About the Maternal Mortality Review Panel and Review Process
The Department of Health (DOH) carries out the Maternal Mortality Review as directed in the Maternal Mortality Review Law (RCW 70.54.450). The Secretary of Health appoints participants to the Maternal Mortality Review Panel (MMRP). The Panel is made up of perinatal health professionals and health equity experts across Washington State from diverse disciplines and backgrounds.
Panel members are invited to participate in a multi-level maternal mortality review process and to serve as expert clinical or subject advisors. The review process is designed to be educational, respectful, and prevention-oriented. It includes a strong focus on improving health equity and addressing racism, discrimination, and bias.
The MMRP reviews deaths of people who died during pregnancy or within a year after pregnancy. For each case, Panel members examine a variety of deidentified records, including information about hospitalizations, vital statistics, medical records, and autopsy reports. Documents and data collected for the maternal mortality review process are confidential; the Panel is prohibited from releasing any information that could identify individuals.
The MMRP determines which deaths were pregnancy-related and preventable. From these cases, the panel makes recommendations to prevent similar situations from happening again. Every three years, the MMRP and DOH prioritize recommendations for a report to the state legislature.
- Findings from the 2019 Report: Review of Maternal Deaths, 2014-2016
The Department of Health will submit a report to the Washington State Legislature in early 2023, summarizing findings from deaths through 2020. That report will be available here. The most recent report summarizes findings from deaths through 2016.
The Washington state Maternal Mortality Review Panel (MMRP) successfully reviewed maternal deaths from 2014–2016 and with the Department of Health published a legislative report of findings. The Panel developed six recommendations and activities for implementation to help reduce preventable maternal deaths and improve perinatal care for all people in the state. These recommendations are included in the report. The report and recommendations were submitted to the health care committees in the Legislature in October 2019.
The findings of the report include:
- Maternal mortality rates in our state have remained steady since the 1990s. As of 2014–2016, rates are not increasing as they are nationally, but they are also not decreasing.
- The review of maternal deaths from 2014–2016 identified 100 pregnancy-associated deaths. These are deaths that occur during pregnancy or within one year after pregnancy, from any cause.
- The Panel determined that in 2014–2016, there were 30 pregnancy-related deaths. These are deaths that occurred during pregnancy or within one year after the end of pregnancy from a pregnancy complication, a chain of events initiated by the pregnancy, or the aggravation of an unrelated condition from the physiological effects of pregnancy.
- This report includes findings on pregnancy-related deaths that resulted from behavioral health conditions such as overdose and suicide. When compared to national pregnancy-related mortality rates published by the Pregnancy Mortality Surveillance System at the Centers for Disease Control, Washington state ranks about 17th in the United States with a pregnancy-related mortality ratio of 11 deaths per 100,000 live births.
- The Panel determined that at least 60% of the pregnancy-related deaths from 2014–2016 were preventable, meaning we still have work to do.
- Panel Recommendations to Reduce Maternal Mortality
Based on findings from 2014 to 2016, the MMRP developed recommendations to help reduce preventable maternal deaths and improve health care for people before, during, and after pregnancy. The recommendations were to:
- Address social determinants of health, structural racism, provider biases, and other social inequities to reduce maternal mortality in priority populations.
- Support active engagement by birthing hospitals, licensed birth centers, and perinatal providers in quality improvement efforts that reduce the leading causes of maternal mortality and morbidity.
- Ensure funding and access to postpartum care and support through the first year after pregnancy.
- Increase access and reduce barriers to behavioral health and community support structures from preconception through pregnancy and the first year postpartum.
- Increase and improve reimbursement for behavioral health care from preconception through all phases of pregnancy and the first year postpartum, including screening, treatment, monitoring, and support services.
- Increase knowledge and skill of providers, patients, and families about behavioral health conditions during and after pregnancy, and the treatment and resources that are available for support.
- Implementing MMRP Recommendations
Since publication of the 2019 report, DOH and its partners have been working on implementing recommendations. Here are some examples.
Centers of Excellence for Perinatal Substance Use
According to the CDC, the number of women with opioid-related diagnoses documented at delivery increased by 131% from 2010 to 2017. The Healthcare Cost and Utilization Project (HCUP), which is managed by the U.S. Agency for Healthcare Research and Quality, published data from 2017 showing that approximately one baby is diagnosed with neonatal abstinence syndrome (NAS) every 19 minutes in the U.S, or nearly 80 newborns diagnosed every day. The number of babies born with NAS increased by 82% nationally from 2010 to 2017. Increases were seen for nearly all states and demographic groups. According to 2018 HCUP data, Washington State has a rate of 9.8 per 1,000 of NAS among newborn hospitalizations.
The Maternal Mortality Review Panel (MMRP) found that opioids were involved in the majority of pregnancy-associated accidental overdose deaths from 2014-2016. The Panel subsequently recommended implementing evidence-based protocols and patient safety tools and guidelines that address this and other leading causes of death among pregnant and postpartum Washingtonians. In response to the Panel’s findings and recommendations, the Washington State Department of Health (DOH), Health Care Authority (HCA), and Washington State Hospital Association (WSHA) collaborated to create the Centers of Excellence for Perinatal Substance Use (COE).
The COE is a voluntary certification program open to birthing hospitals in Washington state. The purpose of this program is to recognize the vitally important role birthing hospitals and care providers play in supporting people who are pregnant and have a substance use disorder and to promote systemic improvements to our perinatal practices.
To become a Center of Excellence, birthing hospitals must meet eight criteria. The criteria, along with instructions on how to apply, are found on the Centers of Excellence webpage.
A pilot program launched in October, 2021, with 13 hospitals enrolled in the AIM Bundle: Obstetric Care for Women with Opioid Use Disorder. DOH, in partnership with the Washington State Hospital Association (WSHA) launched the SUD Learning Collaborative in April 2022. This program supports hospitals’ efforts in becoming a Center of Excellence. The COE program is funded through the ERASE MM grant awarded from the Center for Disease Control and Prevention (CDC).
For more information, contact Tibbs Christensen, Maternal Health Coordinator, firstname.lastname@example.org.
Maternal Behavioral Health Mini Grants
Findings from the 2019 report show one of the leading underlying cause of death among pregnancy-related deaths were behavioral health conditions, including suicide and overdose. Some contributing factors to these deaths include lack of knowledge about behavioral health conditions, treatments, and resources, as well as stigma and bias related to behavioral health conditions.
The Maternal Behavioral Health Mini Community Grant opportunity focused on the Maternal Mortality Review Panel’s recommendation to “Increase knowledge and skill of providers, patients, and families about behavioral health conditions during and after pregnancy, and the treatment and resources that are available for support.”
Funds for these community grants were made available through the ERASE MM project, awarded to DOH by the Centers for Disease Control and Prevention; the Preventative Health Services Block Grant; the Maternal and Child Health Block Grant; and the Maternal Infant Health Opioid Legislative Funding.
Maternal and Behavioral Health Funding Grantees 2021–2023
Community Birth Center
Overview: To decrease disparities and address the role of behavioral health in the maternal and infant mortality crisis, they will conduct (1) bi-weekly gathering spaces for antepartum and postpartum families fostering a community model of maternal and newborn wellness check-ins and support for perinatal mental health, and (2) racial bias training and accountability network for perinatal providers to establish and shift foundational cultural understandings necessary to provide unbiased, culturally competent care.
University of Washington
Overview: Address perinatal mood and anxiety disorders (PMADs) among parents of infants needing care in the NICU through (1) increasing PMAD knowledge and skill among NICU providers through virtual education modules, (2) educating NICU families about PMADs and available resources, and (3) improving PMAD screening during infants NICU course.
Western Washington University
Overview: Implement a Perinatal Support Pathway (PSP), a first-line support for perinatal people with mild-to-moderate behavioral health concerns, through (1) educating perinatal care providers in Whatcom County about perinatal behavioral health, effective screening, and referral to PSP, and (2) implementing PSP by training peer providers in an empirically supported intervention called Listening Visits.
First Five Fundamentals
Overview: Conduct three activities that build upon their existing work and increase perinatal support services for Spanish-speaking and Black and African American families by (1) increasing availability of Group Peer Support groups; (2) increasing health provider awareness of and capacity to address PMADs; and (3) increasing community partner and family awareness of PMADs and the community resources available to support families via social media marketing.
Providence Health Care Foundation
Overview: Support the Maternal Medication-Assisted Treatment (MMAT) program by (1) providing outreach and education to physicians about the MMAT program; (2) strengthening eat-sleep-console community referral program; and (3) implementing TeamBirth, which places emphasis on shared decision making throughout the labor process.
For more information, contact: Tiffany Tibbs Christensen, Maternal Health Coordinator, email@example.com
- Applying to Join the MMRP for Washington State
Although the application deadline has passed to apply to join the Washington State Maternal Mortality Review Panel (MMRP) for a three-year term (2023–2025), we are still recruiting for a few key expertise areas. These may include additional doulas, representatives from community-based organizations, experts in violence prevention (domestic violence, intimate partner violence, gender-based violence), peer counselors, and addiction professionals. Applicants may use the application link below regardless of the stated deadline. Please also let us know you are applying, at firstname.lastname@example.org
The Panel will include experts such as:
- Tribal health or urban Indian health leaders and providers
- Medical, nursing, and service providers specializing in perinatal, obstetric, newborn, or pediatric care, such as clinicians, midwives, doulas, community health workers, nurses, social workers, other providers. This may also include experts in obstetric care with other relevant clinical expertise areas, such as cardiology, oncology, or autoimmune disorders.
- Birthing hospital or licensed birthing center representatives
- Coroners, medical examiners, or pathologists
- Behavioral health and service providers
- State agency representatives
- Experts in health equity and social determinants of health issues (e.g., racism, housing access) as they impact maternal mortality, perinatal care, and pregnancy outcomes.
- Individuals with other expertise areas at the Department of Health’s discretion (e.g., injury and violence prevention, WIC, researchers, CPS, EMS, etc.)
- Individuals or organizations that represent the populations most affected by pregnancy-related deaths or pregnancy-associated deaths and lack of access to maternal health care services.
- In Washington, this includes people who have been pregnant and/or experienced childbirth AND who are Black, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Medicaid (Apple Health) recipients, from low income backgrounds, or have experienced mental and behavioral health conditions such as opioid use disorder or postpartum depression.
- It also includes people are closely related to people who meet these criteria.
If you have any questions, please contact the Maternal Mortality Review Coordinator email@example.com
- Expansion of the Law
Washington state’s maternal mortality law gives the Department of Health the authority to obtain pertinent vital records, medical records, and autopsy reports related to maternal deaths. The law also provides protections for those records and for the panel members who participate in the review. This authority and protection allowed the Department and the Panel to determine which deaths were preventable and identify the issues that lead to preventable deaths.
In 2019, Washington state expanded the law to support and strengthen the maternal mortality reviews conducted by the Maternal Mortality Review Panel. The law was amended to permanently establish the Panel and the maternal mortality review process in Washington. Other changes included:
- Requiring tribal representation.
- Expanding representation to include all types of obstetric, perinatal, and women’s health medical, nursing, and service providers, as well as individuals or organizations that represent populations most affected by maternal mortality and lack of access to maternal care.
- Data related to the maternal mortality review can be shared with the Centers for Disease Control and Prevention, local health jurisdictions, regional maternal mortality review efforts such as American College of Obstetrics and Gynecology District VIII, and tribal entities.
- Access to records from the Department of Children, Youth and Families.
- Requiring hospitals and birthing centers to make good faith efforts to report deaths that occur during pregnancy or within 42 days of pregnancy to the local coroner or medical examiner, who will then conduct a death investigation with autopsy strongly advised. Counties will be reimbursed 100 percent for autopsies. (For more information on reporting and death investigation requirements, see Resources below.)
- Maternal Mortality Review – A Report on Maternal Deaths in Washington 2014-2015 (PDF)
- Maternal Death Reporting and Death Investigation Requirements (PDF)
- Maternal Deaths 2014-2016 Legislative Factsheet 2019 (PDF)
- Maternal Mortality Review Panel: An early look at 2017 Maternal Deaths (PDF)
- Prevention Recommendations and Activities for Policy Makers and State Agencies (PDF)
- Prevention Recommendations and Activities for Perinatal Clinical and Service Providers (PDF)
- Review to Action website – promoting the maternal mortality review process
- Urgent maternal warning signs (Council on Patient Safety in Women's Health Care)
- Maternal Obesity Anesthesia Checklists (PDF)
- Safer Care of Obese Pregnant Patients (PDF)
- Black Mamas Matter report on Maternal Mortality Review Committees
- Maternal Mortality Autopsy Guidelines (PDF)
- Maternal Mortality Frequently Asked Questions (PDF)
- Webinar: Investigating Maternal Mortality in Washington State
- Postpartum Follow-up Care Schedule Recommendations for Women Diagnosed with Hypertensive Disorders during Pregnancy (PDF)
- Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Strategic Plan: 2021-2024
- How Else Can I Be Involved?
The Department of Health welcomes your input on how the Maternal Mortality Review Panel can best meet the goals established by the legislature. There will not be a formal public hearing process (unless necessary to update the Washington Administrative Code). However, we encourage interested parties to share their ideas with Department of Health staff.To ask questions, share ideas, or receive notification when the MMRP report is released, please contact us at firstname.lastname@example.org.