To: Howard A. Zucker, Commissioner
From: Jessica Brown
Date: January 16, 2018
Re: Federal Mandate for Maternal Mortality Reporting Standards and Review Boards

Statement of Issue –

In the United States, the maternal mortality rate (MMR) is approximately 26 deaths per 100,000 live births.  The MMR is decreasing globally, yet the US has seen alarming increases in recent years. In the United States, less than half of the states have maternal mortality review boards. Review boards aid in the gathering of information on race, ethnicity, and income and health insurance status to guide health care providers and state health departments.  Without proper reporting standards and a mandate of full maternal mortality review boards, the US will continue to rank lower than the rest of the world in preventing pregnancy-related deaths and compromise the lives of our nations mothers.

• The United States is not on track to meet the Healthy People 2020 goal to decrease maternal mortality by 10% and has seen increases in MMR in recent years. 
• There is no national standard for data collection and reporting of maternal mortality statistics, disjointing the study of data and slowing the discovery of prevention recommendations.
• New York City has a higher MMR at 31 deaths per 100,000 than the United States average MMR.
• US has higher MMR as women’s healthcare access is inconsistent, racial disparities continue to exist, more women are obese and having children later ages. If the US doesn’t adapt to the changing society, the MMR will continue to increase and our nations mothers will remain at risk.
• African American women are 3-4 times more likely to die during pregnancy/childbirth than white women.

Policy Options –

• Institute a federal mandate for standardized national maternal mortality reporting. As it currently stands in the United States, data is so unreliable that the US government has not published any official counts of fatalities or maternal mortality rates in a decade. Providers (review boards, physicians, NPs, PAs, midwifes, doulas, etc) should be responsible for filing and reporting any maternal death using comprehensive universal data points to ensure consistency in reporting maternal mortalities across the United States.
• Advantages: Allows for providers and policy makers to learn from previous maternal deaths and implement policies that help to prevent future deaths. Allows providers to determine where (from a locational perspective) these deaths are occurring, which population they’re occurring in most often and to devise a plan for preventative measures. Eliminates the unknown maternal mortality statistics holistically for the US and provides reliable data that can be used to elicit change.
• Disadvantages: Those without access to an EHR system may not provide any information, which skews the data in a nationalized data registry. Individuals may not report all necessary information for the fear of legal retribution or sanction. Recording data will take more time away from providers seeing patients, which detracts from the bottom line.
• The federal mandate must include a requirement of standardized state review boards responsible for comprehensive reviews of maternal mortality cases to yield necessary data. As of May 2017, only twenty-nine of the 50 states (58%) have committees specifically designed to review maternal mortality. These state review boards must collect, review and analyze data in a strategic synchronized fashion so data can be shared across the United States in order to learn and avoid further maternal mortality.
• Advantages: Compilation of data in a standardized method in each state individually will allow for significantly more valuable reports, which can be fed to broader national data systems. The data collected from review boards can be used to formulate preventative measures and treatment for women as it relates to their respective geographic locations. This is especially helpful if the women are not from the same region but have the same type of exposure to particular environmental factors.
• Disadvantages: If the individuals are not collecting and compiling the reports properly or trained appropriately there may be an inconsistency with how the information is gathered and reviewed. The funding for these review boards include not only the systems required to run the various processes but also for the time of the individual reviewers, which will be a new expense incurred by the state. Increased opportunities for families of women who have passed away due to “pregnancy related” or “maternal death” to take legal action against the providers who played a role in their care.
• This mandate requires the federal and state governments to work together for the greater good of women’s health. An estimated half of all maternal deaths in the United States are preventable and the various governments (community, local, state and federal) must work together to ensure the growing trend of maternal mortality does not continue. These governments must collaborate to place a greater consistency on obstetric practice and evaluation of patients with chronic conditions to prepare them for pregnancy in order to decrease the MMR rate in the US and execute the proposed policies of this briefing.
• Advantages: Allows for a national forum to share best practices and address the factors leading to the MMR. Will allow and provide hospitals with standard approaches to manage obstetric emergencies so she can receive evidenced-based care. Creates a forum for communities to care for higher-risk women ensuring good health and management of chronic conditions before/during/after pregnancy. Women without health insurance are 3-4 times more like to die of pregnancy-related complications than those with insurance, this proposed collaboration works to avoid maternal morbidity and educate all individuals involved. Allows for individual providers to borrow information from others who may have already experienced an event and use it as a tool to benefit a pregnant woman.
• Disadvantages: States that already have review boards and reporting systems will have to rework their process to fit the requirements of standardized national system. Will require greater coordination between all forms of government, which takes time and effort and funds that will have to be reallocated to this program.

Policy Recommendation –

More American women are dying of pregnancy-related complications than in any other developed country. While maternal mortality is declining in most other industrialized nations, it is continuing to rise in the United States. A federal mandate must be enacted in the attempt to decrease the maternal death and any pregnancy-related death for American women. While there will be some costs associated with enacting a standardized system of reporting and statewide maternal mortality review boards in the short term, it is a necessary in order to provide, protect and prevent any further maternal deaths in the long term. The data and analytics resulting from the review boards will educate pregnant women and providers allowing them to better understand how to care for this population ultimately decreasing the maternal mortality rate in the United States.

Sources –

https://www.health.ny.gov/statistics/chac/birth/b33_999.htm
http://www.who.int/bulletin/volumes/93/3/14-148627/en/

https://www.health.ny.gov/
http://www.amchp.org/programsandtopics/womens-health/Focus%20Areas/MMR/Pages/default.aspx

https://cdn.shopify.com/s/files/1/0776/6403/files/emcimpactreport2016.pdf?17353183482668653647
https://journals.lww.com/greenjournal/Abstract/2017/05001/Current_Status_of_State_Level_Maternal_Mortality.89.aspx
https://www.propublica.org/article/new-york-city-launches-committee-to-review-maternal-deaths
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
https://www.health.ny.gov/facilities/public_health_and_health_planning_council/meetings/2012-09-20/docs/maternal_mortality_review_phc.pdf
https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world

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