Maternal Mortality Review Committees

September 1, 2023

Improving the quality of maternal health care and ensuring full access to it improves health outcomes and reduces preventable pregnancy-related deaths. The United States has one of the highest rates of maternal mortality among high-income countries and wide disparities by race that have been documented since rates separated by race were first published in 1935. Currently, Indigenous and Black women are dying at two to three times the rate of White women, Asian/Pacific Islander women and Hispanic women. Investigating maternal deaths—specifically by obtaining information beyond vital statistics data—is imperative to understanding why people may die while pregnant, during labor and delivery, and in the postpartum period.

Some states first established maternal mortality review committees (MMRCs) to investigate deaths related to pregnancy in the early 20th century, when rates were the highest on record. These jurisdictions reviewed deaths in an effort to understand why many women died in childbirth and to respond to poor medical practices and inadequate care provided by physicians. Many committees became inactive by the late 1980s, following a decline in maternal deaths for several decades. Since 2016, there has been a resurgence of interest in MMRCs because of increased attention on maternal mortality and the disparate rates of death by race, leading many states to renew or strengthen their review of pregnancy-related deaths.

Nearly all jurisdictions review “pregnancy-associated” deaths, defined by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists as the death of a woman while pregnant or within one year of the end of a pregnancy, regardless of the cause. This umbrella term includes “pregnancy-related” and “pregnancy-associated, but not related” deaths. A pregnancy-related death is one that occurs while pregnant or up to a year postpartum from any cause related to or aggravated by the pregnancy or its management. A pregnancy-associated, but not related, death is one that happens during pregnancy or within one year postpartum that is not related to the pregnancy (e.g., postpartum death in a car accident). While many MMRCs determine if a pregnancy-related death was preventable, only some are required to do so. A few MMRCs review cases of maternal morbidity, which is a physical or mental illness directly related to pregnancy or childbirth; some investigate racial disparities when reviewing cases. In some states, another body—such as an advisory committee or task force—works with the state and MMRC on addressing racial disparities in maternal health outcomes and provides recommendations.

In order to conduct comprehensive, multidisciplinary reviews, MMRC members must have the necessary tools, including relevant expertise, access to data, and the ability to confidentially investigate and review case details. MMRCs, whose membership historically was exclusively physicians, generally now include a wider representation of expertise, including midwives, doulas, pathologists, mental and behavioral health experts, representatives from Native tribes and nations, community-based organizations, and those affected by a death or near death. MMRCs are able to gather information beyond what is available through vital statistics data, including reviewing various institutional records (e.g., medical files, law enforcement reports, autopsy records) and interviewing witnesses or family members. Most review committees have legal protections in place to ensure confidentiality of data and the review process, and to shield providers from liability and potential subpoenas, which all allow for more thorough investigations.

After conducting reviews of individual pregnancy-related deaths, committees develop recommendations aimed at preventing future deaths. The MMRC shares these recommendations with a variety of stakeholders, including those who can implement system or policy changes. Stakeholders may include hospitals, health care providers, state perinatal quality collaboratives, state and local policymakers and the public.

Most states have collaborated with the CDC to standardize their maternal mortality review process, including adopting a system developed by the CDC for consistent data gathering, decision making and development of actionable recommendations.

Highlights

Review Committee Scope of Work

49 states, the District of Columbia, New York City, Philadelphia and Puerto Rico have a formal maternal mortality review committee or legal requirement to review pregnancy-related deaths.
- 36 states, DC, New York City, and Philadelphia are required to review deaths that occur up to one year postpartum.
- 31 states, DC and New York City are required to investigate every pregnancy-associated death that is within their scope of work.
- 13 states, New York City and Puerto Rico are required to determine if a pregnancy-related death was preventable.
14 states and New York City evaluate maternal morbidity in the jurisdiction.
- 12 states and New York City review cases or investigate trends of maternal morbidity.
- 6 states and New York City track maternal morbidity data.
10 states, DC and New York City investigate or consider racial disparities and equity in conducting reviews.

Committee Structure and Information

48 states, DC, New York City, Philadelphia and Puerto Rico have requirements for committee membership, access to data and confidentiality.
- 37 states, DC, New York City and Puerto Rico require multidisciplinary committee membership, such as representation of midwifery, obstetrics and gynecology, mental and behavioral health, doulas, nurses, public health experts, Native tribes or nations, and patients or family members affected by a death.
  - 24 states, DC, New York City and Puerto Rico require specific membership expertise.
  - 13 states require committee membership to be representative of the jurisdiction’s demographic composition (e.g. geographic, racial, socioeconomic status, communities most affected) or require such representation to be considered when selecting members.
- 46 states, DC, New York City, Philadelphia and Puerto Rico permit committee access to certain data and institutional records, such as medical files, vital statistics data, law enforcement reports or court records.
- 45 states, DC, and Puerto Rico require confidentiality of the review process and records and information considered by the committee, and provide legal protections for reviewers and participants.

Committee Report Requirements

43 states, DC, New York City, Philadelphia and Puerto Rico have requirements about the frequency and content of reports.
- 38 states, DC, New York City, Philadelphia and Puerto Rico require committees or departments of health to publish reports at certain intervals (e.g., annually, twice a year, every two years).
- 38 states, DC, New York City and Puerto Rico require the committee to provide recommendations focused on preventing future pregnancy-related deaths.
- 6 states and New York City require the committee’s reports to address racial disparities.

Standardized Review Process

41 states and New York City have adopted a standardized review process developed by the CDC, including consistent data gathering, decision making and recommendations.

Current Policy Status Table

Maternal Mortality Review Committees
Jurisdiction	Scope of work							Committee structure
	Reviews maternal mortalities	Pregnancy-associated deaths			Maternal morbidity		Investigate or consider racial disparities	Committee structure
	Reviews maternal mortalities	Review deaths up to one year after pregnancy ends	Investigate every pregnancy-associated death	Determine preventability of death	Review cases or trends	Track morbidity data	Investigate or consider racial disparities	Multidisciplinary membership or expertise beyond physicians	Demographic representation required or considered in membership composition†
State committees
Alabama	X	X	X		X			X
Alaska	X		X		X
Arizona	X	X	X					DOH, HD, LE, PUB, ME or PATH, T, Other
Arkansas	X	X	X	X				X
California	X	X	X		X	X	X	CBO,D, DOH, MH, MW, N, P/FM	X
Colorado	X	X	X				X	X	X
Connecticut	X	X	X					X
Delaware	X						X	CBO, DOH, LE, ME, PAS, Other
Florida	X		X
Georgia	X			X				X
Hawaii	X	X						X
Illinois^§	X	X	X		X		§	DOH, N, HA, HD, PATH, PUB, Other
Indiana	X	X	X			X		AN, CBO, EPI, HA, HD, MH, MW, PAS, PATH, PH, RN, SW, SA	X
Iowa	X	X
Kansas	X	X	X	X
Kentucky	X	X
Louisiana	X				X		X	CBO, D, DOH, HA, PAS, PQC, SU, Other
Maine	X*	X	X					LE, SWPH, Other
Maryland^§	X	X	X	X				X
Massachusetts	X
Michigan	X	X			X
Minnesota^§	X	X
Mississippi	X							X
Missouri	X	X	X				X	X	X
Montana	X							DOH, EMS, HA, HD, LE, ME, MH, N, PATH, T, Other
Nebraska	X	X	X	X		X		DOH, LE, PATH, Other
Nevada	X	X	X		X		X	CBO, DOH, LE, SWPH	X
New Hampshire	X	X	X					DOH, EPI, ME/C MH, PAS, PUB
New Mexico	X	X	X		X	X		DOH, HA, ME, N, PAS, PQC	X
New Jersey	X	X	X	X		X	X	AN, CBO, DOH, ME, MW, N, PAS, PATH, PQC, SU, Other	X
New York^§	X	X	X	X	X			X	X
North Carolina	X		X	X				X
North Dakota	X	X	X	X				X	X
Ohio	X	X	X						X
Oklahoma	X	X	X	X	X	X		DOH, EMS, HD, LE, ME, MH, PAS, P/FM, PQC, SU, T, Other
Oregon	X	X	X		X		X	CBO, D, ME, MH, MW, N, PAS, PH, Other	X
Pennsylvania	X	X	X					AN, DOH, EMS, EPI, ME/C, MH, MW, N, PATH, SWPH, SU, Other	X
Rhode Island	X	X						P/FM, PATH, SA, Other
South Carolina	X	X	X	X				X
South Dakota	X*
Tennessee	X	X	X	X				DOH, ME, N, Other
Texas	X	X			X		X	AN, C, DOH, EPI, ER, ME, MCO, MH, MW, N, O, PATH, SW/PH	X
Utah	X							DOH, HA, PAS, Other
Vermont	X	X					X	DOH, EPI, ME/C, MH, MW, N, PAS, PUB, Other
Virginia	X	X	X					CBO, DOH, EMS, LE, ME/C, MH, PAS, Other
Washington	X	X	X	X				T, Other
West Virginia	X	X	X				X	DOH, LE, ME, Other
Wisconsin	X
Wyoming	X*
City and territory committees
Dist. of Columbia	X	X	X				X	AN, CBO, D, DOH, EPI, HA, ME, MH, N, P/FM, PAS, SWPH, Other
New York City^§	X	X	X	X	X	X	X	CBO, D, DOH, EMS, Other
Philadelphia	X	X
Puerto Rico	X			X				AN, DOH, ER, EPI, PAS, PATH, SW, Other
TOTAL	49 + DC, PHL, NYC, PR	36 + DC, PHL, NYC	31 + DC, NYC	13 + NYC, PR	12 + NYC	6 + NYC	10 + DC	37 + DC, NYC, PR	13

Notes:
Committee members: AN=anesthesiologist, C=cardiologist, CBO=community-based organization or local nonprofit, D=doula, DOH=department of health, EMS=emergency medical service worker/first responder, EPI=epidemiologist, ER=emergency department provider, HD=local health department, LE=law enforcement, ME/C=medical examiner or coroner, MCO=representative from a managed care organization, MH=mental health provider/expert, MW=midwife, N=nurse, O=oncologist, PAS=professional associations (e.g., hospital association, medical society, provider association), P/FM=patient or family member affected by maternal mortality or near maternal mortality, PATH=pathologist, PQC=perinatal quality collaborative, PUB=member of the public, SU=substance use expert, SWPH=social worker or public health professional, T=representative of Native tribe/tribal government

* Jurisdiction reviews pregnancy-related deaths through another fatality committee, such as an infant and child fatality review committee; Wyoming's pregnancy-associated deaths are reviewed by Utah's review committee.
† Committee membership is required to be representative of the jurisdiction's demographic composition (e.g., geographic, racial, socioeconomic status, communities most affected) or such representation must be considered in selecting members.
§ Jurisdiction has an advisory council or task force that addresses racial disparities in maternal health outcomes and provides recommendations to the MMRC and other stakeholders.

Maternal Mortality Review Committees
Jurisdiction	Handling of information		Report requirements			Use standardized CDC system to review deaths
Jurisdiction	Access to records	Members, data and review process protected by confidentiality	Report frequency	Recommendations to prevent pregnancy-related deaths	Recommendations to address racial disparities	Use standardized CDC system to review deaths
State committees
Alabama	EMS, FW, H, LE, ME, SS, V, Other	X		X		X
Alaska	EMS, H, LE, ME, T, V, Other	X	Annually	X		X
Arizona	H, LE, ME, V	X				X
Arkansas	FW, H	X	Annually	X		X
California	H, ME	X	Every three years	X	X
Colorado	FW, H, LE, ME, V		Every three years	X		X
Connecticut	H, ME, V	X	90 days after MMRC meeting	X		X
Delaware	FW, H, V	X	Annually	X		X
Florida	H, V	Only data				X
Georgia	FW, H	X	Annually	X		X
Hawaii	C, E, H, LE, ME, PP, SS, V, W	X	Annually	X		X
Illinois^§	ME, H, MH	Only data	Annually	X		X
Indiana	EMS, FW, H, LE, ME, MH, V, Other	X	Annually	X		X
Iowa	H, V		Every three years	X		X
Kansas	FW, H, LE, ME, SS, V	X		X		X
Kentucky	H, LE, ME, V	X	Annually			X
Louisiana	H, V	X		X	X	X
Maine	FW, H, V	X	Annually	X
Maryland^§	FW, H, LE, ME, PP, SS, V	X	Annually	X	X	X
Massachusetts	V	X				X
Michigan	H, V	X	Every five years			X
Minnesota^§	FW, H, LE, ME	X		X		X
Mississippi	H, LE, ME, V	X	Annually	X		X
Missouri	H, LE, ME, SS, V, Other	X	Annually	X		X
Montana	C, H, T, Other	Only data
Nebraska	E, EMS, H, LE, ME, MH, PP, SS, V	X	Annually	X		X
Nevada	EMS, FW, H, LE, ME, MH, SS, V	X	Annually; maternal morbidity report in even-numbered years	X
New Hampshire	FW, H, ME, V	X	Annually	X		X
New Mexico	H, LE, ME, V, Other	X	Annually	X		x
New Jersey	FW, H, ME, SS, V	X	Annually	X	X	X
New York^§	FW, H, LE, ME, V, Other	X	Every two years	X	X	X
North Carolina	FW, H	X		X		X
North Dakota	H	X	Annually	X
Ohio	FW, H, LE, SS, V	X	Every two years	X		X
Oklahoma	C, EMS, FW, H, LE, ME, MH, SS, V	X				X
Oregon	FW, H, LE, ME, SS, V	X	Every two years	X		X
Pennsylvania	C, EMS, H, LE, ME, SS, V, Other	X	Every three years	X		X
Rhode Island	H, V	X	Annually	X		X
South Carolina	FW, H, LE, ME, V	X	Annually	X		X
South Dakota	H, V		Annually			X
Tennessee	H, LE, ME, SS, V	X	Annually	X		X
Texas	H, V	X	Even-numbered years	X
Utah		X	Annually			X
Vermont		X	Annually	X
Virginia	C, H, LE, ME, SS	X	Annually	X		X
Washington	H, ME, SS, V	X	Every three years	X		X
West Virginia	H, ME, MH, SS, V, Other	X	Annually	X	X	X
Wisconsin	H, V	Only data	Annually			X
Wyoming
City and territory committees
Dist. of Columbia	FW, H, LE, ME, MH, V	X	Annually	X
New York City^§	FW, H, ME, V, Other	X	Annually	X	X	X
Philadelphia	H, V	Only data	Annually
Puerto Rico	H, LE, SS	X	Biannually	X
TOTAL	46 + DC, NYC, PHL, PR	45 + DC, NYC, PHL, PR	38 + DC, NYC, PHL, PR	38 + DC, NYC, PR	6 + NYC	41 + NYC

Notes:
Access to data and records: C=court records, E=educational records, FW=family or witness interviews, EMS=emergency medical service or first responder records, H=health care and medical records, LE=law enforcement records, ME=medical examiner or coroner records, MH=mental health records, PP=parole or probation records, SS= social service records, T=tribal government records, V=vital statistics

§ Jurisdiction has an advisory council or task force that addresses racial disparities in maternal health outcomes and provides recommendations to the MMRC and other stakeholders.