Maternal Mortality Review

Report: Maternal Mortality in New Jersey 1999-2001

New Jersey was the second state to institute a maternal mortality review. As professionals dedicated to the health of the state's pregnant women, New Jersey obstetricians have been reviewing maternal deaths for 70 years. The first State Report of Maternal Death Review was filed in 1932, and annually thereafter. In 1948, "Maternal Mortality Review" was the keynote address of the inaugural meeting of the New Jersey Obstetrical and Gynecological Society. This milestone positioned New Jersey as a leader in maternal mortality review.

In the 1970's, the Department of Health and Senior Services joined with the obstetricians in the review efforts, devising an improved detection technique of linking birth and death certificates. Consequently, the number of maternal mortality cases went from 16 to 30 in the first year of the improved surveillance. In 1978, the New Jersey Public Health Council approved the review process and the study of maternal deaths. Each year, the Maternal Mortality Review Committee of the Medical Society of New Jersey reviewed individual cases of death of a woman that occurred during a pregnancy or within 90 days of termination of the pregnancy (in 1990 the time frame was increased from 42 days to 90 days). The Committee identified at least one topic for which further discussion and education of obstetricians was needed. Presentations of the groups' findings were made at the annual meeting of the New Jersey Obstetrical and Gynecological Society.

Nineteen ninety eight (1998) marked the final year for the Medical Society of New Jersey and the NJ Department of Health and Senior Services model of maternal mortality review. At that time, the Department of Health and Senior Services became aware of several trends occurring nationally in the area of mortality review. In the 1980's, the multidisciplinary Fetal and Infant Mortality Review process, which focuses on systematic service delivery issues, as well as professional and consumer education, was developed and since then has been implemented throughout the country. The Florida Department of Health successfully applied the National Fetal-Infant Mortality Review model to the review of maternal deaths. In addition, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists expanded the traditional definition of maternal mortality to one of "pregnancy- associated deaths."

Pregnancy-associated death: the death of any woman, from any cause, while pregnant or within one calendar year of pregnancy termination of pregnancy, regardless of the duration of pregnancy.

Pregnancy-related death: A pregnancy-associated death resulting from: 1) complications of the pregnancy itself,
2) the chain of events initiated by the pregnancy that led to death, or
3) aggravation of an unrelated condition by the physiologic or pharmacologic effects of the pregnancy that subsequently caused death.

In 1999 the New Jersey Department of Health and Senior Services implemented a revision of maternal mortality review. The current process, New Jersey Maternal Mortality Review Program, is a statewide initiative modeled after the Pregnancy Associated Mortality Review Program in Florida. Objectives of the New Jersey Maternal Mortality Review are:

• To identify all pregnancy-associated deaths;
• To use a systematic case review for review of pregnancy-associated deaths;
• To use a multidisciplinary approach to the review of pregnancy-associated deaths; and
• To improve the ability to examine perinatal systems.

The Process:

Step 1: Case identification:

• Direct report from hospitals, medical examiner to the DHSS;
• Death certificate pregnancy check box;
• Probabilistic match using electronic birth certificate, fetal deaths, death certificate, and hospital discharge file.

Step 2: Standardized Data Collection:  

• Contract with Central NJ MCHC;
• Nurse abstractors with MCH experience;
• On site data abstraction;
• Data collection tool adapted from Florida ;
• Multiple data sources.

Step 3: Multidisciplinary Case Review:

• Obstetricians (5) Social Worker (1)
• MFM (5) Mental Health Professional (1)
• OB Anesthesiologist (1) Substance Abuse Counselor (1)
• Perinatal Pathologist (1) Family Planning Professional (1)
• Critical Care Intensivist (1) Hospital Administrator (1)
• Medical Examiner (1) Risk Manager/Safety (1)
• Public Health Professional (1) Paramedic (1)
• OB Nurses (2) Minority Rights Advocate (1)
• Certified Nurse Midwife (1) Nutritionist (1)
• Clergyperson (1)

Step 4: Case Review:

• Examine social, economic, cultural and health system factors;
• Determine cause of death;
• Classification of death as pregnancy-related, not pregnancy-related, undetermined;
• CRT Summary of findings/recommendations.

Step 5: Utilization of findings and recommendations:

• Integration of findings into QI at state and local level;
• Maternal Mortality Review database.

For information about the nj maternal mortality review, or to report a maternal death (pregnancy associated death) contact :

Elizabeth Ferraro , RN , MSN
Research Scientist I
NJ Department of Health and Senior Services
Division of Family Health Services, MCCH
50 E. State Street, PO Box 364 , Trenton , NJ 08625
Phone: 609-292-9582 or 5616
Email: beth.ferraro@doh.state.nj.us