Pregnancy-associated mortality review in Massachusetts: Using the health impact pyramid to address social and health care disparities

Background. Global comparisons of maternal mortality rates reveal a US rate far above many developed countries. The highest rates are associated with health and social disparities among poor women of color. The Massachusetts (MA) Mortality and Morbidity Review Study examines the causes pregnancy-associated (PA) deaths, defined as the death of a woman while pregnant or within the first year postpartum. Reviewing PA deaths enables the state to make public health recommendations that address women's health during the childbearing years. We will present epidemiologic analyses, case review findings, and recommendations by the MA Maternal Mortality Review Committee (MMRC).

Methods. We identified PA deaths through case finding strategies including hospital mandatory reporting and vital records data linkage. During 2000-2007, 168 women died during the PA period. We calculated PA mortality ratio (PAMR) overall, by medical and injury causes, and PAMRs and relative risk (RR) for demographic characteristics. The MMRC conducted a qualitative review of medical records. We used the Health Impact Pyramid (Friedan, 2010) to frame MMRC individual, system and community level recommendations.

Results. The overall PAMR was 26.1. Black non-Hispanic (RR: 1.9), younger women (RR: 2.0), women with public insurance (RR: 2.7) or lower education (RR: 2.3) were more likely to die than comparison groups. The MMRC determined that one in five deaths were preventable and developed recommendations that were classified using the 5-tier health impact pyramid.

Conclusions. Using the Health Impact Pyramid to understand health disparities for pregnant and postpartum women provides a framework to improve women's health.