As a part of my contribution to Illinois’s Maternal Mortality review process, I was tasked to investigate the maternal mortality review committees, related literature, and other related reports of 26 states, plus Washington D.C. and Illinois. The goal of this project was to give my supervisors and IDPH staff an overview of what has worked, what isn’t working in terms of maternal mortality reduction recommendations in other states. In addition to including incidence rates, racial breakdowns, and other markers, I examined the methods that states used to present their maternal mortality data. The latter refers to graphics selections, terminology, and other creative considerations that might have been used to impact a reader’s connection and understanding of the issue in a state’s report. It is important to acknowledge that not every state had an existing report. Furthermore, in my analysis I found that even for states with existing maternal mortality review committees, reports were not always readily accessible online. Moreover, every state with an existing review committee do not always have a list of recommendations. Therefore, the following summaries are a couple of examples from my complete 26 state analysis, featured on the states of Louisiana, North Carolina, New Jersey, and Ohio, as they were able to provide a direct list of official recommendations.

1. 10
A SILENT CRISIS: MATERNAL
MORTALITY
Chelsea Dade
Graduate Intern, Office of Women’s Health& FamilyServices
Illinois Department of Public Health
Mothersare oftenthe centerpointof the family.Butmothers are alsothe most
undervaluedandoverworkedmembersof oursociety.Itishightime that we start
prioritizingthe livesof those whogive life tous.

2. A Silent Crisis: Maternal Mortality-Problem Statement and State-By-State Analysis of the Issue
Chelsea Dade, Graduate Intern
IDPH-Office of Women’s Health and Family Services
August 23rd, 2018

3. Problem Statement
Introduction
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). 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).
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.
The Problem in Illinois
The problem shows up in the state of Illinois as well. 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

4. vehicular crashes, homicide and suicide. When considering how maternal health changes during
pregnancy, morbidity is an equally important consideration to better understand the root of the
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.
Why is Maternal Mortality Getting So Much Coverage Lately?
Maternal deaths have always been a known problem outside of the U.S in other
undeveloped countries. In the United States, the issue again primarily impacts women of color.
The following image is from Creanga et al (2014), from her research published in the Economist
in 2015. The data clearly shows that Non-Hispanic Black women face the highest risk of dying
after birth from pregnancy associated causes.

5. When tennis star Serena Williams revealed her story about her pregnancy complications
and mistreatment right before the delivery of her first child, Alexis Olympia, the connections
between the risk of maternal mortality and the discrimination in healthcare facing women of
color became clearer (Gay, 2018).
From there, multiple opinion pieces from various news outlets and online magazines
became publishing more stories on the disparities in maternal health care, access to care, and
treatment between white women and women of color. The New England Journal of Medicine
published an article in 2017 titled “A Renewed Focus on Maternal Health in the United States.”
In it, researchers discuss how the rise in chronic conditions complicates maternal health.
Moreover, they suggest that the effect of insurance status before, during, and after pregnancy on
maternal outcomes calls for more research (Molina & Pace, 2017).
How Do Maternal Deaths Impact Society?
In a report on the consequences of maternal morbidity and maternal mortality, findings
depicted in the table below 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 negative maternal health 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).

6. Severe Maternal Morbidities Matter
Furthermore, the severe maternal morbidities, such as high blood pressure and
hemorrhage, that can lead up to maternal mortality cases are important to consider. According to
the IDPH, severe maternal morbidity (SMM) is about 100 times more common than pregnancy-
related mortality and affects thousands of women each year (Illinois Department of Public
Health, 2015, p. 18).

7. Researchers suggest that the rise in severe maternal morbidity is due to the associated rise
in chronic health conditions, such as obesity and diabetes. The following slide comes from the
work of Senior Epidemiologist at the IDPH, Amanda Bennet. It presents how quickly a healthy
woman can move from one stage of health to another during and after pregnancy.
Why Do We Focus on One Year Following Delivery?
A lot can occur in year for mother with a new baby. According to the World Health
Organization, maternal death is the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management but not from accidental or
incidental causes” (WHO, 2018). Illinois and many other states, consider a maternal death as a
mother’s death following one year after delivery (Illinois Department of Public Health, 2015, p.

8. 20). Also, depending on the state and women who live there, the average timing of death will
vary from within the immediate months after birth, to up to almost a year postpartum.
This is why maternal mortality committees are formed, as they help officials get a better
understanding of what factors, whether or not they exist at the community level or are related to
the healthcare system, are contributing to the deaths of women up to one year after birth. What
is striking from these narratives is the fact that maternal mortality impacts a wide variety of
socioeconomic statuses. Some of the women were relatively wealthy and had private insurance.
Other women were publically insured. It goes to show that maternal mortality can, and does,
impact a wide range of women.
What Is Being Done To Reduce The Incidence of Maternal Mortality?
In 2017, 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. Now, other states are following suit and creating their
own maternal mortality review committees, though the creations of a committee is not yet
required for each state. This data is housed on the Review To Action resource website, created
in conjunction with the CDC Foundation, CDC Division of Reproductive Health, and the
Association of Maternal and Child Health Programs (AMCHP).
When lawmakers follow the recommendations of such commissions, they can be a useful
vehicles for reducing preventable maternal deaths (Grossman, 2018). Below you can see where
the United States is in maternal mortality committee statuses in the latest MMRC Map by the
Review To Action online resource.

9. Policy Recommendations from A State-By-State Analysis
As a part of my contribution to Illinois’s upcoming Maternal Mortality report, I was
tasked to investigate the maternal mortality review committees, related literature, and other
related reports of 26 states, plus Washington D.C. and Illinois. The goal of this project was to
give my supervisors and IDPH staff an overview of what has worked, what isn’t working in
terms of maternal mortality reduction recommendations in other states. In addition to including
incidence rates, racial breakdowns, and other markers, I examined the methods that states used to
present their maternal mortality data. The latter refers to graphics selections, terminology, and
other creative considerations that might have been used to impact a reader’s connection and
understanding of the issue in a state’s report.
It is important to acknowledge that not every state had an existing report. Furthermore, in
my analysis I found that even for states with existing maternal mortality review committees,

10. reports were not always readily accessible online. Moreover, every state with an existing review
committee do not always have a list of recommendations. Therefore, the following summaries
are a couple of examples from my complete 26 state analysis, featured on the states of Louisiana,
North Carolina, New Jersey, and Ohio, as they were able to provide a direct list of official
recommendations.
Louisiana.
Summary
The following are a couple of examples from the complete report. The first slide depicts
some of the policy recommendations from the state of Louisiana. Louisiana fairs quite poorly in
terms of both maternal and infant health outcomes, and some existing factors that may
exacerbate this trend are the state’s limited number of OB/GYNs, limited access to health
insurance, and poor access to preconception counseling for low-income women.
Recommendations for Maternal Mortality Prevention
Louisiana hopes to take a legislative route to prevention maternal mortality deaths. Two
bills were proposed in the 2015-2016 session relating to the issue. The first bill was created to
authorize extended maternity leave for school employees. The second bill that was proposed
would require mental health counseling referrals, upon request, for pregnant Medicaid recipients.

11. North Carolina.
Summary
The findings on North Carolina expressed slightly different, but similar notions as
findings from Louisiana. The officials suggest a “Life Course Approach” to addressing maternal
mortality. Among 12 proposed recommendations that addressed access and quality of care for

12. new moms, their report uniquely incorporated the importance of strengthening families through
providing basic resource and better integrating family support services.
Recommendations for Maternal Mortality Prevention
North Carolina’s Perinatal Health Strategic Plan 2016-2020, provided a comprehensive
list of 12 recommendations, adapted from a 12-point plan to close the disparate gap between
Black-White birth outcomes (Lu et al., 2010). The recommendations include the following three
domains: to improve health care for women and men, strengthen families and communities, and
to address social and economic inequities. The steps under the first domain include the provision
of interconception care to women with prior adverse pregnancy outcomes, increasing access to
preconception care, improving the quality of prenatal care, and expanding healthcare access over
the life course.
The second domain refers to strengthening father involvement in families, enhancing
coordination and integration of family support services, supporting coordination and cooperation
to promote reproductive health within communities, and investing in community building and
urban renewal. The third domain addresses steps to close the education gap between high and
low-income communities, reducing poverty among families, supporting working moms, and
undoing racism (“NC Perinatal Health Strategic Plan”, 2016).

13. New Jersey.
Summary
Communicating the data effectively to stakeholders is as important as reporting the
correct information and statistics and creating applicable policies. As shown below, New
Jersey’s report on Maternal Mortality trends from 2009-2013, depict how the maternal mortality

14. review process actually occurs, from case identification to data collection, to steps for action.
This is especially important for the issue of maternal mortality, since there is still a great deal of
confusion, misunderstanding, and miscommunication around it.
Recommendations for Maternal Mortality Prevention
As depicted below, New Jersey’s trend analysis report provided a list with multiple
maternal mortality reduction recommendations, including improved medication education for
consumers and universal screening for postpartum depression (PPD) and domestic violence.
Medication education would consist of developing public health announcements for multiple
consumer types, creating education recommendations for pharmacists during prescribed and
over-the-counter interactions, as well as developing handouts for providers and patients.
Universal screening for postpartum depression would implement a PPD screening item on all
fetal death certificates, especially for women who have a previous history of postpartum
depression or previous pregnancy loss. New Jersey, like other states, hopes to implement more

15. tools for screening women for domestic violence. This would require all obstetric healthcare
providers using the Perinatal Risk Assessment and providing referrals
Another unique recommendation that they propose is simulation training to reduce
healthcare communication errors. Examples of these scenarios that commonly appear range from
common labor and delivery emergencies to recognition and rapid response training for
postpartum hemorrhage.
Ohio.
Summary
Ohio has a maternal mortality rate of 20.9 out of 100,000 women, according to the latest
April 2018 report from The American College of Obstetrics and Gynecologists. The ration of
difference between pregnancy-associated deaths and pregnancy-related deaths from 2008-2014
was relatively close (Ohio Department of Health, 2018).
Recommendations for Maternal Mortality Prevention

16. Similar to the state of New Jersey, Ohio officials recommend Obstetric Emergency
Simulation Trainings for Obstetric Providers. This is one key method towards the rates of
postpartum hemorrhage, cardiomyopathy, and preeclampsia in rural areas. Another
recommendation in Ohio was to establish a Maternal Mortality Module in their public health
information data warehouse. Similar to infant mortality and other population health topics, a
separate maternal mortality database would ensure improved confidentiality, consistency, and
clarity of information for the state recording maternal deaths.
Concluding Points
From the previous selections from Louisiana, New Jersey, North Carolina, and Ohio, we
can see a significant trends in which demographics are particularly affected by maternal
mortality. These happen to be women of color, primarily Non-Hispanic Black women, of all
socioeconomic statuses (Martin & Montagne, 2017). Preventing maternal deaths calls for policy
change to protect lower-wage workers and mothers, as well as to provide precautionary

17. pregnancy measures, such as hemorrhage toolkits in hospitals. Moreover, we have to improve
provider education around maternal mortality prevention. Finally, we need to continue shedding
light onto this important health issue, as far too many people do not know it exists here in the
nation.

18. 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
Creanga AA, Berg CJ, Ko JY, et al. Maternal Mortality and Morbidity in the United States:
Where Are We Now? Journal of Women’s Health. 2014;23(1):3-9.
doi:10.1089/jwh.2013.4617. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/
Gay, E. D. (2018, January 18). Serena Williams Could Insist That Doctors Listen to Her. Most
Black Women Can’t. Retrieved from https://www.thenation.com/article/serena-williams-
could-insist-that-doctors-listen-to-her-most-black-women-cant/
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

19. Louisiana Department of Health and Hospitals. (2008). Louisiana Pregnancy-Associated
Mortality Review. Retrieved from http://ldh.la.gov/assets/oph/Center-PHCH/Center-
PH/maternal/2008PAMRreport.pdf
Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the
black-white gap in birth outcomes: A life-course approach. Ethnicity & disease, 20(1 0
2), S2.
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
Martin, N., & Montagne, R. (2017, December 7). Black Mothers Keep Dying After Giving Birth.
Shalon Irving's Story Explains Why. Retrieved from
https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-
birth-shalon-irvings-story-explains-why
Maternal Mortality Review Information Application. (2018). MMRIA. Retrieved from
http://mmria.org/
Moaddab, et al. (2016). “Health Care Disparity and State-Specific Pregnancy-Related Mortality
in the United States, 2005-2014”. Obstetrics & Gynecology, 128 (4), 869-875. doi:
10.1097/AOG.0000000000001628.
Ohio Department of Health. (2015, August, 28). Ohio Pregnancy-Associated Mortality Review
(PAMR). Retrieved from
https://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/cfhs/Infant%20Mortality/PAMR
%20Fact%20Sheet%2082815.pdf

20. Ohio Department of Health. (2018). Snapshot of Ohio Pregnancy-Associated Deaths, 2008-2014.
Retrieved from https://www.odh.ohio.gov/odhprograms/cfhs/pamr/Pregnancy-
Associated%20Mortality%20Review.aspx
Molina, R. L., & Pace, L. E. (2017). A Renewed Focus on Maternal Health in the United States.
New England Journal of Medicine, 377(18), 1705-1707. doi: 10.1056/NEJMp1709473
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.
World Health Organization. (2018). Maternal Mortality Ratio (per 100,000 live births).
Retrieved from http://www.who.int/healthinfo/statistics/indmaternalmortality/en/