need the MI Board of Licensed
Midwifery to enhance education and
coordination with midwives attending out
of hospital births on timely referral of
women to hospitals as appropriate.
 6. We need to work with Internists and
Family Physicians concerning postpartum
and long-term cardiovascular and
metabolic risk for women with
preeclampsia and gestational diabetes.
• https://bit.ly/2rqBonM

24. MISSISSIPPI
 Mississippi has a state ranking for high
morbidity and negative birth outcomes
 “Association of Maternal Chronic Disease and
Negative Birth Outcomes in a Non-Hispanic
Black-White Mississippi Birth Cohort”
 The researchers for this study examined
data from the linked birth and death
certificate files for all Mississippi infants
delivered between 1999 and 2003
• https://bit.ly/2y1QGpA

25. MISSISSIPPI
 The main finding was that infants of White
and African American mothers experience
different levels of risk when associated with
maternal chronic disease
 This has important implications for prenatal
and preconception interventions for mothers
 Emphasis=preconception and pregnancy
care
• https://bit.ly/2y1QGpA

26. MISSISSIPPI
 “Pregnancy-Related Deaths by Public
Health District, MS, 2011-2012
 Including the number of
Pregnancy-related deaths by
public health district might be
helpful to include in IL maternal
Mortality report, to help readers
visualize where maternal mortality in
Illinois is occurring
 Another important factor to include
in the report is the number of
Pregnancy-Related Deaths by
Payer Source, MS, 2011-2012
• https://bit.ly/2JDXcUY

27. NORTH CAROLINA
 North Carolina’s Perinatal Health Strategic Plan: 2016-2020
 Based on the elements from the paper, “Closing The
Black-White Gap in Birth Outcomes: A Life-Course
Approach (Lu et al., 2010)
 A “Life Course Approach”
 12 Key Recommendations
 Among the recommendations related to maternal
mortality, these included:
 Increase access to preconception care
 Support low-wage and working mothers and
families (e.g. paid maternity leave)
 Improving the quality of prenatal care
 Giving quality health behavior advice to mothers • https://bit.ly/2t5bjeL

28. NORTH CAROLINA
 Improving not only access to care, but
quality of care
 Assuring the availability of quality
auxiliary services, such as childbirth
education classes, mental health or
periodontal services, breastfeeding
support, which are in short supply in
under sourced Black communities in
this state and other southern states
• https://bit.ly/2t5bjeL

29. NEW JERSEY
 “Trends in Statewide Maternal
Mortality New Jersey 2009-2013”
 Depiction of the Case Review Process
 Clearly shows how the committee
receives and reviews each maternal
mortality case
• https://bit.ly/2M2qkFY

30. NEW JERSEY
 Recommendations
 Case identification
 Universal screening for postpartum
depression and domestic violence
 Treatment for Drug Use
 Reproductive life planning and treatment
of women with chronic disease
 Importance of simulation training to
reduce healthcare communication errors
 Recognition and rapid response for
postpartum hemorrhage
 Pregnancy testing for all women of
childbearing age in emergency room
departments
 Medication education for all consumers
• https://bit.ly/2M2qkFY

31. NEW YORK
 Recommendations
 Improving the Assessment and Quality of Care
 After examining the maternal cases in conjunction with
hospital data, this report shows that 17.7% of the
healthcare settings associated with theses pregnancy
related deaths were deemed not in accordance with
national professionally recognized standards or
guidelines
 Thus its important to examine the types of facilities
that are providing care in correspondence with the
count of maternal mortality cases
 Moreover, examine the rate of caesarian births in
reference of the number of maternal mortality
cases
 https://on.ny.gov/2jVUcbc

32. CAN DOULAS & MIDWIVES HELP REDUCE THE
RISING INCIDENCE OF MATERNAL MORTALITY?
Chelsea Dade
IDPH-OWHFS-Graduate Intern
Master of Science Candidate, Health Communication, 2018
Northwestern University

33. THE ROLE OF THE MIDWIFE
LAWYERING FOR REPRODUCTIVE JUSTICE, 2017
 Midwives help reduce overuse of caesarian deliveries
 Midwife led births held a c-section rate well below the national average, at 9.3%.
 Midwives help promote breastfeeding
 Women who gave birth with a midwife were also more likely to breast feed, with a national average of 85.3% of
women breastfeeding within the first 48 hours of life.
 Midwives extend post-partum care access
 Midwives often offer life-saving postpartum care that traditional hospitals do not, including home visits the first
ten days after birth

34.  Certified nurse-midwives (CNMs) tend to serve not only childbearing women, but women in all stages of
life
 For example, in a survey in Massachusetts, CNMs were shown to have greater outreach in caring for young
women 20 and under, as well as caring for immigrants,
 Midwives help provide care to both underserved rural and urban areas
 For example, the New York State the Midwifery Modernization Act, passed in 2010, helps rural and urban areas
that face shortages of health care providers, including obstetric providers.
If, When, How Issue Brief: The Role of The Midwife
Lawyering For Reproductive Justice, 2017

35. HOW IS THIS RELATED TO MATERNAL
MORTALITY?

36. SUSTAINABLE FUNDING FOR DOULA PROGRAMS
HEALTHCONNECT ONE
 What is a community-based doula?
 They provide culturally sensitive pregnancy and childbirth education and provide women with a long lasting
continuity of care
 Results
 Higher breastfeeding rates
 Lower C-Section rates
 This ability to reduce unnecessary C-sections is important because on average, Black and other minority
women report higher rates of having caesarian sections for their deliveries. Many of these deliveries lead to
future complications, as shown by the following studies:
 Washington, S., Caughey, A. B., Cheng, Y. W., & Bryant, A. S. (2012). Racial and ethnic differences in indication
for primary cesarean delivery at term: experience at one US Institution. Birth, 39(2), 128-134.
 Huesch, M., & Doctor, J. N. (2015). Factors associated with increased cesarean risk among African American
women: Evidence from California, 2010. American journal of public health, 105(5), 956-962.
 Edmonds, J. K., Hawkins, S. S., & Cohen, B. B. (2014). The influence of detailed maternal ethnicity on cesarean
delivery: findings from the US birth certificate in the State of Massachusetts. Birth, 41(3), 290-298.

37. SUSTAINABLE FUNDING FOR DOULA PROGRAMS
HEALTHCONNECT ONE
 Doula Compensation
 Most doulas are compensated through salary, though
some are paid on a stipend and others volunteers to
serve
 More than 7 in 10 doula programs are privately funded
 State doula programs need more government support
(i.e. Medicaid)
 Funding=the greatest challenge to expanding these
programs

38. OVERDUE: MEDICAID AND PRIVATE INSURANCE
COVERAGE OF DOULA CARE TO STRENGTHEN
MATERNAL AND INFANT HEALTH
 Reducing the High Cost of Maternal Care
 According to The Agency for Healthcare
Research and Quality, childbirth-related
hospital charges exceed charges for any
other type of hospitalization.
 In 2013, hospitals billed $126 billion for
combined maternal and newborn care.
 Cesarean births cost almost twice as
much as vaginal births
 “Eliminating spending on non-
beneficial procedures, avoidable
complications and preventable chronic
conditions would each contribute to
significant savings that would cover
the cost of doula care.” https://bit.ly/2Na7ZaF

39. OVERDUE: MEDICAID AND PRIVATE INSURANCE COVERAGE OF DOULA
CARE TO STRENGTHEN MATERNAL AND INFANT HEALTH
 Example Doula Programs
https://bit.ly/2Na7ZaF

40. OVERDUE: MEDICAID AND PRIVATE INSURANCE COVERAGE OF
DOULA CARE TO STRENGTHEN MATERNAL AND INFANT HEALTH
 State Level Recommendations
 6. States should seek CMS approval of state
plan amendments to cover continuous labor
support and home visits as reimbursable
preventive services provided by non-licensed
service providers under 42 CFR §440.130(c).
 7. States should seek to include coverage of
doula support under new and existing DSRIP
programs
 8. Medicaid managed care organizations and
other health plans should offer doula services
as a covered benefit, and states should enact
legislation requiring plans to do so.
• State Level Recommendations
9. States should require health plans to
include doula services within their covered
benefits.
Community Level Recommendation
10. Local governments, public and other
safety net hospital systems, Medicaid
managed care organizations, community
health centers and other agencies and
organizations should establish
interdisciplinary teams to continue to
explore and develop innovative approaches
to making doula support available to
women enrolled in Medicaid.

41. REFERENCES
 Amnesty International. (2011). Deadly Delivery: The Maternal Health Care Crisis in the U.S.A. Retrieved from https://www.amnestyusa.org/wp-
content/uploads/2017/04/deadlydeliveryoneyear.pdf
 Bennett, A. (2018, February). Illinois Maternal Mortality Review: Orientation for New Committee Members. Retrieved from
file:///C:/Users/CDADE/Desktop/IL%20MMR-Orientation%20for%20New%20Members-Amanda-Epi.pdf
 Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from Nine Maternal Review Committees. Retrieved from
https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf
 Centers for Disease Control and Prevention. (2018). Pregnancy-Related Deaths. Retrieved from
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm
 Grossman, J. L. (2018, July 31). Deadly Deliveries”: USA Today Report Sheds Disturbing Light on Shocking Rates of Maternal Mortality in the United States.
Retrieved from https://verdict.justia.com/2018/07/31/deadly-deliveries-usa-today-report-sheds-disturbing-light-on-shocking-rates-of-maternal-mortality-in-
the-united-states
 Illinois Department of Public Health (2015, July). Illinois Maternal and Child Handbook. Retrieved from
http://www.dph.illinois.gov/sites/default/files/publications/publications-owh-il-title-v2015-databook-042816.pdf
 Martin, N., & Montagne, R. (2017, May 12). Focus On Infants During Childbirth Leaves U.S. Moms In Danger. Retrieved from
https://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger
 Maternal Mortality Review Information Application. (2018). MMRIA. Retrieved from http://mmria.org/
 Reed H.E., Koblinsky, M.A., Mosley, W.H. (2000). The Consequences of Maternal Morbidity and Maternal Mortality: Report of a Workshop. Washington:
National Academies Press.

42. REFERENCES
 Lawyering for Reproductive Justice. (2017). Maternal and Infant Health & Mortality: IF/WHEN/HOW ISSUE BRIEF. Retrieved from
https://www.ifwhenhow.org/download/?key=cMtwtEBBq9WyhOKvRop80ww8WEPAXnX4wX9ssi1UklmviHqlAkUyxgHRJ6aJd0gU
 HealthConnect One. (2017). Sustainable Funding for Doula Programs: A Study. Retrieved from
https://www.ifwhenhow.org/download/?key=ytuDxYlv7wXxkVFc9vhOojiGBjS3aTadKPV2W4UoFXFS3T0QtPw1EUtG21eFn3lR
 Agency for Healthcare Research and Quality. (2012). Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Retrieved from
http://hcupnet.ahrq.gov
 National Partnership for Women & Families. (2016, January). Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and
Infant Health. Retrieved from http://www.nationalpartnership.org/research-library/maternal-health/overdue-medicaid-and-private-insurance-coverage-of-
doula-care-to-strengthen-maternal-and-infant-health-issue-brief.pdf

43. THANK YOU!
 Chelsea Dade
 M.S. Candidate, Health Communication, Northwestern University, 2018
 chelseadade2018@u.northwestern.edu
 https://www.linkedin.com/in/chelseadade/