Pa. could speed up maternal mortality review impact

House has approved creation of committee that now goes to Senate

A proposed statewide Maternal Mortality Review Committee was unanimously approved by the state House in December with the idea that if it is finally approved, committee members would begin reviewing maternal deaths as they arise.

But if it is approved by the state Senate in its current form, that could mean it could be up to five years before the committee has any usable data to make recommendations on cutting the state’s increasing maternal death rate, and supporters of the legislation want to see it happen sooner than that.

“I think we’d rather see something quickly,” said Amanda Flicker, an obstetrician-gynecologist who first brought the idea for the committee to state Rep. Ryan Mackenzie, R-Lehigh. It was Mr. Mackenzie who sponsored the legislation that was approved by the House on Dec. 12.

“We could at least do a short

retrospective review, maybe one to three years,” Dr. Flicker said.

Mr. Mackenzie said he had not contemplated that, but he said if that is something experts like Dr. Flicker said is needed, “we could consider it” after talking with the state Department of Health staff.

Though the committee would be made up mostly of volunteer experts in the field, the health staff would end up doing much of the heavy lifting compiling the data and “we would have to see if they could do” a retrospective study, Mr. Mackenzie said.

State Sen. Lisa Baker, a Republican from Luzerne County who heads the Senate’s Health and Human Services Committee that would take up the bill, said in an emailed statement that she liked the idea behind the bill because “a comprehensive evaluation could help us take action to prevent future deaths, so it is certainly worthy of discussion.”

Asked if she would consider including a retrospective review, her spokesman, Andrew Seder, said in an email reply that “that’s certainly something for the [Senate] committee to consider once the bill is actually referred.”

The state does have much of the data readily available to do that.

Since 2012, the year the state adopted the U.S. Standard Death Certificate first proposed to states in 2003, it has had a series of pregnancy-related questions on death certificates for physicians or coroners to check. Previously, there were no pregnancy questions on the death certificate.

Those questions now include whether they were pregnant at the time of death, or if they were pregnant within 42 days prior to their death, or 43 or more days prior to their death.

While the newly proposed state committee legislation gives the committee the authority to review death certificates — where many of the cases they review will likely come from — it also allows it to use other sources of data to find cases where women died because of a pregnancy, including referrals from hospitals and medical personnel, law enforcement, and any other source where it can find cases.

Dr. Flicker said when Philadelphia set up its own city-focused maternal mortality commission in 2010, she was told they even scanned obituaries to find some cases.

“There’s a reason to look more broadly” using every source available to find cases, she said, because most experts believe the figures of maternal deaths the state currently gathers annually from a maternal death form are clearly low.

The state data only counted 18 in the entire state in 2014, for example.

“We expect there’s much more than that,” said Dr. Flicker, who is the treasurer for the Pennsylvania section of the American Congress of Obstetricians and Gynecologists, which has been pushing for the creation of maternal mortality committees in every state.

There would probably be a large increase in the number of cases the state counts under the proposed bill. That is in part because the state now only counts deaths that occurred within 42 days of the termination of a pregnancy, while the maternal mortality committee would look out up to one year after.

In Philadelphia, for example, the commission’s 2015 report found that there were 19 pregnancy related maternal deaths from 2010 to 2012 in the city alone, while the state only counted 15.

The state’s data showed that even with the limited data it has gathered, Pennsylvania reflects at least one troubling trend seen nationally and in other states where they have done better at documenting their maternal deaths: African-American women are three times more likely to die a maternal death than white women.

Pennsylvania’s data shows that from 1999 to 2014, therewereat least 260 maternal deaths, one-third of them were African-American in a state that is only about 11 percent African-American.

To get at why that is, and why other women are dying as well, Loren Robinson, deputy secretary for health promotion and disease prevention with the state department of health, said it is important to have enough data from several years of cases “so we can make targeted interventions.”

“From that, we want to make programs that support high-risk pregnancies and high-risk moms,” she said.

A similar effort famously has had a dramatic impact on the maternal mortality rate in California.

There, an effort begun in 2006 to investigate every maternal death, and implemented changes learned from the data led the state to cut its death rate in half.

It dropped from nearly 16 maternal deaths per 100,000 live births in 2006 — when California had a death rate higher than the U.S. overall rate of about 12 — to just 7.3 in 2013, when the U.S. rate was 22.

“California has done some quality research and implemented protocols that reduced maternal mortality,” said Stacy Beck, an obstetrician-gynecologist at Magee-Women’s Hospital of UPMC and an assistant professor in the department of obstetrics, gynecology and reproductive sciences at the University of Pittsburgh.

The California case also demonstrated that pulling together data across a state can show some trends that might not otherwise be obvious within one or two hospitals, because, even though the death rate has been rising steadily, the numbers are still small in any one year.

Each maternal death at any one hospital is a big deal, said Richard Beigi, primary investigator at MageeWomen’s Research Institute.

“For an obstetrics unit, a maternal death is like a plane crash,” he said. “Fortunately, they don’t happen often.”

They still don’t happen often at any one hospital, but they happen much more often in the U.S. than they do in any other first world country.

In Canada, for example, the maternal death rate was just 11 deaths per 100,000 live births in 2013, when the U.S. rate was double that.

“And Canada has a vast rural area. They’re still able to take better care of their moms than we are,” Dr. Robinson said.

“People expect in a firstworld country with our resources like ours that expectant mothers would not die,” she said. “It’s just a matter of getting the right care to the right people, something this committee will help us do.”