Wisconsin Maternal Mortality Review

Using RQA for population health surveillance: The Wisconsin Maternal Mortality Review Experience

Maternal mortality and morbidity are critical indicators of maternal health and health care quality in Wisconsin. Every maternal death represents the loss of a woman’s life and the impact on her family and community. Instances of severe maternal morbidity can be traumatizing for women and families, have lasting health consequences, and avoidable medical expenses.

Though maternal health in the United States has significantly improved during the past century, recent increases in pregnancy-related deaths and significant racial disparities in maternal health demonstrate the need for systematic improvements in the care of pregnant women and mothers.

One way to address maternal mortality is to conduct maternal mortality reviews. The Wisconsin Maternal Mortality Review Team (MMRT) was started in 1997 by the Wisconsin Division of Public Health and the Wisconsin Section of the American College of Obstetricians and Gynecologists. The MMRT is supported by a CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant, the CDC Foundation Rapid Maternal Overdose Review (RMOR) grant, and the Title V Maternal and Child Health (MCH) Block Grant administered by the federal Health Resources and Services Administration.

The purpose of the Wisconsin Maternal Mortality Review Team (MMRT) is to identify and review pregnancy-associated deaths, identify factors that contribute to these deaths, and propose recommendations that aim to prevent future deaths.

The mission is to increase awareness of the issues surrounding pregnancy-associated and related deaths and make recommendations to promote change among individuals, communities, and health care systems to eliminate preventable maternal deaths among Wisconsin residents.

Each review meeting the team discusses the circumstances surrounding a maternal death and identifies the critical factors that contributed and forms recommendations that could prevent future deaths.

The UW-Madison Prevention Research Center partnered with Wisconsin Department of Health Services to analyze the critical factors and recommendations from eleven maternal overdose cases using a rapid qualitative analysis. The PRC Community Advisory Board convened to provide feedback on the feasibility and actionability of the Wisconsin Maternal Mortality Review Team’s current recommendations. A core group of Maternal Mortality Review Team members provided additional feedback on the themes identified by community partners. Themes including care coordination, trust, and access to care among others were identified by both parties. You can read more about our findings in the full MMR report.