Strategies to Reduce 

Pregnancy-Related Deaths 

From Identification and Review to Action 

TM 
Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

American College of Obstetricians and Gynecologists 

American College of Nurse-Midwives 

Association of Maternal and Child Health Programs 

CityMatCH


Maternal and Child Health Bureau


Health Resources and Services Administration


U.S. Department of Health and Human Services


National Association of Public Health Statistics 


and Information Systems


Suggested citation: Berg C, Danel I, Atrash H, Zane S, Bartlett L 

(Editors). Strategies to reduce pregnancy-related deaths: from 

identification and review to action. Atlanta: Centers for Disease 

Control and Prevention; 2001. 
Strategies to Reduce 

Pregnancy-Related Deaths 

From Identification and Review to Action 

Editors 

Cynthia Berg, M.D. 

Isabella Danel, M.D. 

Hani Atrash, M.D. 

Suzanne Zane, D.V.M. 

Linda Bartlett, M.D. 
Acknowledgments 

Without the generosity and cooperation of many experts who 

shared their knowledge and skill with us during the past several 

years, we could not have produced this manual. 

The ACOG/CDC Maternal Mortality Study Group, formed in 

1986, provided insight into the pregnancy mortality surveillance 

process from a variety of perspectives. Members reviewed the 

text and provided helpful comments on numerous drafts of the 

manual. Staff from many state health departments provided the 

impetus to develop this manual, and much of this document is a 

compilation of their experiences. They also freely gave us their 

materials and other information. In particular, we thank the 

Florida Pregnancy-Associated Mortality Review Committee, the 

Ohio Department of Health, the New York State Department of 

Health, and the Massachusetts Department of Public Health for 

sharing examples of their reports and data collection forms. Our 

partners in producing this manual—listed on the inside front 

cover—provided valuable insight into the surveillance process, 

each agency from its own unique perspective; they also reviewed 

and improved the text. 

We also thank Debbie Kowal who helped write the first draft of 

this manual and Helen McClintock who helped with the final 

version. 

Finally, we thank all the pregnancy mortality review committees 

for all their efforts to reestablish, continue, and enhance their 

work and improve the health of women. 
Ordering information 

To order a copy of this publication, contact— 


Centers for Disease Control and Prevention


Division of Reproductive Health


Safe Motherhood Activity, Mail Stop K-23


4770 Buford Highway, N.E.


Atlanta, GA 30341


or 


E-mail


nccddrhsmp@cdc.gov


or


Visit our Internet site at


 www.cdc.gov/nccdphp/drh/
Contents 

Prologue: Why Surveillance Still Matters — i 


1.	 Structure of Pregnancy-Related Mortality Surveillance


in the United States — 1


2. Definition of Terms — 5


3.	Classifying a Woman’s Death in Relation to Pregnancy — 7


Cases where causal relationship may be unclear — 10


4.	Identifying Cases — 13


Cause-of-death codes on death certificates — 15


Manual review of death certificates — 16


Check box indicating pregnancy on death certificates — 17


Linking vital records — 18


Searches of other computerized data sources — 20


Other sources of information — 21


Autopsy record review — 21


Medical record review — 21


5. Reviewing Pregnancy-Related Deaths — 23


Maternal mortality review committees — 25


Issues to review — 29


Sources of information — 30


Components of review — 32


Correcting or improving cause-of-death information 


on a death certificate — 36


Legal issues: liability and confidentiality — 37


6.	Analyzing and Interpreting the Findings — 39


Quantitative analysis — 39


Qualitative analysis — 41


Using quantitative and qualitative data together — 42


Issues related to small numbers — 43


7.	 Taking Action — 45


Making and implementing recommendations — 46


Disseminating findings and recommendations — 46


8.	 Evaluating the Surveillance System — 49


Internal evaluation — 49


External evaluation — 50


9.	 Special Issues — 51


Funding — 51


Monitoring maternal health and morbidity/near misses — 51


Epilogue — 53

Appendices 

A.	 Instructions for completing the cause-of-death section 


of death certificates


B.	 States with check boxes to indicate pregnancy on 


their death certificates


C.	 The pregnancy-related portion of the proposed U.S.


standard certificate of death


D. State Review Provisions, ACOG 2000


E. Examples of data abstraction forms for medical records


F.	 Example of questionnaire for interviews after pregnancy-


related deaths


G.	 Extracts from “State Level Expert Review Committees—


Are They Protected?”


H. Measures of pregnancy-related mortality


I. Example of a maternal mortality review committee’s report

Prologue


Why Surveillance Still Matters


Each year in the United States, almost 1,000 women die 

of pregnancy-related complications.1 Although the number of 

such deaths has decreased dramatically since the late 19th and 

early 20th centuries, there has been no decrease in the maternal 

mortality ratio during the last 15 years.2,3 On a population level, 

this number may appear small; however, on the individual level, 

each death is a heartbreaking loss. 

Because each pregnancy-related death is a sentinel event, every 

death counts and every death should be counted. Many of these 

deaths could have been prevented through changes in the health 

and behaviors of women before pregnancy, the timing of 

conception, access to heath care and social services, or the 

quality of care received. Every death prevented is meaningful. 

Improved surveillance is needed to help develop interventions 

to reduce pregnancy-related deaths. 

The major causes of pregnancy-related deaths are the same 

today as in the past: bleeding, hypertensive disorders of 

pregnancy, embolism, and infection.1 These can pose a 

threat to any pregnant woman. Yet not all women with these 

conditions die. Why do some women survive while others do 

not? Moreover, some groups of women are at increased risk 

for pregnancy-related death. For example, although most 

women who die of pregnancy-related complications are white, 

black women continue to have a four-times greater risk for 

pregnancy-related death and Hispanic women a 70% greater 

risk for death than white women.1,4,5 The risk of pregnancyrelated death also dramatically increases with maternal age. 

Comprehensive, broad-based surveillance is needed to identify 

the factors, from before pregnancy through the puerperium, that 

affect a woman’s chance of survival and that place minority and 

older women at increased risk for pregnancy-related death. With 

the resources available today, we should be able to eliminate this 

gap in such an important health outcome. 

Pregnancy-related deaths are the tip-of-the-iceberg with regard 

to complications of pregnancy. For every woman who dies of a 

pregnancy-related cause, several thousand suffer morbidity 

Behind each number 

is a human face. 

—William Foege, M.D. 

i 
Strategies to Reduce Pregnancy-Related Deaths 

related to pregnancy—before, during, or after delivery. Each 

year six million women become pregnant, almost four million 

give birth, and over one million experience pregnancy-related 

complications. This means that pregnancy-related complications 

are a significant burden on women, their families, and society 

in economic, social, and personal terms (Unpublished article: 

Danel I, Berg CJ, Atrash HK, Johnson CH. The magnitude of 

maternal morbidity during labor and delivery, United States, 

1993-1997.). 

Public health surveillance—identifying and reviewing 

pregnancy-related deaths, analyzing the findings, and taking 

action—should decrease a woman’s risk of mortality due 

to pregnancy as well as help the many women who suffer 

pregnancy-related morbidity without dying. 

ii 
1 Structure of Pregnancy-


Related Mortality 


Surveillance in the 

United States 

This manual describes strategies for conducting 

pregnancy-related or maternal mortality surveillance in the 

United States. This surveillance is an ongoing process of 

identifying pregnancy-related deaths, reviewing the factors that 

led to those deaths, analyzing and interpreting the information 

gathered, and acting on the results so as to reduce such deaths in 

the future. The ultimate purpose of this surveillance process is to 

stimulate action rather than merely to count cases and calculate 

rates or ratios. All these steps—identification, data collection and 

analysis, and action—are needed on an ongoing basis in order to 

justify the effort and reduce pregnancy-related deaths. 

For pregnancy-related mortality surveillance to be successful, 

many people from many groups in many different roles must 

collaborate. In the United States, pregnancy-related mortality 

surveillance is a public health function, primarily coordinated 

by the states, although some large counties and cities also 

undertake this activity. Clinicians and health care professionals 

play vital roles in many parts of the surveillance process, as 

do social service and educational agencies, professional 

organizations, community groups, and the health care industry. 

Federal agencies assist in coordinating surveillance activities, 

providing technical assistance, and compiling national data. 

This manual addresses issues and tasks that are important 

for health departments, clinicians, vital statistics personnel, 

pregnancy-related mortality review committees, legislators, 

and community groups. 

Pregnancy-related mortality surveillance consists of several steps 

that occur in a more or less sequential fashion. Although each 

1 
Strategies to Reduce Pregnancy-Related Deaths 

state has its own unique structure, in every state, pregnancyrelated mortality surveillance requires similar steps: 

Identify pregnancy-related deaths. 

Review the medical and non-medical causes of death. 

Analyze and interpret the findings. 

Act on the findings. 

The concept of pregnancy mortality surveillance as an ongoing 

process with the ultimate purpose of action is an important 

one. Too often surveillance stops after identifying and counting 

deaths. However, pregnancy-related mortality surveillance 

requires all four steps—identification, investigation, analysis, 

and action—in a continuing fashion to make the effort 

worthwhile. 

The following chapters will address these steps in detail. 

However, first we provide an overview of the process and 

the role of the various agencies and health care providers. 

Pregnancy-related mortality surveillance is usually coordinated 

by the state health department, frequently by the unit 

responsible for maternal and child health. 

Identification 

Finding as many pregnancy-related deaths as possible is 

important. Women die at home, in clinics, or in hospitals. 

They die during pregnancy, while giving birth, or after delivery; 

they die of complications from childbirth, abortion, or ectopic 

pregnancy. To have a representative picture of the determinants 

of maternal death, one needs to have as complete a picture of 

the women who died as possible. Women who die at home may 

be different from women who die in referral hospitals. Women 

who die on labor or delivery wards may have different stories 

from women who die on gynecology wards or emergency 

rooms. Possible or known pregnancy-related deaths are usually 

identified by the vital statistics office, although other methods 

such as computerized data systems and reports from health care 

providers or surveys may also be used. 

2 
1. Structure of Pregnancy-Related Mortality Surveillance in the United States 

Review 

Reviewing data on pregnancy-related deaths is the next step. 

Information on the medical and non-medical factors that led 

to the deaths is collected, by the state, a review committee, or 

an individual or group assigned the task. A pregnancy-related 

mortality review committee then meets to review and discuss 

the deaths. Members of these committees come from health 

departments, clinical medicine, other appropriate agencies 

and professional organizations, the health care industry, and 

community groups. 

Analysis and interpretation 

The information collected during the review must be analyzed if 

it is to be used to reduce maternal deaths. Each case should be 

individually assessed for the medical and non-medical factors 

that led to the death, especially the factors that were preventable. 

The deaths can then be considered as a group in order to find 

patterns or similar factors. This can be done both quantitatively 

(i.e., determining whether certain groups of women are more 

likely to die) and qualitatively (i.e., determining which scenario 

led to each death). 

Action—the reason for all the 

previous work 

The details of this step depend on the findings of the analysis. 

Action may include interventions in the community, in the 

schools, by the health care sector, or by local or state agencies. 

It is important that people with the ability to make changes are 

involved in the surveillance process, so that they understand the 

findings and are ready to act. 

Once action is taken, it must be evaluated to see if it was 

effective. The surveillance process then continues with 

identification and review of deaths in order to modify and 

refine the actions needed to make pregnancy safer for women. 

3 
2 Definition of Terms


Before we can discuss surveillance of pregnancy-related 

deaths, we must discuss and define our terms. Clear definitions 

are particularly necessary because of the variety of definitions 

and terms used by different groups when they discuss mortality 

related to pregnancy (Box 1). 

If we are to understand clearly what is being measured, monitor 

trends consistently, and compare similar events, terms must be 

well-defined and understood by everyone involved in the 

surveillance activities. The World Health Organization (WHO), 

in collaboration with the official vital registration groups from 

the member countries, periodically develops and publishes a 

revision of the International Classification of Diseases,

6 which is 

used throughout the world to classify causes of death. The term 

traditionally used, including in the United States, to describe 

deaths caused by pregnancy is maternal mortality, defined in the 

International Classification of Diseases Ninth Revision (ICD-9)6 

as “the death of a woman while pregnant or within 42 days of 

termination of pregnancy, irrespective of the duration and site 

of the pregnancy, from any cause related to or aggravated by 

pregnancy or its management but not from accidental or 

incidental causes.” This definition is used by the Centers for 

Disease Control and Prevention’s (CDC’s) National Center for 

Health Statistics7 in its calculations of, and official publications 

on, maternal mortality statistics for the United States. 

In 1986, the American College of Obstetricians and 

Gynecologists (ACOG)/CDC Maternal Mortality Study Group 

developed new terms, to expand those in ICD-9 (Table 1). 

These terms are— 

■	 Pregnancy-associated death. The death of a woman while 

pregnant or within 1 year of termination of pregnancy, 

irrespective of cause. 

■	 Pregnancy-related death. The death of a woman while 

pregnant or within 1 year of termination of pregnancy, 

irrespective of the duration and site of the pregnancy, from 

any cause related to or aggravated by her pregnancy or its 

management, but not from accidental or incidental causes. 

Two sets of terms* 

Having two sets of definitions and 

terms can be confusing. However, 

each set has a different purpose. 

ICD terms 

■	 Used by many nations, so they 

require coding conventions to be 

applied in a comparable fashion. 

■	 Used to monitor trends and 

make comparisons. 

■	 Only cause-of-death data from 

death certificates can be used to 

identify deaths that meet ICD 

definitions. 

ACOG/CDC terms 

■	 Used by individual states or 

cities. 

■	 Used to identify deaths for 

review and action. 

■	 A variety of data sources, 

including vital records and 

hospital data, can be used to 

identify deaths that meet 

ACOG/CDC definitions. 

* 	 See Table 1 for definitions of ICD and 

ACOG/CDC terms. 

Box 1 

5 
Strategies to Reduce Pregnancy-Related Deaths 

■	 Not-pregnancy-related death. The death of a woman while 

pregnant or within 1 year of termination of pregnancy, due 

to a cause unrelated to pregnancy (Figure 1). 

These terms improve surveillance in several ways: 

■	 They help identify deaths caused by pregnancy by 

promoting the idea of first identifying deaths with a 

temporal relationship to pregnancy (pregnancy-associated 

deaths) as a group from which to find those deaths caused 

by pregnancy (pregnancy-related deaths). 

■	 Including deaths caused by pregnancy but which occurred 

more than 42 days after pregnancy ended (increasingly 

common with improved medical care) gives a more 

complete picture of the effect of pregnancy on mortality. 

■	 Since pregnancy is usually a time when women are in close 

contact with the health care system, some regard all 

pregnancy-associated deaths as ones that the health care 

system—especially professionals involved in prenatal care— 

should have an interest in and could have an effect on. 

Pregnancy-associated deaths 

(deaths during or within a year after 

pregnancy from any cause) 

Pregnancy-related 

Not-pregnancy-related 

Figure 1 

ICD-10,8 which was published in 

1992, has been used in the United 

States to code deaths since 2000 

(beginning with 1999 data). ICD-10


kept the term maternal mortality and


added two new terms (Table 1). The


first new term is late maternal death,


which refers to deaths caused by


pregnancy that occurred from 43


days to 1 year postpartum. The


second new term added is pregnancy-


related death: ICD-10 uses pregnancy-


related to refer to deaths from any


cause during or within 42 days of


pregnancy; however, according to the


ACOG/CDC definitions, these deaths


are pregnancy-associated deaths that


occurred during or within 42 days


after pregnancy.


Similar terms with different


meanings cause confusion. In this


manual, we will use the ACOG/CDC Table 1


Maternal Mortality Study Group


Definitions of death in relation to pregnancy* 

Source of definition 

ACOG/CDC† ICD-9‡ ICD-10§ 

When death and pregnancy 

are causally related: 

■ Death during pregnancy or 

within 42 days postpartum. 

■ Death 43–365 days 

postpartum. 

When death and pregnancy 

are not causally related: 

■ Death during pregnancy or 

within 365 days postpartum. 

When death and pregnancy 

may or may not be causally 

related: 

■ Death during pregnancy or 

within 42 days postpartum. 

■ Death 43–365 days 

postpartum. 

Pregnancy-related 

death 

Pregnancy-related 

death 

Not pregnancyrelated death 

Pregnancyassociated death 

Pregnancyassociated death 

Maternal 

death 

Not defined 

Not defined 

Not defined 

Not defined 

Maternal 

death 

Late maternal 

death 

Not defined 

Pregnancyrelated death 

Not defined 

* Adapted from Atrash et al.9 

† American College of Obstetricians and Gynecologists/Centers for Disease Control 

Maternal Mortality Study Group. 

‡ WHO 1997.6 

§ WHO 1992.8 

terms, as defined on page 5 (see also Table 1). 

6 
3 Classifying a Woman’s Death 


in Relation to Pregnancy


The first step in identifying pregnancy-related deaths 

is to find all pregnancy-associated deaths (deaths that occurred 

during or within a year after pregnancy) to establish the 

pool from which to identify pregnancy-related deaths. Next 

categorize pregnancy-associated deaths into those that are 

pregnancy-related and those that are not pregnancy-related. 

To decide whether a woman’s death is pregnancy-related, ask 

this question: 

If she had not been pregnant, 

would she have died? 

In most cases, the answer is straightforward. 

Pregnancy-related deaths are caused by one of the following: 

■ Complications of the pregnancy itself. 

■ A chain of events initiated by the pregnancy. 

■	 The aggravation of an unrelated condition or event by the 

physiologic effects of pregnancy. 

Each death must be considered individually. To determine if a 

woman would have died if she had not been pregnant, look at 

the cause, the pathologic process leading to the death, and the 

timing of the death with respect to pregnancy. The experience 

of states shows that the classification of most deaths is clear. 

In most cases, an experienced clinician can review the death 

certificate and any associated birth or fetal death certificate 

and determine if the death was pregnancy-related or not. In a 

few cases, determining the relationship to pregnancy requires 

additional information (see “Other sources of information,” 

page 21) and expert knowledge of the medical and non-medical 

factors surrounding the death. 

7 
Strategies to Reduce Pregnancy-Related Deaths 

The following three questions are helpful for determining the 

causal relationship between pregnancy and death: 

■	 Is the condition or procedure that caused death unique to 

pregnancy? 

■	 Is the condition that caused death more likely to occur during 

or to be exacerbated by pregnancy? 

■	 What is the temporal relationship between the pregnancy, the 

condition, and death? 

Each question is discussed in detail below: 

1. Is the condition or procedure that caused death unique 

to pregnancy? 

Deaths caused by conditions and procedures unique to 

pregnancy are, by definition, causally related to pregnancy 

and should therefore be classified as pregnancy-related. 

Examples of such conditions are hypertensive disorders 

of pregnancy, including preeclampsia and eclampsia; 

hyperemesis; amniotic fluid embolism; and placental 

conditions such as placenta previa, placenta abruption, 

and retained placenta. Likewise, deaths from complications 

of ectopic or molar pregnancy, abortion, or cesarean delivery 

are pregnancy-related. 

For deaths due to conditions that are not unique to 

pregnancy, the next questions need to be asked to establish 

if the condition that caused death is one that is affected by 

pregnancy and if the timing of the condition, pregnancy, 

and death indicate causality. 

2. Is the condition that caused death more likely to occur 

during or to be exacerbated by pregnancy? 

Some conditions are more common, worsen, or are more 

serious when a woman is pregnant or postpartum. Examples 

include many types of cardiac disease; hypertension; 

hematologic conditions (especially sickle cell disease, 

sickle-C, and sickle-beta thalassemia disease); immune 

thrombocytopenic purpura (ITP); diabetes mellitus; 

intracranial hemorrhage; pneumonia; bacterial infections; 

varicella; urinary tract infections; cirrhosis; gall bladder 

disease; systemic lupus erythematosus; and ulcerative colitis. 

In cases of deaths from these conditions during or after 

pregnancy, answer question 3 to determine if the death is 

pregnancy-related. 

8 
3. Classifying a Woman’s Death in Relation to Pregnancy 

For other medical conditions, such as epilepsy and asthma, 

the effect of pregnancy is variable. Pregnancy may exacerbate 

the condition in some women, have no effect in others, and 

actually improve the condition in still other women. This 

makes determining the causal effect of pregnancy on a death 

more complex. 

For still other conditions, pregnancy does not appear to affect 

the risk of mortality: for example, cancer, HIV/AIDS, chronic 

glomerulonephritis (unless there is severe superimposed 

preeclampsia or abruptio placentae), sarcoidosis (unless 

there is extensive pulmonary involvement), and acute viral 

hepatitis (except for hepatitis E). 

3. What is the temporal relationship between the pregnancy, 

the condition, and death? 

When evaluating the causal relationship between a condition 

and pregnancy, consider the temporal relationship between 

events, including both the absolute amount of time elapsed 

between pregnancy and death as well as the sequence and 

timing of the events leading to death. 

The anatomic and physiologic effects of pregnancy vary 

by period of gestation and amount of time elapsed since 

delivery. The traditional definition of a maternal death as 

one that occurs during or within 42 days of delivery can 

be a helpful starting point in many cases. Although the 

relationship between pregnancy and the function of organ 

systems has not been exhaustively studied, most experts 

believe that the effects of pregnancy on many systems 

(e.g., the cardiac system) have resolved by 6 weeks postpartum 

(i.e., these systems have returned to their prepregnancy state). 

The anatomic effects of pregnancy on the lungs begin to 

resolve as soon as the uterus is emptied, although effects from 

surgery and anesthesia may last longer. Therefore, a death 

from pneumonia or epilepsy that occurs the day after delivery 

would be considered pregnancy-related; deaths from those 

conditions 6 or 11 months after delivery would not if the 

woman had otherwise been well during the intervening time. 

It is possible for a pathologic process to begin during 

pregnancy or the puerperium and continue for months, 

ultimately leading to death. Therefore, it is important to 

establish whether a condition that began during pregnancy 

or the postpartum period became progressively worse, or 

whether the woman recovered but later developed a 

recurrence after the effects of pregnancy were gone. For 

9 
Strategies to Reduce Pregnancy-Related Deaths 

example, during pregnancy a woman with systemic lupus 

erythematosus may develop renal failure with an unremitting 

course that ends in death months after delivery. However, 

she may also give birth, have no sequelae from the pregnancy 

and—months later—develop a complication of lupus and 

die. The first example is pregnancy-related, and the second 

is not pregnancy-related. Similarly, a woman may develop 

a condition such as adult respiratory distress syndrome 

(ARDS) after a hemorrhage and be on a ventilator for 

months before dying of pneumonia. Women who have 

severe complications from anesthesia and who are in a 

coma may die months after the actual procedure; however, 

if the causal chain of events began with the pregnancy, the 

death is pregnancy-related. 

Cases where causal relationship 

may be unclear 

Determining the causal relationship between pregnancy and 

death is usually straightforward, although for some causes of 

death the relationship to pregnancy may be more difficult to 

determine. In such situations, it is important to have experts 

in a variety of areas on the review committee to help evaluate 

such cases. 

■	 Deaths from infection 

The contribution of pregnancy to a death from infection, 

particularly during the postpartum period, can be difficult 

to determine. Scientific data are unclear about the effect of 

pregnancy on the immune system. Although overall immune 

function during pregnancy is largely intact, there is some 

evidence of decreased cell-mediated immunity and of 

increased susceptibility to, and severity of, some infections. 

These include influenza10 and varicella. Most researchers find 

that pregnancy does not increase the likelihood of dying for 

women with HIV.

11 Even if they occur during or within 

a year after pregnancy, deaths that would have occurred 

even without pregnancy, such as those from HIV, are not 

pregnancy-related because there is no causal relationship. 

■	 Deaths from injuries 

All women are at risk of death from injuries, both intentional 

and unintentional. Indeed injuries are the major cause of 

death for women of reproductive age.12 Deaths from injuries 

that occur during pregnancy or in the postpartum period 

may be pregnancy-related or not pregnancy-related. Severe 

Three case studies 

A. A 20-year-old female G2P1 

with sickle cell anemia has 

an acute sickle crisis at 28 

weeks gestation and dies on 

the second postpartum day. 

Is this death causally related 

to pregnancy? 

Yes. 

B. A 20-year-old female G2P1 

with sickle cell anemia has 

an acute sickle crisis at 28 

weeks gestation and suffers 

a cardio-respiratory arrest 

during delivery. She is 

resuscitated and placed on 

life support. She survives 

for 4 months but eventually 

becomes septic and dies. 

Is this death causally related 

to pregnancy? 

Yes. 

C. A 20-year-old female G2P1 

with sickle cell anemia gives 

birth to a healthy baby girl 

at 37 weeks gestation. Eight 

months later she develops 

an acute sickle crisis and 

dies. 

Is this death causally related 

to pregnancy? 

No. 

10 
3. Classifying a Woman’s Death in Relation to Pregnancy 

postpartum depression, which affects about 1–2 per 1,000 

women after childbirth,13 may lead to suicide; such a death 

would obviously be pregnancy-related. Homicide may or 

may not be causally related to pregnancy, depending on the 

circumstances of the death. The prevalence of intimate 

partner violence against pregnant women does not appear 

to be higher than that against nonpregnant women;14 overall, 

the mortality rate due to homicide is not elevated in the 

postpartum period.15,16 Pregnancy-associated deaths due 

to homicide need to be reviewed for a possible causal 

relationship to pregnancy, just as deaths due to other causes 

not unique to pregnancy need such a review. These reviews 

will almost always require information beyond that found 

in vital records. 

Motor vehicle-related injuries are a significant cause of death 

for all women of reproductive age: nonpregnant, pregnant, 

and postpartum. In some cases, the causal relationship with 

pregnancy is clear (e.g., amniotic fluid embolus or abruptio 

placentae resulting from a motor vehicle-related injury). In 

other cases, anatomic or physiologic changes caused by 

pregnancy may have made a woman more prone to injury 

and resultant death. For example, a woman who normally 

wears a seat belt may not do so when pregnant She may be 

misinformed about the need to do so or not know the proper 

way to wear it when pregnant, particularly during the last 

trimester. 

However, in many cases, particularly those that occur 

postpartum, injury-associated deaths may be causally 

unrelated to pregnancy, especially deaths from motor 

vehicle-related injuries. One-third of adult Americans 

do not routinely wear a sear belt,17 and the decision by a 

pregnant woman not to use a seat belt may be unrelated to 

pregnancy. In addition, several studies indicate that, overall, 

pregnant and postpartum women may actually have a lower 

risk than nonpregnant women of death from unintentional 

injury for reasons that are not yet clear.

15,16 Including injuryrelated deaths that are not pregnancy-related will falsely 

increase the pregnancy-related mortality estimate and make 

comparisons and analysis of trends difficult. 

During pregnancy, women are in frequent and close contact 

with the health care system. Providers should be educated about 

1) the possibility of intimate partner violence and the need for 

appropriate referrals in such cases, and 2) the need to explain 

the proper use of a seatbelt during pregnancy. Many injuryrelated deaths are preventable with appropriate interventions. 

Injury-related death and 

pregnancy 

Deaths from injuries during 

pregnancy or the year after 

pregnancy may be pregnancyrelated or not-pregnancyrelated. To determine which, 

answer two questions: 

■ Was the death the result of 

“a chain of events initiated 

by pregnancy”? 

■ If the woman had not been 

pregnant, would she have 

died? 

Pregnancy-associated 

deaths 

This manual focuses on 

pregnancy-related deaths 

(i.e., deaths that would not 

have happened if the woman 

had not been pregnant). 

In recent years many groups 

have become interested in the 

larger group of pregnancyassociated deaths, about threequarters of which are not 

causally related to pregnancy. 

Because pregnancy is a unique 

time, usually one with close 

association between a woman 

and her health care provider, 

many researchers believe it 

should be a key intervention 

point to reduce other causes 

of mortality. 

11 
4 Identifying Cases


The first challenge in pregnancy mortality surveillance is 

to find all cases of pregnancy-related death. Pregnancy-related 

mortality is a clinical definition. Unlike infant mortality rates, 

which include all infants who die before the age of 1 year, 

pregnancy-related mortality calculations do not include all 

pregnant women who die. To determine whether a woman’s 

death is pregnancy-related, one must first know both the 

temporal and causal relationship between pregnancy and 

the death. 

Several studies show that routine methods of identifying 

pregnancy-related deaths underestimate the number by one-half 

to two-thirds.1,18 Because deaths identified by routine methods 

may differ from those less easily found, it is important to try to 

find all pregnancy-related deaths in order to have a complete 

and accurate picture of the scope of the problem, to monitor 

trends, and to determine the characteristics of women at risk 

(see Chapter 6 “Analyzing and Interpreting the Findings”). 

Currently, no single source of information captures all 

pregnancy-related deaths, despite all deaths and essentially 

all live births in the United States being registered by Vital 

Statistics. Several reasons account for this failure: 

■	 Lack of physician training in, or knowledge about, how 

to fill out a death certificate. 

■	 ICD coding rules that make the cause-of-death code on 

a death certificate fall outside the range of conditions 

considered to be pregnancy-related (in ICD-9, those 

codes are 630–676; in ICD-10, chapter O). 

■ Reliance on death certificate data to estimate cause of death. 

■	 Medical records that fail to indicate that the events leading to 

death began with pregnancy, especially if the death occurred 

during the postpartum period. 

■	 Medical and autopsy records that cannot be located or are 

not available for review. 

Goal of pregnancy 

mortality surveillance 

The goal of pregnancy 

mortality surveillance is to 

find and review deaths caused 

by pregnancy in order to 

understand what happened 

and learn how to decrease 

such deaths in the future. 

Thus, a pregnancy mortality 

surveillance system tries to 

identify all deaths caused by 

pregnancy. This is a related but 

separate undertaking from 

identifying deaths at a national 

level that meet the National 

Center for Health Statistics 

(NCHS) criteria for maternal 

deaths. However, as discussed 

in Chapter 2 “Definition of 

Terms,” each system has a 

different purpose and use. 

13 
Strategies to Reduce Pregnancy-Related Deaths 

To increase case identification, one should start by trying to 

find all possible pregnancy-associated deaths. This establishes 

a pool from which pregnancy-related deaths can be identified. 

After establishing the cause of death by reviewing the death 

certificate and (where necessary) other data, one can then 

divide the pregnancy-associated deaths into those that are 

pregnancy-related and those that are not pregnancyrelated (Figure 1). 

The pregnancy-associated deaths easiest to find are those that 

occur after the birth of a live infant. This is done by linking 

computerized death and birth records; some states also link 

death and fetal death certificates. When death records are 

linked to birth records, about one-quarter to one-third of 

the post-delivery deaths identified are found to be pregnancyrelated.15,19 

Each source used for identifying deaths can capture deaths 

with different characteristics. Each source also requires specific 

resources, such as personnel, computer time, and legal access 

to the data. Some of the states most successful at identifying 

pregnancy-related deaths have been those with active maternal 

mortality review committees that encourage clinicians to report 

such deaths to the committee or its chair. Sources of pregnancyrelated deaths are listed below in order of simplicity and 

convenience: 

■	 Death certificate cause-of-death codes—the core source 

for finding cases. 

■ Manual review of death certificates. 

■ Pregnancy check boxes on death certificates. 

■ Computerized linkages of vital records. 

■ Other computerized data sources. 

■ Obstetricians, other clinicians, and groups. 

■ The news media. 

■ Autopsy and medical records. 

Using multiple sources 

of information 

We strongly recommend 

using multiple sources of 

information to identify deaths. 

However, reviewing records 

(e.g., medical and autopsy 

records of all deaths of women 

of reproductive age) for 

case identification is labor 

intensive and not feasible for 

routine use. Such a method is 

used to identify cases only for 

special projects. 

On the other hand, for the 

review process, obtaining and 

reviewing records of alreadyidentified pregnancy-related 

deaths is necessary for verifying 

the cause of death and 

understanding the medical 

events that led to the death. 

14 
4. Identifying Cases 

Cause-of-death codes on 

death certificates 

Vital records are always the first source of pregnancy-related 

deaths. Part I of the cause-of-death section on the death 

certificate has four lines on which the immediate and underlying 

causes of death are recorded (Figure 2). 

Cause-of-death section on a death certificate 

Figure 2 

In ICD-9, the codes for the conditions leading to maternal 

deaths are 630 through 676.9. However, relying solely on these 

codes identified only about one-third of pregnancy-related 

deaths.18 In addition, ICD-9 codes pertaining to maternal death 

could be used only when the death occurred during pregnancy 

or within 42 days postpartum. Therefore, deaths that occurred 

43 through 365 days postpartum were not coded in this range. 

However, the percentage of pregnancy-related deaths that occur 

more than 42 days postpartum is only between 5% and 10% 

of all pregnancy-related deaths.1 Therefore, failure to identify 

pregnancy-related deaths occurring more than 42 days 

postpartum is not the major reason for the under-ascertainment 

of pregnancy-related deaths when vital records are used as the 

only data source. 

ICD-10 has a single cause-of-death code for late maternal death. 

Deaths that are caused by a complication of pregnancy and 

occur from 43 through 365 days after the end of pregnancy 

15 
Strategies to Reduce Pregnancy-Related Deaths 

receive this code as the immediate cause of death. Thus, all late 

maternal deaths are recorded as having the same immediate 

cause, regardless of the pathologic process that led to the death. 

To identify the underlying causes of death when using the 

national vital statistics mortality tapes, the multiple cause-ofdeath files must be used. However, using the maternal and late 

maternal death codes will identify the pregnancy-related deaths. 

How clinicians record causes of death on death certificates can 

sometimes lead to deaths not being identified as pregnancyrelated. Clinicians may not indicate that pregnancy was a factor 

in the death; for example, death might occur after a long series 

of complications, and the role of pregnancy in initiating the 

causal pathway is lost or forgotten. In other cases, clinicians 

might use general terms, such as hemorrhage or sepsis, and 

not specify the uniqueness and relationship to pregnancy, 

such as ectopic pregnancy or chorioamnionitis (Box 2). 

There are also specific rules governing coding of causes of death 

that may leave the coder (nosologist) unable to assign a code 

that indicates a relationship to pregnancy. Unfortunately, 

physicians are rarely trained in these rules or in the correct way 

to complete vital records (Box 2). “Instructions for Completing 

the Cause-of-Death Section of the Death Certificate,” a two-page 

guide published by NCHS, provides help for this important 

activity. The document is available on the Internet at 

http://www.cdc.gov/nchs/about/major/dvs/handbk.htm 

or laminated copies may be obtained by calling NCHS at 

301-458-4636 (Appendix A). 

Manual review of death certificates 

Because of issues surrounding the reliance on computerized 

cause-of-death codes discussed above, manual review of death 

certificates is strongly recommended. Manual review of death 

certificates of women of reproductive age allows the reviewer to 

read notes in the margin, which may be the only indication that 

the woman was pregnant or postpartum (Box 2). Manual review 

is also helpful for finding pregnancy-related deaths when coding 

conventions were not followed by the certifier, such as when 

more than one condition is listed on a line (Box 2) or when 

pregnancy key words are not indicated in Part I of the causeof-death section on the death certificate. 

Cause-of-death codes are 

not always reliable 

Discovered during a manual 

review of death certificates 

was one certificate that listed 

the cause of death and the 

ICD-9 codes as follows: 

cardiorespiratory arrest (427.5) 

secondary to hypovolemic 

shock (785.59) secondary to 

hemorrhage (459). This death 

would not be classified as a 

maternal death on the basis of 

ICD-9 codes. However, uncoded 

but written in the margin of the 

certificate was the following: 

“ruptured right tubal 

pregnancy.” 

A clinician certifying a death 

wrote “Cardiorespiratory arrest 

secondary to amniotic fluid 

embolus” across the first causeof-death line on the death 

certificate. Because coders are 

allowed to code only the first 

item on the line, the amniotic 

fluid embolus could not be 

indicated as the cause of death. 

In the space denoting the 

time between the onset of a 

condition and death (Figure 2), 

a clinician indicated death as 

having occurred 6 months after 

pregnancy, although the death 

actually occurred during the 6th 

month of pregnancy. Therefore, 

a pregnancy code was not 

assigned as the cause of death. 

Box 2 

16 
4. Identifying Cases 

However, even a careful review of death certificates cannot 

ascertain all cases. The certifier may focus on specific diagnoses 

or may fail to indicate a relationship to pregnancy because the 

events surrounding the actual death were so complex that events 

earlier in the causal chain are not mentioned. In other instances, 

pregnancy may not be documented because the family or 

clinician did not wish to indicate the woman’s pregnancy status. 

Some deaths that occur early in pregnancy may not be identified 

as pregnancy-related because the woman, her family, or her 

health care providers were unaware of the pregnancy. 

Check box indicating pregnancy on 

death certificates 

A 1998 review found that death certificates for 16 states and 

New York City had check boxes or specific questions asking 

the certifier whether decedent had been pregnant within a 

specific period prior to death19 (Appendix B). Having a check 

box to indicate pregnancy on the death certificate improves 

identification of pregnancy-associated deaths (Table 2). 

However, determining the causal relationship between the 

death and pregnancy may require review of additional 

information. In some instances, a check box does not help 

in identifying pregnancy-associated deaths; for example, 

sometimes the certifier neglects to mark the check box; other 

times, the check box is marked when the decedent was not 

pregnant (e.g., on a man’s death certificate). 

Effect of pregnancy check-box on death certificates on the identification 

of pregnancy-related deaths 

Number of deaths Maternal mortality ratio 

Code only Code and box Code only Code and box Percentage increase 

Puerto Rico 13 22 19.5 33 69 

1989 

Texas 27 58 115 

1991 

Table 2 

17 
Strategies to Reduce Pregnancy-Related Deaths 

The time between death and pregnancy indicated by the check 

box varies from state to state: 42 days, 90 days, 6 months, 1 year, 

or 18 months. Under ICD-9, if the time indicated by the check 

box is greater than 42 days—the cut-off for maternal death 

under ICD-9—the check box indication of pregnancy cannot 

be taken into account in assigning a cause-of-death code. 

The United States is in the process of revising its Standard 

Certificate of Death, which will include a series of check boxes 

for pregnancy (Appendix C). The intervals between pregnancy 

and death will be consistent with the ICD-10 maternal mortality 

definitions put into use in 2000. The standard certificate, which 

will serve as a model for the states when they develop new death 

certificates, is now being reviewed. It is anticipated that the new 

standard certificate will be in use by the states in 2003 or 2004. 

This change could greatly increase the use of a pregnancy check 

box and also alleviate the confusion over the use of different 

intervals between pregnancy and death. 

Linking vital records 

Death certificates for reproductive-aged women who die can 

be linked with certificates of reportable pregnancy outcomes 

(live births and fetal deaths) that occurred during the preceding 

year. Although many states require that induced abortions be 

reported, only one includes on its records identifying data that 

could be used to link those records with other computerized 

records. Linking data sets is being done in an increasing number 

of states, and published reports indicate that such links can 

increase case ascertainment by 36% to 153% (Table 3, Box 3). 

However, linking vital records cannot ensure that all pregnancyrelated deaths will be identified, since only about two-thirds to 

three-quarters of pregnancy-related deaths are associated with 

either a live birth or a fetal death. Excluded from linkages would 

be deaths associated with ectopic pregnancies, induced and 

some spontaneous abortions, gestational trophoblastic disease, 

and undelivered pregnancies. 

The method used to link vital records (death certificates 

of women of reproductive age, birth certificates, and fetal 

death certificates) and to link death certificates with other 

computerized data bases depends on the data for consistency 

elements in each data base. Some data sets may contain social 

security numbers, which should be unique identifiers but are 

Effect of linking birth 

and death certificates 

When birth certificates were 

linked to death certificates 

for a state-based analysis, 

the number of identified 

pregnancy-related deaths 

due to embolism, infection, 

cardiomyopathy and other 

causes increased substantially. 

If ICD-9 codes 630–676.9 

had been used for the same 

deaths, 89% of the deaths from 

hemorrhage would have been 

found, but 35% to 45% of 

the deaths due to infection, 

anesthesia, cardiomyopathy, 

and other medical conditions 

would have been missed20 

(see also Table 3). 

Box 3 

18 
4. Identifying Cases 

frequently not recorded accurately or are missing.

21,22 Some 

states may strip identifiers (e.g., name, date of birth, and social 

security number) off certain data sets or restrict the use of 

computer files to certain uses or personnel. 

Effect of linking vital records on the identification of pregnancy-related deaths 

Number of deaths Maternal mortality ratio 

Type of 

records With Without With Percentage 

State Years linked* linkage linkage linkage linkage increase 

Washington 1977-84 LB & FD 34 57 6.8 10.9 68 

West Virginia 1985-89 LB 7 16 5.4 12.4 129 

North Carolina 1988-89 LB & FD 19 48 9.5 24 153 

Georgia 1990-92 LB 56 73 16.8 21.9 30 

* Records linked with death certificates of women of reproductive age: LB = live birth; FD = fetal death. 

Without 

Table 3 

States that want to link vital records have two options: 

■	 Use commercially available software specifically designed 

to link records. 

■	 Create custom software using common computer languages 

for consistency or data base systems. If simple matching rules 

are used, the programming is relatively straightforward; for 

complicated probabilistic linkages, more sophisticated 

programming would be required. 

After the original linkage algorithm and programming are 

established, the process can be repeated in later years with 

minimal resources. One state health department statistician 

estimates that—with its system—linking a year’s worth of 

data takes about 5 hours. 

An example of a deterministic scoring system, containing 10 

variables, that Tennessee used to link death files with live birth 

and fetal death files is in Table 4. Exact matches, partial matches, 

and non-matches each received different scores, which were then 

added together to determine if two records were a match. 

19 
Strategies to Reduce Pregnancy-Related Deaths 

Variables used to link death, birth, and fetal death 

certificates in a Tennessee study and scores assigned for 

levels of matching* 

Variable 

Points credited 

Exact match Partial match Mismatch 

Date of birth 

Area of state 

County of residence 

Race 

Current surname 

Maiden surname 

First name 

Address 

State of birth 

Marital status 

Reversal of maiden 

name and surname 

Date of delivery versus 

date of death 

5 

0 

0 

0 

2-8 

2-8 

2-8 

4 

0 

0 

0 

0 

3 

0 

0 

0 

1-4 

1-4 

1-4 

1-3 

0 

0 

0 

0 

-3 

-3 

-1 

-3 

-3 

-3 

-2 

-1 

-1 

-1 

-3 

-4 

* A score of 13 points or greater indicated a potential match.21 

Table 4 

Searches of other computerized data 

sources to identify deaths of women of 

reproductive age 

As more and more medical, program, and administrative data 

bases are computerized, the ability to identify deaths of women 

of reproductive age and thus pregnancy-related deaths increases. 

State-based hospital discharge data can be linked with death 

certificates or searched for cases with diagnostic or procedure 

codes that indicate pregnancy and discharge codes that indicate 

death. Medicaid prenatal care files or WIC files can also be 

linked with death files, if sufficient data are available. Linking 

these types of records allows identification of women who 

died before delivery or whose deaths were associated with other 

pregnancy outcomes besides live births or fetal deaths. Hospital 

computerized systems with data on hospital discharges 

(including vital status at discharge) and reliable information 

on diagnoses and procedures could be used to screen for 

pregnancy-related deaths. 

20 
4. Identifying Cases 

Other sources of information 

Resourcefulness can uncover numerous other ways to identify 

pregnancy-related deaths. Here are some suggestions: 

■	 Contact hospital maternal mortality review committees and 

hospital quality assurance coordinators and request their 

reports. 

■	 Ask hospitals or labor and delivery services to review any 

lists of deaths they maintain. 

■	 Send letters periodically to the heads of delivery rooms, 

emergency departments, police departments, and Emergency 

Medical Teams. 

■ Scrutinize newspaper obituaries. 

■ Scan newspapers for reports of women’s deaths. 

■	 Search data bases, such as Lexis Nexis, which has abstracts 

from hundreds of newspapers and magazines, for 

information on deaths that may be pregnancy-related. 

■	 Scan medical journals for case reports involving deaths of 

reproductive-aged women. 

■	 Examine court records and data bases of court records (e.g., 

those in Lexis Nexis); pregnancy-related deaths may involve a 

lawsuit, and depositions are in the public record. 

Autopsy record review 

Reviewing medical examiners’ (MEs) and coroners’ records and 

autopsy records is another method of identifying pregnancyrelated deaths. Not all women who die are autopsied; however, 

if available, autopsy records provide an accurate and detailed 

picture of the cause of death. Since these records are usually not 

computerized, it is helpful to have a prospective agreement with 

MEs and coroners that they notify surveillance staff of any 

deaths of women of reproductive age. 

Medical record review 

The gold standard for identifying pregnancy-related deaths 

is the Reproductive Age Mortality Study (RAMOS), which 

involves reviewing the medical records of physicians, clinics, 

and hospitals on all women who died from age 10 through 50. 

21 
Strategies to Reduce Pregnancy-Related Deaths 

This method should find all pregnancy-related deaths. Such a 

review in France in 1989 more than doubled the number of 

maternal deaths found in that country.

18 However, as a method 

of case identification,a RAMOS is used only for special periodic 

surveys, not for routine surveillance. Once a death is identified 

as possibly pregnancy-related, medical records provide crucial 

information on the cause of death, whether it was pregnancyrelated, and the medical factors that contributed to the death 

(see Chapter 5 “Reviewing Pregnancy-Related Deaths”). 

A less costly “silver” version of a RAMOS could be used to 

identify pregnancy-related deaths through a review of medical 

and autopsy records of selected deaths with causes likely to 

be associated with pregnancy (e.g., deaths from hemorrhage, 

embolism, or sepsis). Deaths from causes such as motor 

vehicle-related injuries and cancer would not be reviewed. 

Computerized records of hospital discharges with information 

on diagnoses, procedures, and discharge status could be used 

for this purpose, as well as records of deaths in hospitals with 

age, sex, and cause of death. 

22 
5 Reviewing Pregnancy-


Related Deaths 


During the early and middle part of the 20th century, 

most states had maternal mortality review processes. As 

pregnancy-related mortality decreased and fear of professional 

liability suits increased during the past few decades, many states 

disbanded their committees. In the 1990s, however, many states 

began to reactivate them. 

The purpose of reviewing pregnancy-related deaths is to gain 

insight into the medical and social factors that lead to such 

events in order to decrease such deaths in the future. In this 

manual we focus on pregnancy-related mortality review at the 

state level—although maternal mortality reviews are sometimes 

conducted by hospital-based peer-review committees that 

focus strictly on medical events leading to the death (Box 4). 

The pregnancy-mortality review process needs to include nonmedical as well as medical causes underlying the death. Some 

states take a systems approach to identifying ways of reducing 

pregnancy-related deaths. This approach includes looking for 

problems with the health care system as a whole—including 

the public health system—and not merely at individuals or 

individual practices. 

One useful way to assess systemic problems that contribute 

to maternal deaths is to look at the barriers women face 

when they need health care. WHO developed a framework 

for assessing the situation in developing countries.23 This 

framework outlines three barriers to optimal health care: 

■	 The first level occurs when a woman or her family either does 

not recognize there is a health problem or fails to seek health 

care when a problem is recognized. Examples of these barriers 

include 1) a lack of knowledge or understanding of normal 

pregnancy and the signs and symptoms of pregnancy 

complications and 2) making a decision not to seek care 

due to lack of comfort with a health care system perceived 

as not culturally appropriate. 

23 
Strategies to Reduce Pregnancy-Related Deaths 

■	 The second level of barriers occurs when a woman 

has difficulty reaching health care once she 

or her family has decided to seek 

care. Examples of these types of 

barriers include affordability issues, 

problems with transportation, and 

availability of appointments at local 

facilities. 

■	 The third level pertains to quality 

of care and includes problems in 

receiving timely and appropriate care 

once health care has been accessed. 

Traditionally, maternal death review 

concentrated on issues at the third level. 

However, looking at more than just 

clinical factors reinforces that the 

purpose of mortality review is not to 

focus solely on the clinical aspects of care 

but to find ways to reduce such deaths 

by actions at all levels of the health care 

system, including interventions at the 

community level. 

Understanding the medical factors 

that contribute to each death is 

accomplished by reviewing medical 

records and, if appropriate, interviewing 

health care providers. The non-medical, 

social, or community factors may be 

assessed by collecting information from 

social services records, interviews with 

care providers, and, where appropriate, 

people who knew the deceased, such 

as the woman’s partner and family. 

Pregnancy mortality review should 

be anonymous, confidential, and 

nonjudgmental. The findings should not 

result in disciplinary action. Reviews of 

Types of review committees 

Expert review committees 

Function: 

To identify the most effective means of reducing 

morbidity and mortality. 

Members: 

Usually physicians and other professionals with 

expertise in the area of health being reviewed. 

Features: 

■	 Usually operate at the state level (e.g., as a standing 

committee of the state medical society that 

cooperates with the state health department). 

■ Are not used for disciplinary purposes. 

■	 Do not need to know names of patients or 

physicians. 

■	 Do not review the qualifications of the health care 

provider. 

Peer review committees 

Function: 

To evaluate medical treatment to ensure the quality of 

the care provided. 

Members: 

Usually physicians, nurses, and administrators. 

Features: 

■ Usually operate at the local level (e.g., at a particular 

hospital) but sometimes operate at the state level. 

■ Are often used for disciplinary purposes. 

■ Review the qualifications of health care providers. 

■	 Results of reviews are often used to enforce 

improved medical practice and evaluate costs of 

medical care. 

Box 4 

relevant state laws, first done in 198924 and updated by ACOG in 

2000 (Appendix D), have shown that—in most states—statutes 

protect the reports, proceedings, and findings of the review 

committee from being used (discovered or admitted into 

24 
5. Reviewing Pregnancy-Related Deaths 

evidence) in civil lawsuits. Most 

states also have laws that grant the 

participants on expert review panels 

immunity from liability (see “Legal 

Issues,” page 37). 

Maternal mortality 

review committees 

In most cases, the state is the level at 

which pregnancy-related deaths are 

reviewed, although the process can 

occur in some very large cities and 

counties. The legislation that enables 

maternal mortality review and the 

review committee’s place within the 

governmental organization vary 

widely from state to state. The 

committees usually operate within 

state health departments; they 

frequently work in close collaboration 

with the state medical society, state 

obstetric and gynecological society, 

or the state section of ACOG. 

These committees are considered 

expert review committees with no 

authority to take disciplinary action or 

judge the qualifications of health care 

providers. Many hospitals have peerreview maternal mortality committees 

that monitor and assess the medical 

care received by any pregnant woman 

who dies at their facility. The process 

of state-based maternal death review 

described here includes medical and 

non-medical, social, and economic 

factors (such as barriers to health 

care) in addition to health care 

system issues. Hospital-based review 

committees usually do not address 

systems issues that may have 

contributed to the death; nor 

do these local reviews provide 

population-based information. 

Steps in a state-based maternal mortality review 

1. Establish a multidisciplinary maternal mortality review 

committee. 

2. Agree on procedures, schedule, and logistics for 

reviewing deaths. 

3. Review the state laws on immunity and confidentiality 

as they relate to review committees. 

4. Have all committee members and health department 

staff sign an agreement of confidentiality before they 

receive any information on cases. 

5. Identify individuals responsible for each activity 

required for a death review. 

6. Arrange to receive notice of deaths from multiple 

sources, including the state vital statistics office. 

7. Collect relevant information from medical records, 

autopsy reports, social services reports, health care 

providers, and the families of the deceased women 

(when appropriate). 

8. Review all available information on each case and 

synthesize information into case summaries for the 

committee. 

9. Remove identifiers from records, and assign a case 

number. 

10. Disseminate de-identified information to committee 

members before meeting to discuss deaths. 

11. Present cases to the full committee for discussion— 

possibly in consultation with the people involved in the 

care of the patient—to identify medical, non-medical, 

and systems problems. 

12. Determine whether the death was pregnancy-related or 

not. Ascertain the medical and non-medical causes of 

death and any health care systems problems. Determine 

whether the death was preventable and, if so, how. 

13. Recommend steps for preventing similar deaths in the 

future. 

14. Disseminate findings in order to educate medical and 

non-medical personnel, and recommend the system 

changes needed to reduce pregnancy-related deaths. 

15. Facilitate actions based on the recommendations. 

25 
Strategies to Reduce Pregnancy-Related Deaths 

Maternal mortality review should be part of each state’s core 

public health function of assessment. Pregnancy-related death 

identification and review should be a routine component of the 

work of the health department and should not depend on a 

particular individual being interested in such reviews. State 

maternal mortality review committees make important 

contributions to public health by improving the identification 

of pregnancy-related deaths; conducting or overseeing the 

review of these deaths; recommending actions to help prevent 

future deaths; and synthesizing and disseminating the review 

results. 

State-based review is most appropriate for several reasons. 

Review should occur at the level at which decisions can be made 

and resources allocated to reduce pregnancy-related deaths. The 

National Fetal and Infant Mortality Review program (NFIMR), 

carried out jointly by ACOG and the Maternal and Child Health 

Bureau of the Health Resources and Services Administration 

(HRSA), promotes community-based review of fetal and infant 

deaths and was a leader in including both medical and nonmedical factors in the review.

25 However, because pregnancyrelated deaths are relatively uncommon, it is usually more 

appropriate for states to review pregnancy-related deaths than 

for cities or communities to do so. States are more likely to have 

a sufficient number of cases to identify any patterns and to keep 

the proceedings confidential. In addition, states can more easily 

disseminate results, make recommendations, and take action 

to decrease pregnancy-related mortality. 

Function 

Maternal mortality review committees or their staff are 

responsible for collecting the materials relevant to each case, 

preparing the materials for review, and convening meetings to 

review the findings. The review committees or their staff also 

facilitate or obtain the cooperation of state medical societies, 

health departments, and hospitals. Although the procedure 

may vary, committee meetings usually involve presentation 

of the case, discussion of the essential components of the 

case, sometimes consultation with people involved in the care 

of the patient, and the development of recommendations to 

improve the health care system. 

Members 

As the factors to be reviewed expand from the purely medical 

to include social and other factors, so must the experience 

and expertise of review committee members be broadened to 

Pregnancy-related death 

identification and review 

should be a routine 

component of the work of 

the health department and 

should not depend on a 

particular individual being 

interested in such reviews. 

26 
5. Reviewing Pregnancy-Related Deaths 

reflect the scope of the review. Committee membership 

should reflect the diversity of the areas being reviewed and 

provide broad, less traditional insight on maternal death 

prevention. For example, managers of family planning 

programs can increase their understanding of which women 

are at higher risk of maternal death and tailor their programs 

to prevent pregnancy among women who have high-risk 

medical conditions and do not wish to become pregnant. 

Representatives from boards of education may increase their 

awareness of the risks associated with teenaged pregnancy 

and develop programs to reduce such pregnancies. 

Committees may include representatives from various 

disciplines and organizations: 

■	 Medical specialties, including obstetrics and gynecology, 

family practice, internal medicine, anesthesiology, 

neonatology, and pathology. 

■ Nursing and nurse midwifery. 

■ State medical societies. 

■ Public health departments. 

■ State Title V maternal and child health agencies. 

■ State Title X family planning programs. 

■	 Social services programs for women, including programs 

on family planning, women’s health, WIC, intimate partner 

violence, and substance abuse. 

■ Social work. 

■ Nutrition. 

■ Medical examiners and coroners. 

■	 Hospitals, managed care organizations, and other health 

industry organizations. 

■ Education boards. 

■ Clergy and other religious leaders. 

Committee members should be selected as official 

representatives of the leaders of their organizations, rather 

than as individuals from particular disciplines. The goal of 

the surveillance process is action, and leadership structures 

of organizations have greater capacity than individuals to 

take the needed actions to implement changes in policies and 

practices. However, it is helpful to have individual members 

who are knowledgeable about maternal health and interested 

in trying to reduce pregnancy-related mortality. 

27 
Strategies to Reduce Pregnancy-Related Deaths 

Staff requirements 

In states with perinatal care regions, some review functions, 

including medical and non-medical data collection and 

family and care provider interviews, may be delegated to the 

staff of the regional perinatal center. Because the number of 

deaths in each perinatal region is usually relatively small, the 

amount of work required per region should be small enough 

to allow it to be integrated into the activities of the existing 

staff. States may hire health care professionals to abstract case 

data (i.e., review the records) and write case summaries. In 

such instances, the abstractor needs to have the experience 

and expertise to appreciate the critical issues involved in the 

case. Florida’s Department of Health’s Pregnancy-Associated 

Mortality Review (PAMR) estimated that PAMR requires the 

equivalent of one full-time position divided between three 

people: a half-time coordinator, a quarter-time data analyst, 

and a quarter-time clerk. In addition to these designated 

personnel, Florida pays experienced clinical abstractors a 

flat fee to review all medical and social services records and 

to abstract the data, allowing 10 hours per case. (Personal 

communication, A. Phelps, Florida Department of Health, 

2001.) 

Cost 

The cost of conducting maternal mortality reviews depends 

on the existing infrastructure, the number of deaths, and the 

type and amount of information collected. Depending on the 

location in the health department where the review activity is 

situated, secretarial support may be needed for such tasks as 

sending out letters and organizing meetings. Funds will also 

be needed to abstract medical records and de-identify cases. 

Travel costs for committee members are handled in different 

fashions in different states. Some states rely on individuals 

donating their time and traveling at their own expense; other 

states reimburse travel costs and provide a per diem. In New 

Mexico, committee members are not paid but receive 

Continuing Medical Education (CME) credit for their time 

at review meetings. 

28 
5. Reviewing Pregnancy-Related Deaths 

Issues to review 

Every review of a pregnancy-related death should consider the 

range of factors that could have contributed to the death, many 

of which are interrelated: 

Medical (pathologic) cause of death. 

Non-medical (social) causes underlying the death. 

■ Intendedness of pregnancy. 

■	 Woman’s and her family’s knowledge about pregnancy, the 

warning signs of complications, and the need for care. 

■	 Timeliness on the part of the woman in recognizing a 

problem, making decisions, and taking action. 

■	 Accessibility and acceptability of health care (cultural, 

experience, financial, geographic, transportation, logistic). 

■	 Cultural competence and communication skills of health 

care providers. 

■	 Woman’s adherence or non-adherence to medical advice 

and health interventions. 

Quality and content of medical care.


■ Preventive services.


■ Community and patient education.


■ Nutrition, substance abuse, and social services.


■ Preconception services.


■ Prenatal care.


■ Labor and delivery services.


■ Postpartum care and follow-up.


■ Treatment and management.


■ Diagnostic procedures.


■ Medical interventions.


■ Patient education and follow-up.


Each state must decide which data items they want to collect.


A list of top priority data items should be developed, along with


a list of data items of secondary importance, which could be


collected if available and if specific plans for their analyses and


interpretation are developed.


29 
Strategies to Reduce Pregnancy-Related Deaths 

A tendency in surveillance or data collection systems is to collect 

too much data without a clear plan for how they will be stored, 

analyzed, or used for action. As with other health surveillance 

systems, when identifying core or key data items, it is helpful to 

have an analysis plan that shows how the information gathered 

can be used for programs or activities. For example, collecting 

data on the smoking status of each woman who died is useful 

only if the information will be used to inform smoking cessation 

programs geared toward pregnant women. In addition to 

looking at the frequency of different characteristics or factors, 

identifying informative rates and ratios, mock-ups of table shells 

and figures (graphs) may be useful to lead decisions regarding 

what data need to be collected. If a use for data cannot be 

identified, do not collect them. 

Kathleen Buckley, coordinator of the NFIMR project, learned 

some valuable lessons from her experience working with 

NFIMR data collection: 

■	 Decide what you want to know before you develop the core 

data set. 

■ Get buy-in from a diverse group of stakeholders. 

■ Compromise. 

■ Remember that bigger is not always better. 

■ A data set is a work in progress. 

In collaboration with its partners—who include HRSA and 

ACOG—CDC’s Division of Reproductive Health is working to 

develop tools to assist in maternal mortality review. Included 

will be a list of suggested core and secondary data items; 

instruments for collecting medical, social, and interview data; 

and software for data input, cleaning, and analyses as well as 

for report generation. When completed, this data collection 

system will be available to interested groups. 

Sources of information 

The committee may draw upon a wide range of sources for 

information when reviewing a pregnancy-related death. Vital 

records, medical records, and autopsy or coroner’s reports are 

core records that should be reviewed. Various other types of 

information that may be useful and are recommended, as 

30 
5. Reviewing Pregnancy-Related Deaths 

appropriate, include interviews with medical staff, social service 

staff who may have been involved with the deceased woman, 

and relatives and friends of the decedent. Two factors can affect 

the types of information that are requested or obtained: 

■	 State laws that either allow or prohibit access to particular 

data sources. Some states have statutes that give committees 

access to a wide array of sources of information; other states 

have statutes that actually make some information difficult 

or impossible to use or obtain. 

■	 The amount of financial support for items such as staff, 

record fees, and postage needed to obtain and process 

records. 

Depending on the details of the case, different data sources may 

be more or less appropriate. They include the following: 

■ Vital records. 

■ Hospital records. 

■ Prenatal records. 

■ Postpartum records. 

■ Clinic records. 

■ Autopsy reports. 

■ Coroners’ or medical examiners’ reports. 

■ Hospital maternal mortality committee findings. 

■ Neonatal records. 

■ WIC records. 

■	 Registries, such as those for tuberculosis, infectious disease, 

and cancer. 

■ Domestic violence and child abuse reports. 

■ Human services files, such as case management records. 

■ Insurance files. 

■ Police reports. 

■ Fatal accident reporting system files. 

■ State bureau of investigation files. 

■	 Interviews with health care providers, administrators, and the 

family and friends of the deceased. 

31 
Strategies to Reduce Pregnancy-Related Deaths 

Components of a review 

To reiterate, a pregnancy-related death warrants a review of both 

the medical and non-medical or social factors that contributed 

to the death. 

Determining the medical (pathologic) cause of death 

One function of a maternal mortality review committee is 

to determine the medical or pathological cause of death, 

which may or may not be reflected on the death certificate. 

Death certificates, medical records, and autopsy reports are 

the basis for this determination. As noted in Chapter 4, a 

death certificate often does not indicate that the deceased 

was pregnant even if she was. If the deceased was or had been 

pregnant, reviewers must also determine whether the death 

was caused by the pregnancy or its management or whether 

the pregnancy aggravated an underlying medical condition. 

Usually a clear determination of the cause of death and its 

relationship to the pregnancy can be made. If not, the 

committee must use its expert judgment to decide. 

Determining the effect of health services factors 

on the woman’s death 

A variety of health service records may be useful for 

identifying problems in health care delivery that could be 

modified to improve maternal health outcomes. Using the 

framework of barriers to health care access23 can help identify 

areas that are important to consider. A trained abstractor or 

health professional should review written records including, 

as appropriate, the following: 

■	 Private physician, WIC, clinic, or public health records 

■ Maternal medical history. 

■ Contraceptive practices. 

■ Clinical conditions before and after pregnancy. 

■	 Emergency room/Emergency Medical Team records 

■ History of early pregnancy loss. 

■ Pre-admission history. 

■	 Prenatal care records 

■ Number of visits and date of first visit. 

■ Woman’s weight. 

■ Medications. 

■ Parity/gravidity and dates of previous deliveries. 

32 
5. Reviewing Pregnancy-Related Deaths 

■ Underlying medical conditions. 

■ Blood pressure, hemoglobin, and hematocrit levels. 

■ Other laboratory test results. 

■ History of substance abuse. 

■	 Complications of new or preexisting conditions, their 

diagnosis, and management. 

■ Records of home visits 

■ Hospital records 

■	 Admission sheet(s): date(s) of admission and discharge, 

source of payment 

■ Obstetrical admission assessment 

Nurse 

Time admitted.


Woman’s health status, weight, fundal height.


Mode of transportation to the hospital.


Physician 

Admission history. 

Results of physical examination. 

Complications of labor or delivery: tocolysis, steroids, 

antibiotics; augmentation or induction of labor. 

■ Progress notes from medical and nursing staff 

Complications of labor or delivery. 

Tocolysis. 

Medications, number of doses. 

Duration of labor. 

Use and monitoring of anesthesia. 

■ Delivery note 

Nurse 

Time of delivery.


Complications during delivery.


Length of labor, use of anesthesia.


Outcome of the pregnancy.


Physician 

Type of delivery. 

Reasons for cesarean delivery or anesthesia 

(if appropriate). 

Other procedures. 

33 
Strategies to Reduce Pregnancy-Related Deaths 

■ Anesthesia record 

Type of anesthesia. 

Patient’s weight. 

Intraoperative events. 

■ Recovery room notes 

■ Autopsy or medical examiner record 

■ Cause of death. 

■ Date and time of death. 

■ Deceased’s age, height, and weight. 

A combination of structured and semi-structured data 

abstraction forms can be used to record the information. 

Structured forms should be formatted to allow accurate and 

efficient coding, and semi-structured forms should allow for 

a narrative description of the events leading to death. As 

mentioned earlier, CDC and partners are working to develop 

instruments for data collection for maternal death review, 

which will be available on completion. Appendix E contains 

examples of abstraction forms already in use in several states. 

Interviews with medical personnel who were involved in the 

care of the woman can provide additional insights into ways 

in which health services could be improved. 

Determining the factors related to the woman, her family, 

and her community that contributed to the woman’s death 

Medical factors are only some of the circumstances 

surrounding a pregnancy-related death. In many cases, nonmedical factors play an important underlying causal role in 

the death. Review non-medical factors that might present 

barriers to health care access—factors that hindered a woman 

or her family from recognizing a health problem or seeking 

care once a problem was recognized. 

For example— 

■ Did the woman intend to become pregnant? 

■ Did she have knowledge of pregnancy warning signs? 

■	 Would her support systems allow her to act on the 

knowledge of a suspected medical problem? 

■ Did she have access to health care? 

■	 Did financial problems or language, cultural, or 

community issues limit or impair her ability to get or 

follow medical advice? 

34 
5. Reviewing Pregnancy-Related Deaths 

Answers to these questions can identify areas of the health 

care system—and other systems such as education and 

legislation—that need strengthening. Obtain information 

from multiple sources. Prenatal and hospital records often 

have social service assessments, as do many records of home 

visits. They can provide a wealth of information. If there are 

no such records, lack of appropriate social services may be a 

problem that contributed to the death. Police reports may be 

helpful in cases of deaths from injury because they have 

information on items such as history of intimate partner 

violence and the use or non-use of seat belts. 

In the United States, there is a growing body of experience 

with family interviews during the review of fetal and infant 

deaths; the NFIMR programs report that their family 

interviews provide extremely beneficial information not 

available from other sources. In other countries, family 

interviews or verbal autopsies are frequently used to identify 

maternal deaths and preventable causes. However, in the 

United States, there is little experience with family interviews 

after maternal deaths. In some states, health care providers 

are concerned that interviewing families may raise a red flag 

and lead to litigation. This should not happen 1) if it is clear 

that all maternal and infant deaths are followed by a family 

interview and 2) if the interviews are seen as a public health 

intervention to identify systems issues that might have 

prevented the woman’s death and as a way of identifying 

which social or health care services are needed by the 

surviving family, including the infant. The value of a family 

interview as a tool for assessing the underlying causes of 

maternal death needs to be evaluated as our experience 

with this process grows. 

If proxy interviews are conducted, it is usually with the 

deceased woman’s spouse or partner, other family members, 

or friends. Because these interviewees are experiencing grief 

and loss, interviewers should first receive thorough training 

in how to collect information completely and objectively in a 

situation in which they must deal sympathetically with the 

interviewee. 

Interviews may be structured, semi-structured, or openended. During structured interviews, prescribed questions 

must be asked in a given order and in given words; semistructured interviews allow the interviewer to alter words 

and sequence. Closed-ended questions have a list of possible 

35 
Strategies to Reduce Pregnancy-Related Deaths 

responses; open-ended questions allow those interviewed to 

answer as freely and as fully as they wish. When interviewing 

someone about a pregnancy-related death, a combination of 

interview formats may work best: ask closed-ended questions 

about demographics and other facts and open-ended 

questions about the interviewee’s interpretations of events. 

CDC and partners are developing a questionnaire that can 

be used for family interviews. Appendix F is an example of a 

family interview questionnaire used in one state. 

Determining factors related to the health care system that 

contributed to the woman’s death 

We distinguish between the health care system as a whole and 

the services provided by individual health care practitioners. 

Factors related to the health care system include those related 

to medical insurance, bureaucratic requirements for 

obtaining Medicaid, access to health care providers that 

accept Medicaid, issues with managed care organization 

plans, availability of health education, prenatal and family 

planning services, care coordination and other social services, 

regionalization of maternal health care, and referrals to the 

appropriate level and types of care and to the appropriate 

social services. 

Correcting or improving cause-of-death 

information on a death certificate 

According to the NCHS (which uses ICD terms and definitions 

for maternal mortality), the completeness and quality of 

maternal death reporting could be improved if physicians 

completed the cause-of-death section of the death certificate 

more accurately. If a maternal mortality review committee or 

other investigative body discovers that the cause of death is 

incorrect, the certifying physician should be contacted and 

encouraged to file an amended certificate with the state office of 

vital statistics. However, NCHS closes its statistical file 7 months 

after the end of the calendar year, so any changes to records 

made after that time would be reflected in the state, but not the 

national, death records. 

Physicians receive minimal training in how to correctly 

complete death certificates. The cause of death on many 

certificates does not adequately reflect the events leading to the 

death, as evidenced by the under-ascertainment of pregnancy36 
5. Reviewing Pregnancy-Related Deaths 

related deaths when case identification is based solely on death 

certificate data. Maternal mortality review committees or state 

medical associations, in cooperation with state vital statistics 

departments, should promote continuing education for 

physicians and hospital personnel in this important public 

health task. (Written directions are available in Appendix A 

and on the Internet from NCHS at http://www.cdc.gov/nchs/ 

about/major/dvs/handbk.htm.) 

One method states use to ensure training of practicing 

physicians in a particular subject is to require continuing 

education credits on the topic of interest in order to renew a 

medical license. With the advent of new methods of distance 

learning (e.g., videos and, particularly, Internet courses), a state 

could develop and require completion of a course on the correct 

completion of vital statistics for a physician to be relicensed. 

Legal issues: liability and confidentiality 

Legal concerns are a major deterrent to pregnancy-related 

mortality surveillance. Issues such as anonymity, confidentiality, 

and legal protection are concerns for families, clinicians, health 

care facilities, and health departments. It is vital that those 

responsible for the surveillance system be aware of their state 

statutes and the protections they do and do not offer. This 

information should be included, in clear language, in all 

communications with those whose participation is needed in 

the surveillance process. If a state’s laws are not adequate, efforts 

should be made to have appropriate laws or regulations enacted. 

Although this requires time and effort, the results can be 

invaluable for making the system function. 

The legal protection offered to maternal mortality review 

committees varies from state to state and can change with 

time. Various levels of protection safeguard members of review 

committees from civil liability and safeguard the confidentiality 

of information collected during the review process. It is essential 

to get legal advice about your state’s statues when planning the 

structure of the maternal mortality review committee. Once 

established, the committee should also regularly consult with 

legal counsel. 

Concerns about liability and confidentiality have caused many 

state maternal mortality review committees to cease functioning 

and others to consider doing so. Committee members and staff 

37 
Strategies to Reduce Pregnancy-Related Deaths 

worry about their own liability and whether committee 

proceedings could be used in litigation. Health care providers 

are often concerned that they might incur liability if they 

cooperate with the committee’s investigation. These perceptions 

hamper the committee’s ability to obtain accurate information 

about a pregnancy-related death. 

In reality, however, the risk of liability related to participating 

on an appropriately structured expert review committee, such 

as a maternal mortality review committee, is negligible in the 

overwhelming majority of states. A study of legal protections 

in each state showed that—with few exceptions—most states 

protect members of expert review committees and providers 

of medical information from civil liability. They generally also 

protect information gathered during case review from disclosure 

or from use in other litigation. 

Those planning to form a maternal mortality review committee 

should investigate that state’s relevant statues to learn the 

extent of its protections and the statutory requirements for 

the structure and conduct of committee work. Gathering this 

information before starting or reactivating a committee can 

alleviate committee member concerns and ensure the most legal 

protection possible. For example, standing committees of the 

state medical society may, in some states, be able to seek greater 

protection by having their work authorized by the health 

department. 

Appendix G is excerpted from an article entitled “State Level 

Expert Review Committees—Are They Protected?” It was 

published when the status of protective laws was first reviewed 

in 1989.24 The excerpted portion is a general discussion of 

the issues related to maternal mortality review committees. 

Appendix D is the 2000 ACOG review of applicable state 

statutes. This recent review is a good reference on the 

immunity and confidentiality protections in the states. 

Recommended steps to 

help ensure confidentiality 

■ Record no identifiers on 

data abstraction forms so 

that data forms are 

anonymous. 

■ Have each person associated 

with the committee sign a 

pledge of confidentiality. 

■ Provide case summaries to 

review committee members 

only if they confirm in 

advance that they will 

attend the meeting at which 

decisions on those cases will 

be made. 

■ After each case has been 

reviewed, collect all 

summaries from committee 

members and shred them 

immediately after the 

meeting. 

Adapted from a presentation on 

pregnancy-associated mortality 

review, January 9, 2001. A. Phelps, 

Florida Department of Public Health. 

38 
6 Analyzing and Interpreting 

the Findings 

Although they occur too frequently and are in many 

cases preventable, pregnancy-related deaths are relatively 

rare events in developed countries such as the United States. 

Therefore, the statistics usually calculated, such as the 

pregnancy-related mortality ratio, are subject to wide variation 

if they are calculated for small areas, such as most cities and less 

populous states. Consequently, it is hard to use such statistics 

to monitor change over a short time. Therefore, to gain the 

most insight into pregnancy-related mortality, the information 

gathered during the review of pregnancy-related deaths should 

be analyzed both quantitatively and qualitatively. 

Quantitative analysis 

In analyzing pregnancy-related mortality data, it is helpful to 

look for patterns and trends among the deaths by a variety of 

characteristics (see “Issues related to small numbers,” page 43). 

First tabulate the data by the basic epidemiologic descriptors 

of person, place, and time. 

Person:Age, race/ethnicity, education, socioeconomic 

status. 

Place:Geographic location where deceased woman 

resided; where she delivered; where she died; 

characteristics of place of residence (e.g., urban 

or rural area, proximity to environmental 

toxins); the level and size (number of deliveries 

per year) of the hospital where pregnancy 

ended. 

Time: Date of death, season, day of week, time of day. 

Then tabulate the data by other variables: 

Gravidity Number of previous pregnancies and births. 

and parity: 

Pregnancy Live birth, stillbirth, induced or spontaneous 

outcome: abortion, ectopic pregnancy, undelivered 

pregnancy, molar pregnancy, multiple gestation. 

39 
Strategies to Reduce Pregnancy-Related Deaths 

Gestational Number of weeks of pregnancy. 

duration: 

Method of Vaginal birth, cesarean birth, surgical or medical 

termination: termination for induced abortion or ectopic 

pregnancy. 

Event-to- Time of death relative to the pregnancy, 

death delivery, abortion, or termination of 

interval: pregnancy. 

Cause of Immediate cause (e.g., hemorrhage, sepsis); 

death: associated conditions (e.g., placenta previa, 

primary hypertension). 

Next compare the basic characteristics of person, place, and time 

between groups (e.g., between black and white women, between 

younger and older women). The simplest way to analyze data 

is to determine where, when, and among whom the greatest 

number of deaths occur. However, keep in mind that if one 

of the groups being compared is larger than the other, then 

the number of deaths may be greater in that group even if the 

risk of pregnancy-related death is the same or smaller. 

Calculating the pregnancy-related mortality ratio is the 

traditional way to eliminate the effect of the size of the 

population at risk. 

Pregnancy-related Number of pregnancy-related deaths x 100,000 

mortality ratio: Number of live births 

To calculate the pregnancy-related mortality ratio for 

various groups, the number of pregnancy-related deaths (the 

numerator) and the number of live births (the denominator) 

must be from the same group. For example, to calculate the 

pregnancy-related mortality ratio for women of different ages, 

one needs to know the number of live births and the number 

of pregnancy-related deaths in each age group. Data on all live 

births in a state are collected and computerized by the state 

office of vital statistics. In addition, NCHS has public-use data 

tapes of all live births in the United States, by state, with much 

of the data needed to calculate the various denominators. Some 

other measures used to understand and compare mortality 

caused by pregnancy are in Appendix H. 

40 
6. Analyzing and Interpreting the Findings 

Useful basic comparisons for quantitative analyses might include 

the following: 

By person:Compare the data for different subpopulations 

(e.g., compare women of different ages, race or 

ethnicity, socioeconomic status, residence, 

parity). 

By place:Compare the risk of pregnancy-related 

mortality for women in different regions of the 

state or across areas with different medical 

services or different access to medical services. 

Compare the risk for women in your state with 

the risk for women in other states or in the 

nation as a whole. 

By time:Examine trends over time in the state overall or 

by specific characteristics. 

Qualitative analysis 

Even if the number of deaths is small and quantitative analysis 

is difficult, qualitative analysis should be done, because it may 

provide insights into the factors that led to the death. Although 

the medical cause of many pregnancy-related deaths may be the 

same, the reasons for those deaths may vary. For example, a 

woman may die of bleeding for any of several reasons: she may 

not have been aware of the seriousness of her symptoms and 

may not have taken prompt action; she may not have had the 

financial resources for appropriate medical care; or she may 

have received medically inadequate care. 

A qualitative analysis takes into account the medical and nonmedical factors that contribute to a pregnancy-related death. For 

qualitative analysis, one needs to analyze data on the deceased 

woman, the health care she received, the health care system as it 

relates to her care, and any state or local policies as they affected 

her. Examples of factors possibly related to pregnancy-related 

deaths include the following: 

Woman: ■ Her personal risk factors (e.g., substance 

abuse). 

■ Her knowledge of pregnancy and of the 

symptoms associated with complications. 

■ Her beliefs about the need for health care 

during pregnancy. 

■	 Her previous experience and comfort with 

receiving health care and with the health 

care system. 

41 
Strategies to Reduce Pregnancy-Related Deaths 

Health care ■ The provider’s knowledge and skill. 

provider:

■ The resources of the health care facility. 

■ The skills and schedules of staff. 

■ The attitude and courtesy of staff. 

Health care ■ The woman’s ease or lack of access to the 

system: health care system. 

■ The availability of health education, prenatal 

care, and family planning services. 

■ The availability of levels of service appropriate 

to the woman’s needs. 

■	 Appropriate credentialing by relevant groups 

of individuals and institutions that provide 

care. 

Policy: ■	 The availability of federal or state financing 

and insurance coverage. 

Using quantitative and 

qualitative data together 

Separately, qualitative and quantitative data are frequently 

unsatisfactory if we are attempting to understand the pathways 

to pregnancy-related death and to develop effective and efficient 

interventions. Quantitative analysis shows which groups are 

at increased risk for pregnancy-related death but offers no 

insight into the specific reasons. Qualitative analysis provides 

information on individual cases, but evaluating the significance 

of individual cases in a case series can be difficult. Qualitative 

analysis tells why women with certain characteristics died but 

not if the number of deaths is out of proportion to the number 

of such women in the population. 

A combination of quantitative and qualitative analyses can 

provide more insights than either can provide alone. Begin 

with quantitative analysis. Compare groups of women, 

determine which groups are at higher risk for pregnancy-related 

death. Is it, for example, women of a certain age, ethnicity, place 

of residence, parity? Then, using qualitative data from the review 

process, look for differences in what happened with and to the 

women in the high risk group that might have made them more 

likely to die. Were there differences in lifestyle; access to health 

care, including family planning, preconception care, prenatal or 

delivery care; or the type or quality of care received? 

42 
6. Analyzing and Interpreting the Findings 

Issues related to small numbers 

Data collected by states on births and deaths are complete 

counts of these events in the state and are not subject to 

sampling error. However, when the number of pregnancyrelated deaths is small, they often fluctuate from year to year, 

which causes variation in the pregnancy-related mortality ratio 

(PRMR) or maternal mortality ratio (MMR). For instance, 

according to vital statistics reported to NCHS, Michigan had 

nine maternal deaths in 1995 (MMR = 6.7) and five in 1996 

(MMR = 3.8) for a nearly 50% decrease. However, because the 

number of deaths is small, the ratios are not reliable. In fact, the 

95% confidence intervals (3.1, 12.7) and (1.2, 8.9) overlap, and 

the difference is not statistically significant. 

Many states have fewer than 20 pregnancy-related deaths 

annually. Generally, NCHS recommends reporting MMRs 

only when there are at least 20 deaths (relative standard error 

<23%).26 One way to get more reliable estimates of pregnancyrelated mortality is to aggregate several years. Depending on 

the number of deaths, from 2 to 10 years can be aggregated. 

Rolling averages of, for example, 5 years may also allow numbers 

sufficient for analysis. However, by aggregating several years, 

the ability to detect trends or changes over time is lost. Another 

approach to dealing with the problem of small numbers is to 

combine data from several similar states in a region—either 

the federal public health regions or the ACOG districts. 

Aggregating data and thus increasing the number of pregnancyrelated deaths available for analysis can improve the state’s 

understanding of the causes of deaths and its ability to develop 

and implement interventions. 

If there are fewer than five deaths, ratios should not be reported 

without a clearly stated explanation that the point estimate is 

extremely unreliable; confidence intervals must be included with 

these point estimates. In such cases, pregnancy-related deaths 

are better treated as sentinel events. Each should be reviewed 

and reported separately (as in a line listing), although in a 

manner that preserves anonymity. 

Although it is best to aggregate years so as to have more than 

19 deaths in the numerator, some states have few deaths and 

must publish data on 5 to 19 deaths. In such cases, confidence 

intervals should always be provided, and the estimates should 

have a caveat that they are based on small numbers and should 

be used with caution. 

43 
Strategies to Reduce Pregnancy-Related Deaths 

When the number of pregnancy-related deaths is small, the 

PRMR or MMR is not an adequate indicator of changes in 

maternal health. Ideally, other indicators should be used. 

Nationally, new indicators for monitoring pregnancy-related 

morbidity, including very severe or near-miss morbidity, are 

being considered (see Chapter 9 “Special Issues”). 

An important issue that arises because of the relatively small 

number of pregnancy-related deaths in most states is the 

confidentiality of the review process. At a local level, many 

people on a review committee might know the families of the 

women who die or their health care providers, and 

confidentiality could not be maintained. For this reason, most 

maternal mortality reviews are done at the state level. 

44 
7 Taking Action 

The primary objective of pregnancy-related mortality 

surveillance is to take action to reduce future pregnancy-related 

mortality and morbidity. However, in too many cases, it is just 

at this important point that the process stops. Because action is 

the ultimate goal of the system, it is important that those with 

the ability to make the needed changes understand the findings 

and recommendations of the analysis. Those with the ability to 

take action should either be members of the committee, have 

designated representatives on the committee, or receive a 

detailed report of the findings of both the quantitative and 

qualitative analysis. Changes to decrease pregnancy-related 

mortality will need to take place on many levels, so the analyses 

need to be disseminated to a broad array of individuals and 

organizations. Devising a formal plan for ways of disseminating 

the information and having changes made is part of any 

committee’s work. 

The issue of protecting the confidentiality of the deceased 

woman and her family, her care providers, and members of 

the review committee runs throughout the surveillance process. 

Those who abstract the medical records or interview family 

members will obviously know the identities of those involved. 

Case summaries provided at review committee meetings for 

discussion should have identifying data removed, although some 

people present may be familiar with the case. Written assurances 

of confidentiality should be obtained from members and staff 

of the review committee as well as all who attend the review 

meeting, promising that none of the presentations, discussions, 

documents, or proceedings will be shared outside the meeting. 

For any dissemination beyond the review committee, content 

must be carefully reviewed to avoid breaches in confidentiality 

and misuse of information. Any written reports or summaries 

should focus on ways to improve the system and not single out 

errors committed. For example, if a woman died of hemorrhage 

because blood was not available, then the needed action is to 

ensure that blood bank services are adequate at hospitals with 

emergency rooms or maternity units, without focusing on lack 

of blood at the hospital involved in the specific case. 

45 
Strategies to Reduce Pregnancy-Related Deaths 

Making and implementing 

recommendations 

The actions taken to decrease pregnancy-related mortality 

will be determined by the findings of the review process 

and analysis. Thus, it is impossible to say what the specific 

recommendations will be. Interventions to improve maternal 

health and decrease pregnancy-related mortality fall into three 

types of strategies, which are defined below along with some 

examples. 

Primary prevention strategies: These strategies prevent the 

condition from occurring through education and services. 

Examples include improving sex education and fully funding 

family planning programs to prevent unintended and high-risk 

pregnancies; implementing nutrition programs; improving 

preconception care; and improving diagnosis and treatment of 

sexually transmitted diseases to prevent ectopic pregnancy 

and intrapartum and postpartum infections. 

Secondary prevention strategies: These strategies detect and 

treat conditions early in order to minimize the effects. Examples 

include increasing community awareness and patient knowledge 

about normal pregnancy and the signs and symptoms of 

possible problems; increasing emphasis on patient satisfaction 

with care in order to improve patients’ adherence to their 

physicians’ instructions or recommendations; and improving 

prenatal care, labor and delivery techniques, and postpartum 

follow-up. 

Tertiary prevention strategies: These strategies treat conditions 

in an optimal fashion in order to reduce case-fatality rates. 

Examples include improving obstetric and medical treatment 

of complications and improving practices, facilities, referral 

services, and regionalization of services. 

Disseminating findings and 

recommendations 

Communicating with programs and other groups, 

including the public and the news media 

Preventing pregnancy-related deaths involves a variety of 

individuals and groups. Because many people outside the state’s 

surveillance system are not familiar with surveillance activities 

or terms, communications must be easy to understand and 

46 
7. Taking Action 

compelling. Determine who needs to know the results of your 

reviews. Find out which groups or individuals can use the 

findings about the pathways to such deaths. They may be 

hospital associations, programs for women, insurance carriers, 

medical and nursing associations, legislators who appropriate 

funding, credentialing agencies, consumer advocacy groups, or 

federal agencies involved in compiling and reporting national 

surveillance data. Concise bulletins, fact sheets, and briefing 

notes spread the information efficiently and effectively. An 

example of an effective report from a maternal mortality review 

committee—developed by Massachusetts—is in Appendix I 

and on the Internet at http://www.state.ma.us/dph/pubstats.htm. 

Feedback to those involved in surveillance 

Establish regular communications with the people who work 

within the surveillance system. Such people may include state 

health department personnel involved in family health, Title V 

Maternal and Child Health programs, epidemiology, and vital 

records; Medicaid staff; district and county health officers; 

maternal mortality review committee members; clinicians; 

hospital administrators, coders, clergy, and others involved 

in identifying and reviewing pregnancy-related deaths. 

Good communication improves the surveillance system by 

promoting discussion of the surveillance process and showing 

how each surveillance task produces useful information. 

Communication methods include reporting results of data 

analyses, writing reports, holding annual or semi-annual 

meetings, and personal encounters (see Box 5). The free 

exchange of ideas is especially helpful for maintaining 

momentum and vitality. Have face-to-face or telephone 

contact with the key individuals. Encourage these individuals 

to do the same with their staff or group. 

Effective feedback also includes training and giving technical 

assistance on the various tasks involved in surveillance. For 

example, coders may need training in how to use new forms. 

Hospital review committees may need technical assistance in 

setting up a computerized system that is more responsive to 

surveillance needs. Vital records personnel may need to be 

educated about how to provide the data needed for finding 

and confirming pregnancy-related deaths, including how to 

link vital records and other data sets. 

Methods of 

disseminating results of 

surveillance 

■ Printouts of tabulated data. 

■ Committee reports. 

■ Interdepartmental reports. 

■ Newsletters and bulletins. 

■ Legislative briefings. 

■ Fact sheets. 

■ Press releases. 

■ Telephone conversations. 

■ E-mail correspondence. 

■ Annual or semi-annual meetings. 

■ Consultations. 

■ Technical assistance. 

■ Scientific articles. 

■ Training programs. 

■ Posters. 

■ Messages from clergy. 

■ MTV. 

Box 5 

47 
8 Evaluating the 

Surveillance System 

Evaluation is an integral step of any surveillance 

system, and it serves many purposes. The overall objective 

of evaluation is to ensure that the surveillance system is both 

effective and efficient. To achieve this objective, all components 

of a surveillance system must be evaluated, in addition to 

measuring how successful the system is at meeting its objectives. 

Furthermore, evaluation extends beyond the data collection and 

review components of the surveillance system itself. It is 

essential to evaluate the interventions and actions developed 

as a result of the review process. The results of the evaluation 

of a surveillance system will be used as a basis for modifying 

or redeveloping the system to serve its purpose better. 

An evaluation plan should be designed into a surveillance 

system, and the system should undergo evaluation on an 

ongoing basis. There are two separate, independent, but 

equally essential questions that need to be answered during an 

evaluation: 

■	 Is the system functioning properly as designed? (internal 

evaluation) 

■	 Is the system achieving the objectives for which it was 

designed? (external evaluation) 

Of course, before the system can be evaluated, both the design 

and the objectives of the system have to be clearly defined and 

documented so that those performing the evaluation can 

compare what is happening with what is supposed to happen. 

Internal evaluation 

Any surveillance system must undergo reassessment of its 

objectives and methods. For internal evaluation, the main 

questions are these: 

■ Is the system meeting its objectives? 

■ Can its utility and efficiency be improved? 

■ Is it operating as effectively as possible? 

49 
Strategies to Reduce Pregnancy-Related Deaths 

Internal evaluation should include a description of how the 

system operates, an assessment of the system’s quantitative 

and qualitative attributes, and an estimate of the cost of the 

system (including, for example, personnel time and equipment) 

in relation to available resources. The attributes of the 

system that should be evaluated include the operation of 

the system, its simplicity, flexibility, sensitivity and specificity, 

representativeness, timeliness, and acceptability to its users. 

External evaluation 

In an external evaluation the main purpose is to learn whether 

the objectives of the surveillance system have been achieved: 

■ Does it serve a useful public health function? 

■ Did the system generate solutions to problems? 

■	 Was it useful to planners, researchers, health care providers, 

and public health professionals? 

■ How was the information used? Was it worth the effort? 

■ Are those who participated in the system willing to continue? 

■ What can be done to improve each attribute of the system? 

Because public health surveillance is oriented toward action, 

evaluation should address two questions in particular: 

■	 Are the findings of the surveillance process being 

communicated to those who need to know them? 

■	 Has the information had a beneficial effect on the health 

problem or condition of interest? 

When evaluating a surveillance system, one must decide which 

criteria are most relevant for that specific system. Specific steps 

for conducting an external evaluation of the surveillance system 

should be developed and documented. 

50 
9 Special Issues 

Funding 

Maternal mortality surveillance is an important state 

function and should be integrated into routine maternal 

and child health program activities. Reviews, conclusions, 

recommendations, and implementation of prevention strategies 

should all be linked through the agencies responsible for the 

health of women in the state. State funds should be allocated 

to maintain ongoing pregnancy-related surveillance at the state 

level. Specific caucuses within the state legislature or public 

interest groups may become advocates for funding surveillance 

activities if they are educated about the importance of the issues. 

Frequently the women’s caucus will be interested in this issue. 

In addition, certain groups (e.g., black, Hispanic, or rural 

women) who are at increased risk of pregnancy-related 

problems may provide support. 

In some cases, technical support and seed money may be needed 

for start-up activities, and special in-depth projects may call 

for extra resources. In some cases, federal agencies, including 

CDC and the Health Resources and Services Administration, 

have provided technical and financial support to develop and 

implement such activities. Support may also be available 

through national organizations involved in the health care 

of mothers as well as from nonprofit organizations (e.g., 

The Association of Maternal and Child Health Programs, 

CityMatCH, Council of State and Territorial Epidemiologists, 

ACOG, the American College of Nurse-Midwives, March of 

Dimes). Collaboration with such organizations is most likely 

to be effective at the level at which maternal mortality review 

is organized (usually states but sometimes large metropolitan 

areas). 

Monitoring maternal health and 

morbidity/near misses 

In many states, the annual number of pregnancy-related 

deaths is small, and pregnancy-related mortality alone is 

not an adequate indicator of maternal health. Furthermore, 

because the decline in pregnancy-related mortality has stalled 

51 
Strategies to Reduce Pregnancy-Related Deaths 

nationally since 1982,2 we need to look at what happens to 

women with serious pregnancy-related morbidity in order 

to prevent their deaths. We need to know why some women 

survive major complications of pregnancy and others die. 

The U.S. Department of Health and Human Services has 

begun to develop new indicators for monitoring maternal 

health. One indicator previously used was the number of 

antepartum hospitalizations for every 100 deliveries.27,28 

However, since antepartum complications are increasingly 

treated on an outpatient basis, the recent fall in antepartum 

hospitalizations almost certainly does not reflect improvements 

in maternal health.28 Experts are now looking at the use of 

serious life-threatening morbidity, referred to as near-miss 

events, as indicators of maternal health problems. Such events 

could include eclampsia; HELLP syndrome; hemorrhage 

requiring transfusion; post-delivery hysterectomy; cesarean 

hysterectomy; cardiac arrest; and conditions requiring 

intubation, ventilation, intensive care, or life support. 

The proposed revision of the U.S. birth certificate has check 

boxes for some of these events and has enormous potential to 

improve monitoring of maternal health. Other methods for 

monitoring near-miss events are also being examined, such 

as use of statewide computerized hospital discharge records. 

Some states have begun to review maternal morbidity as part 

of the maternal mortality review process. As experiences 

accumulate, they will be evaluated and the results disseminated. 

The recommendations made in this document will be modified 

to reflect new knowledge. 

52 
Epilogue 

Each year in the United States, 1,000 women die of 

pregnancy-related complications, making such deaths relatively 

uncommon. They are even more uncommon in an individual 

state or city. Why then should the state mount an intervention 

to prevent what may appear to be random incidents? 

There are several reasons. First, improving the health of women 

and children is important—the future of our society depends 

on it. And our society needs to be aware of this fact. Second, 

there is much we still do not know about pregnancy and its 

complications. For example, why do some women have lifethreatening complications? Why do some women survive them 

and others do not? Why are some groups of women more likely 

to die? Third, we need to understand how to foster the best 

outcome for all women, children, and families—strategies 

to make pregnancy and childbirth safer for all women. 

So whose faces are behind the numbers? What were their stories? 

What were their dreams? They left behind children and families. 

They also left behind clues as to why their lives ended early. It is 

the obligation of those who cared for and about these women to 

retrace their journeys through pregnancy in an effort to unravel 

the circumstances surrounding their deaths. The pregnancyrelated mortality ratio will never be zero, but many pregnancyrelated deaths can be avoided. The plateau in the U.S. maternal 

mortality ratio and the racial disparity in pregnancy-related 

mortality will be reduced only by diligently searching for the 

reasons for these rare but devastating events and applying 

what is learned to the care of all pregnant women. 

William M. Callaghan, M.D., M.P.H. 

53 
References 

1.	 Berg C, Atrash H, Koonin L, Tucker M. Pregnancy-related 

mortality in the United States, 1987-1990. Obstet Gynecol 

1996;88:161-7. 

2.	 Centers for Disease Control and Prevention (CDC). 

Maternal mortality—United States, 1982-1996. Mor Mortal 

Wkly Rep 1998;47:705-7. 

3.	 Centers for Disease Control and Prevention (CDC 99B). 

Healthier mothers and babies. Mor Mortal Wkly Rep 

1999;48:849-57. 

4.	 Hopkins FW, Mackay AP, Koonin LM, Berg CJ, Irwin M, 

Atrash HK. Pregnancy-related mortality in Hispanic 

women in the United States. Obstet Gynecol 1999;94:721-5. 

5.	 Centers for Disease Control and Prevention. Pregnancyrelated deaths among Hispanic, Asian/Pacific Islander, and 

American Indian/Alaskan Native women—United States, 

1991-97. Mor Mortal Wkly Rep 2001;50:361-4. 

6.	 World Health Organization. Manual of the international 

statistical classification of diseases, injuries, and causes of 

death (ICD-9), vol. 1. Geneva (Switzerland): World Health 

Organization; 1977. 

7.	 National Center for Health Statistics (NCHS). Physicians’ 

handbook on medical certification of death. Hyattsville 

(MD): Public Health Service; 1996. Available from: URL: 

http://www.cdc.gov/nchs/data/hb_cod.pdf. 

8.	 World Health Organization. International statistical 

classification of disease and related health problems. Tenth 

Revision (ICD-10). Geneva (Switzerland): 1992. 

9.	 Atrash HK, Alexander S, Berg CJ. Maternal mortality in 

developed countries—not just a concern of the past. Obstet 

Gynecol 1995;86:700-5. 

10.	 Neuzil KM, Reed GW, Mitchell EF, Simonsen L, Griffin MR. 

Impact of influenza on acute cardiopulmonary 

hospitalizations in pregnant women. Am J Epidemiol 

1998;148:1094-102. 

55 
Strategies to Reduce Pregnancy-Related Deaths 

11.	 Bessinger R, Clark R, Kissiner P, Rice J, Coughlin S. 

Pregnancy is not associated with the progression of HIV 

disease in women attending an HIV outpatient program. 

Am J Epidemiol 1998;147:434-40. 

12.	 Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data 

for 1997. In: National Vital Statistics Reports, vol. 47, no. 

19. Hyattsville (MD): National Center for Health Statistics; 

1999. 

13.	 Hopkins J, Marcus M, Campbell SB. Postpartum depression: 

a critical review. Psychol Bull 1984:95;498-515. 

14.	 Wilt S, Olson S. Prevalence of domestic violence in the 

United States. J Am Med Womens Assoc 1996;51:77-82. 

15.	 Jocums SJ, Berg CJ, Entman SS, Mitchell EF. Postdelivery 

mortality in Tennessee, 1989-1991. Obstet Gynecol 

1998;91:766-70. 

16.	 Dietz PM, Rochat R, Thompson BL, Berg CJ, Goldner T, 

Griffin G. Differences in the risk of homicide and other 

fatal injuries between postpartum women and other women 

of childbearing age: implications for prevention. Am J 

Public Health 1998;88:641-3. 

17.	 Centers for Disease Control and Prevention (CDC 99A). 

Achievements in public health, 1900-1999: motor vehicle 

safety: a 20th century public health achievement. Mor 

Mortal Wkly Rep 1999;48:369-74. 

18.	 Bouvier-Colle MHH, Varnoux N, Costes P, Hatton F. 

Reasons for the underreporting of maternal mortality in 

France, as indicated by a survey of all deaths among women 

of childbearing age. Intl J Epidemiol 1991;21:717-21. 

19.	 Mackay AP, Rochat R, Smith JC, Berg CJ. The check box: 

determining pregnancy status to improve maternal mortality 

surveillance. Am J Prev Med 2000;19(Suppl):35-9. 

20.	 Centers for Disease Control and Prevention (CDC). 

Pregnancy-related mortality—Georgia, 1990-1992. 

Mor Mortal Wkly Rep 1995;44:93-5. 

21.	 Jocums SJ, Mitchell EF, Entman SS, Piper JM. Monitoring 

maternal mortality using vital records linkage. Am J Prev 

Med 1995;11:75-8. 

22.	 Adams MM, Wilson HG, Casto DL, Berg CJ, McDermott 

JM, Gaudino JA, McCarthy BJ. Constructing reproductive 

histories by linking vital records. Am J Epidemiol 

1997;145:339-48. 

56 
References 

23.	 Graham W. Safe motherhood needs assessment: maternal 

death review. Geneva (Switzerland): World Health 

Organization; 1996. Report no. WHO/RHT/MSM/96.18. 

24.	 Wright R, Smith JC. State level expert review committees— 

are they protected? Public Health Rep 1990;105:13-23. 

25.	 Buckley KA, Koontz AM, Casey S. Fetal and infant mortality 

review manual: a guide for communities. Washington (DC): 

American College of Obstetricians and Gynecologists; 1998. 

26.	 Murphy SL. Deaths: Final Data for 1998. In: National Vital 

Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National 

Center for Health Statistics; 2000. 

27.	 Franks AL, Kendrick JS, Olson DR, Atrash HK, Saftlas AF, 

Moien M. Hospitalization for pregnancy complications, 

United States, 1986 and 1987. Am J Obstet Gynecol 

1992;166:1339-44. 

28.	 Bennett TA, Kotelchuck M, Cox CE, Tucker MJ, Nadeau DA. 

Pregnancy-associated hospitalizations in the United States in 

1991 and 1992: a comprehensive review of maternal 

morbidity. Am J Obstet Gynecol 1998;178:346-54. 

57 
Appendix A 

Instructions for Completing 

the Cause-of-Death Section 

of Death Certificates 


1 

Appendix B 

States with Check Boxes 

to Indicate Pregnancy on 

Their Death Certificates 

Below is a chart showing the NCHS reporting areas that have 

a check box or question on their death certificates to indicate 

a certain interval between a woman’s death and the end of 

pregnancy. Also given is the text of the question that asks about 

the time between pregnancy and death. United States, 1997. 

Interval between 

Reporting area pregnancy and death Text of question about pregnancy 

Alabama 42 days Was there a pregnancy in the last 42 days? (Specify yes, no, or unk) 

Florida 3 months If female, was there a pregnancy in past 3 months? Y N 

Georgia 90 days Other significant conditions: Conditions contributing to death but not 

related to cause given in part IA: (if female, indicate if pregnant or 

birth occurred within 90 days of birth). 

Illinois 3 months If female, was there a pregnancy in past 3 months? Y N 

Indiana 90 days Was decedent pregnant or 90 days postpartum? Yes, No 

Iowa 12 months If female, was there a pregnancy in past 12 months? (Yes No) 

Louisiana 90 days Was decedent pregnant or less than 91 days postpartum? 

(YES or NO) 

Maine 90 days	 Other significant conditions contributing to death but not resulting in 

the underlying cause given in part 1. If not specified in part 1, 

indicate if the decedent was pregnant or less than 90 days 

postpartum at the time of death. 

Missouri 90 days If deceased was female 10–49, was she pregnant in the last 90 days? 

Yes No Unknown 

Nebraska 3 months If female, was there a pregnancy in past 3 months? Yes No 

New Jersey 90 days If female, was she pregnant at death, or any time 90 days prior to 

death? Yes No 
2 

Strategies to Reduce Pregnancy-Related Deaths 

(continued) 

Interval between 

Reporting area pregnancy and death Text of question about pregnancy 

New Mexico 6 weeks Was decedent pregnant within last 6 weeks? Yes No 

New York City 6 months If death of female under 50 

a. Pregnancy in last 6 months? No, Yes 

b. If yes, outcome of pregnancy? 

1. Live Birth 

2. Spontaneous Termination 

3. Induced Termination 

0. None 

New York (upstate) 6 months a. If female, was decedent pregnant in last 6 months? Yes, No 

b. Date of delivery: (m/d/y) 

North Dakota 18 months Was decedent pregnant within 18 months of death? (Yes or No) 

Texas 12 months ■ Was decedent pregnant at time of death? Yes No Unknown 

■ Was decedent pregnant during the last 12 months? 

Yes No Unknown 

Virginia 3 months If female, was there a pregnancy in past 3 months? Yes No Unk 
Appendix C 

The Pregnancy-Related Portion 

of the Proposed U.S. Standard 

Certificate of Death 

The proposed revision of the U.S. certificate of death will 

include the following: 

37. IF FEMALE:


■ Not pregnant within past year•

■ Not pregnant, but pregnant within 42 days of death•

■ Not pregnant, but pregnant 43 days to 1 year before death•

■ Pregnant at the time of death•

■ Unknown if pregnant within the past year•

1 
Appendix D 

State Review Provisions, 

ACOG 2000 

Reproduced with permission from the American College 

of Obstetricians and Gynecologists. 
THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS 

STATE REVIEW PROVISIONS 
State Review Provisions 

In this document, The American College of Obstetricians and Gynecologists updates its previous 

survey of state statutes and case law regarding legal protections for review activities. The 

statutory information and court decisions were compiled in 2000. 

Although this analysis provides an overview of available protections, it is not intended to be an 

exhaustive analysis of the protections that may be available to every type of review. There are 

two important sources of protection for reviewers that are covered by this analysis. First, the 

research includes statutes protecting review committees. It addresses the laws which, in effect, 

give derivative immunity to those who contract with state agencies or work on state funded 

projects. These may be significant sources of protection to reviewers working outside the 

hospital setting. Second, we included analyses of court decisions interpreting immunity and 

confidentiality provisions. 

It cannot be overemphasized that individuals with specific questions about the legal protections 

available for a given review activity should consult the laws in their state in order to understand 

the provisions that may applicable to their individual review project. 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

1­
Alabama 

Three provisions of the Code of Alabama that limit liability for peer review activities could 

apply to state-level infant and maternal review. Section 6-5-333 covers peer review committees, 

utilization and quality control committees, professional standards review committees, and similar 

committees established by any state or county medical association. A physician or an individual 

who serves as a member, consultant, or employee of the committee is not liable for damages as a 

result of actions taken or recommendations made by the committee in response to a requested 

review of medical care. This protection only applies if the action or recommendation was taken 

without malice and in a reasonable belief that the action is warranted by the facts. The statute 

also protects state and county medical associations from damages based on actions or 

recommendations taken by their committees. 

Under this same section, all information, interviews, and reports furnished to the committee and 

any findings or recommendations made by the committee are privileged and are not available for 

court subpoena for discovery proceedings. The statute does not exempt from discovery 

preexisting records presented to the committee that would otherwise be subject to discovery. 

Section 22-21-8 provides that materials concerning the accreditation or quality assurance of a 

hospital, clinic, or medical staff are confidential and are not subject to discovery or introduction 

into evidence in any civil action arising out of matters which are the subject of the review. 

Furthermore, persons involved in preparation, evaluation, or review of the materials shall not be 

permitted or required to testify in any such civil action. However, materials available from 

original sources may not be construed as privileged merely because they were presented in or 

used in the preparation of accreditation or quality assurance activities. Persons involved in 

preparation, evaluation or review of such materials may testify as to matters within his/her 

knowledge, but may not be asked about opinions or data he/she provided in preparation, 

evaluation, or review of accreditation, quality assurance or similar materials. 

Section 34-24-58 of the Code protects from liability physicians and surgeons who are members 

of utilization or similar committees of any state, county, or municipal medical association, 

licensed hospital, clinic or medical staff thereof. The decisions made or actions taken by these 

committees are also privileged. 

Alaska 

Alaska Statutes Sections 18.23.010 to 18.23.070 limit liability for members of "review 

organizations" established by a hospital, clinic, state or local medical association or an 

organization of health care providers for the purpose of reducing morbidity or mortality. In 

addition, the statute also gives protection for a committee established by the commissioner of 

health and social services and approved by the State Medical Board to review public health 

issues regarding morbidity or mortality, where at least 75 percent of the members are health care 

providers. 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

2­
A member, employee, or advisor to these review organizations is not liable for damages sought 

by the individual whose activities are being scrutinized, provided the member, employee, or 

advisor was not motivated by malice, and acted in the reasonable belief that the action was 

warranted after reasonable efforts were undertaken to ascertain the facts. The statute also 

protects any person providing information to a review organization from an action for damages 

unless the person knew or had reason to know that the information was false. Testimony, 

documents, proceedings, and other evidence before a review organization are confidential and not 

subject to subpoena or discovery. The statute also prevents any witness from being compelled 

to testify about matters occurring before the organization, with some exceptions. A health care 

provider may obtain testimony, documents, and other evidence of the review organization if the 

denial of the material is unreasonable. In addition, a plaintiff who claims that the person 

providing the information knew or had reason to know the information was false may obtain 

documents. Finally, a person whose conduct or competence has been reviewed may obtain 

information and documents for appellate review of the review organization's actions. 

Arizona 

Sections 36-2401 to 36-2404 of the Arizona Revised Statutes cover quality assurance committees 

of a health care entity, such as a professional organization of health care providers, that is 

investigating the quality of health care or encouraging proper utilization of health care services 

and facilities. These committees must have written standards and criteria on the quality 

assurance process. Committee members, individuals who furnish information to the committee, 

and the professional organizations operating the committee (such as a hospital or medical 

association) are not subject to liability for civil damages or any legal action so long as they acted 

without malice. The information considered by the committee and any records of its actions are 

confidential. This material is not subject to subpoena or discovery. Furthermore, no member or 

staff of a committee, or an individual furnishing information to a committee may be subpoenaed 

to testify if the subpoena is based solely on activities related to the quality assurance process. 

Sections 36-445 to 36-445.03 require that hospitals and outpatient surgical centers have 

committees to review the institution’s professional practices for the purposes of reducing 

morbidity and mortality and the improvement of patient care. This statute contains similar 

immunity and confidentiality provisions to the ones described above. 

The 1993 case, Yuma Regional Medical Center v. Superior Court in and for County of Yuma 

(175 Ariz. 72, 852 P. 2d. 1256, review denied) clarified what information used in peer review is 

privileged in a subsequent malpractice suit. Protected information included a list of those present 

at the peer review meeting and a list of the documents submitted to the committee. Patient 

medical records presented to the committee, hospital administrative or personnel records, 

information on whether a doctor's privileges were changed or whether there was disciplinary 

action, and information on the date and place of the meeting were not protected. Additionally, 

any other information available from sources outside the peer review process was discoverable. 

However the plaintiff, "was not entitled to engage in fishing expedition to ascertain what 

information was considered by peer review committee and where such information might reveal 

deliberative process of participants." 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

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Arkansas 

Arkansas Statutes Annotated Section 20-9-501 defines peer review committees as committees of 

a state or local professional association established to evaluate and improve the quality of health 

care. Members of committees are provided immunity from monetary liability and actions for 

damages for any act or proceeding taken without malice or fraud, under Section 20-9-502. 

Proceedings and records are not subject to discovery or use as evidence, and no person is 

permitted or will be required to testify about committee matters, including the findings. These 

protections only extend to civil suits arising out of the matters which are at issue before the 

committee. Documents available from original sources are not immune from discovery simply 

because the committee saw them. Similarly, witnesses may testify about matters discussed 

before the committee if the witness had independent knowledge of those matters. This 

permission to testify does not extend to any opinion formed as a result of the committee meeting. 

Section 20-9-503. 

In 1995, Section 16-46-105(a) of the Arkansas Code was amended to provide that records, 

testimony, and reports of organized committees of hospital medical staffs or medical review 

committees of local medical societies are not subject to discovery or admissible in any legal 

proceeding and is absolutely privileged communication. Testimony at such committee meetings 

is also not subject to discovery. 

California 

Section 1156 of the California Evidence Code provides that written records, interviews and 

reports of in-hospital medical staff committees organized for the purpose of reducing morbidity 

and mortality may not be admitted as evidence in any action before any administrative body, 

agency or person. This section does not affect the discoverability of documents that may be 

discovered from original sources, nor does it exclude evidence relevant in a criminal action. 

Section 1157 of the California Evidence Code protects from discovery proceedings and records of 

organized hospital medical staff committees charged with evaluating and improving the quality of 

care rendered in the hospital, and of local medical society review committees similarly charged. 

No person attending a committee meeting can be required to testify about what transpired. 

However, these protections do not apply to statements made by a person in attendance at a 

committee meeting who is a party to an action or proceeding where the subject matter was 

reviewed at the meeting or to any individual requesting hospital staff privileges. 

Section 43.7 of the California Civil Code provides that no monetary liability or cause of action 

for damages will arise from any act or proceeding undertaken by members of duly appointed 

committees of professional or medical specialty societies formed to maintain the professional 

standards of the society or its bylaws. A similar protection applies to members of peer review 

committees reviewing physicians and to members of hospital governing boards reviewing their 

medical staffs. In order for the immunity to attach, the professional society, committee, or board 

The American College of Obstetricians and Gynecologists 4 

Copyright © 2001 
member must have acted without malice, made a reasonable effort to obtain the facts, and acted in 

the reasonable belief that the action was warranted. 

Under Section 43.8, persons providing information to a hospital, hospital medical staff, 

professional society or peer review committee are protected from monetary liability and causes 

of action for damages arising from the communication of information intended to help evaluate 

the qualifications of a practitioner. 

Section 43.97 protects hospitals from monetary liability and causes of action for damages, other 

than economic or pecuniary damages, as a result of actions taken upon the recommendation of its 

medical staff. 

Colorado 

Under Colorado Revised Statutes section 12-35.5-203, a professional review body, its members 

or staff, persons under contract with the professional review body, or persons assisting the 

professional review body can not be liable for damages in civil actions with respect to their 

participation with the professional review body. This immunity applies only to professional 

review actions as defined by the statute. Persons providing information to professional review 

bodies are not protected if they knowingly provide false information. 

Colorado Revised Statutes Sections 12-36.5-101 to 105, the Colorado Professional Review Act, 

cover professional review committees authorized to study and review professional conduct and 

the quality and appropriateness of patient care provided by physicians. Professional review 

committees and their members, entities establishing such committees, and their governing boards 

and individuals who participate in the proceedings are provided immunity in any civil or criminal 

action, including antitrust, brought by the physician being investigated. In order for this 

immunity to apply, the member of the review committee must have made a reasonable effort to 

obtain the facts, acted in the reasonable belief the action was warranted and acted in good faith. 

Entities that establish these committees, their governing boards, witnesses or other participants 

in the process must also act in good faith to receive the immunity protection. 

Professional review committees may be established by many different groups, including hospital 

or hospital-related medical staffs, physician associations with membership of at least one-third of 

the state's physicians, and certain medical specialty societies. All matters, records, proceedings 

and formal recommendations related to a committee hearing are confidential. 

The 1996 judicial decision Nicholas v. North Colorado Medical Center, Inc. v. Committee on 

Anticompetitive Conduct (914 P.2d 902) stated that the legislative purpose of the Colorado 

Professional Review Act was not only to provide immunity protections to persons involved in 

peer review proceedings, but also to protect the public's health and safety by regulating 

unprofessional and anticompetitive conduct. 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

5­
Connecticut 

Connecticut General Statutes Section 19a-17b covers medical review committees of a state or 

local professional society or health care institution engaged in peer review for the purpose of 

evaluating and improving the quality of health care or reducing morbidity or mortality. Members 

of these committees are protected against monetary liability and lawsuits for damages for any act 

or proceedings, provided that their actions or recommendations were taken without malice in the 

reasonable belief the action was warranted. Individuals providing testimony to these committees 

are also protected against monetary liability and lawsuits for damages. 

The proceedings of medical review committees are not subject to discovery and may not be 

introduced as evidence in civil actions against the health care provider. In addition, no person in 

attendance at a meeting is permitted or required to testify in these civil actions. There are some 

restrictions on this prohibition. In any civil action, written documents recorded independently of 

the review process are discoverable and witnesses may testify regarding facts acquired 

independently of the review process. The fact that staff privileges were restricted or terminated 

may be disclosed; and the nature of any restriction of staff privileges may be disclosed. Finally, 

in health care provider proceedings, other than peer review, that concern termination or 

restriction of privileges, data discussed or developed during a peer review proceeding may be 

used. 

Section 19a-25 protects information procured in studies of morbidity and mortality carried out 

by the Department of Public Health or staff committees of facilities accredited by the 

Department of Health. It provides that this information shall be confidential and shall be used 

solely for the purposes of scientific or medical research. Such information is not admissible as 

evidence in any court or before any other tribunal, board or agency. However, in some 

circumstances personal data collected during a morbidity or mortality may be disclosed to 

another governmental agency or private research organization for research purposes. This statute 

is not designed to prevent a physician from testifying, but rather to prevent him/her from 

disclosing confidential matters. 

Delaware 

Title 24 Section 1768 of the Delaware Statutes protects the Board of Medical Practice, the 

Medical Society of Delaware, their members or committee members, and members of hospital 

committees and other review organizations. These groups or individuals are immune from civil or 

criminal lawsuits, claims, or damages arising from any act, decision or recommendation made in a 

review, so long as the committee members acted in good faith and without malice. Physicians, 

hospitals or other organizations that furnish information or data to review committees are also 

protected from civil or criminal lawsuits. 

The records and proceedings of these committees are confidential and are not subject to discovery 

or court subpoena. In addition, no person in attendance at a review may be required to testify as 

to what transpired. However, the provisions of this section do not apply to subpoenas issued 

by the Board of Medical Practice, under Title 24 Section 1731A(h), during investigations 

regarding physician competency or quality of care. Patient-identifying information must be 

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removed from peer review records disclosed to the Board of Medical Practice pursuant to a 

subpoena. 

District of Columbia 

Sections 32-501 to 505 of the District of Columbia Code cover any peer review body, member, 

or person acting as its staff or who assists such a body. Peer review in defined as, "the procedure 

by which health-care facilities and agencies, group practices, and health professional associations 

monitor, evaluate, and take actions to improve the delivery, quality, and efficiency of services 

within their respective facilities, agencies and professions...." Peer review bodies and their 

members or staff are not liable for damages or equitable relief by reason of conducting the peer 

review. The peer review must be within the scope of the review body's functions, and members 

must act in a reasonable manner. Individuals, health care facilities, health professional 

associations or group practices providing any report, information, opinion, or testimony are not 

liable for damages or equitable relief. This immunity does not apply if the person or entity 

providing the information knew it was false. 

The files, records, findings and recommendations of a peer review body, information provided to 

or obtained by the body, and the identity of persons providing information to the body is 

confidential and neither discoverable nor admissible into evidence in any civil, criminal, legislative, 

or administrative proceeding. However, this protection is qualified. In criminal proceedings, a 

court may order the peer review body to provide information if it determines that disclosure is 

essential to protect the public interest, and the information can be obtained from no other source. 

Records available from original sources are also discoverable. Health professionals may admit into 

evidence the minutes and reports of a peer review body for the limited purpose of reviewing the 

appropriateness of the adverse action. Individuals who participated in or provided information 

to the peer review body may not be compelled to testify in matters relating to the peer review 

proceeding. 

The 1995 case Jackson v. Scott (App. D.C., 667 A. 2d. 1365) confirmed that in order to be 

discoverable, materials contained in a peer review body's report must not owe their existence to 

the peer review investigation. The Court also ruled that testimony of persons who observed the 

events reviewed by a peer review committee and reported their observations to the committee 

could not testify about their statements to the committee in a medical malpractice case. 

Florida 

Florida Statutes Section 766.101 covers medical review committees of a hospital, ambulatory 

surgical center, health maintenance organization, state or local professional medical society, or 

hospital medical staff whose purpose is to evaluate and improve the quality of health care or to 

determine that services provided met the applicable standard of care. Members of a medical 

review committee, medical health care providers who furnish information, witnesses, and 

committee investigators are immune from monetary liability and causes of action. This 

protection only applies if the committee member or health care provider acts without intentional 

fraud. 

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Investigations, proceedings, and records of a medical review committee are not subject to 

discovery or introduction into evidence in any civil action against a health care provider for 

matters which are the subject of the investigation. Individuals attending medical review 

committee meetings may not testify in any civil action as to any evidence including the findings, 

recommendations or opinions of the committee. However, documents or records otherwise 

available from original sources are not immune from discovery in a civil action merely because 

they were presented in medical review committee proceedings. Persons who testified before the 

review committee or were members of the committee may testify in civil actions regarding 

matters within their knowledge but cannot be asked about their testimony to the committee or 

their opinions formed as a result of the committee's hearings. 

Under section 395.0193, health care facilities must provide for peer review aimed at reducing 

morbidity and mortality and improving patient care as a condition of licensure. The statute 

outlines peer review requirements. It also provides that members of the peer review panel may 

not be subject to a civil action for damages, nor may they be held monetarily liable for an action 

taken without intentional fraud. 

Four recent cases clarify the protections provided to peer review proceedings. Munroe Regional 

Medical Center v. Rountree ( 721 So. 2d. 1220, 1998) reaffirms the confidentiality provisions of 

section 766.101, but also states that information available from original sources other than the 

peer review committee proceedings does not become privileged simply because it was presented 

to the review committee. Furthermore, the decision allowed a witnesses to testify about what 

he/she saw or heard during surgery; but the witness could not testify regarding what he/she told a 

peer review committee about the surgery. 

In Columbia Park Medical Center v. Gibbs (728 So. 2d. 373, 1999) and Ordna Healthcorp v. 

Berghof (722 So. 2d. 961), the court ruled that physicians' applications for staff privileges, 

documents outlining them and applications for malpractice insurance were protected from 

disclosure under Florida's peer review protection statute. 

Finally, the 1999 decision Joseph L. Riley Anesthesia Associates, P.A. v. Karstetter (729 So. 2d. 

517) provided that a physician who was a member of a peer review committee that evaluated a 

medical malpractice incident could not testify as a expert witness in a malpractice action regarding 

the same incident. 

Georgia 

Georgia Code Sections 31-7-131 to 133 cover review organizations primarily composed of 

professional health care providers engaged in peer review to evaluate and improve the quality of 

care, reduce morbidity or mortality, or evaluate claims against health care providers. 

Professional health care provider is defined broadly and includes a corporation operating a 

hospital or health care facility, as well as the officers, directors, or employees of the organization 

performing peer review. Professional health care providers, members or employees of health 

care providers or peer review organizations have criminal and civil immunity for peer review 

activities. This immunity does not apply if the person was motivated by malice in conducting the 

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peer review activity. Witnesses and other individuals providing information to a review 

organization are similarly protected, unless the person providing the information knew it was 

false. 

The proceedings and records of a review organization are not subject to discovery or introduction 

into evidence in any civil action. Individuals attending a review organization's meeting cannot 

testify in a civil action as to matters presented or any findings, recommendations, evaluations, 

opinions, or other actions of the review organization. Documents or records available from 

original sources are not covered under this protection. Furthermore, individuals who participated 

in the peer review may testify as to matters within their personal knowledge. 

Sections 31-7-140 to 143 of the Georgia Code provide parallel protections for medical review 

committees. A medical review committee is defined as a committee of the state or local 

professional society or of a medical staff, hospital, or a peer review committee, which operates 

according to written bylaws to evaluate and improve the quality of care, or determine that 

services provided meet the standard of care. 

In the 1998 decision, Fulton-DeKalb Hospital Authority v. Dawson (509 S.E.2d. 28) the court 

ruled that the peer review immunity statute "does not provide an absolute shield of immunity" 

protecting utilization review providers from the consequences of their administrative acts. 

Hawaii 

Section 624-25.5 of the Hawaii Revised Statutes establishes confidentiality protection for peer 

review committees. Proceedings and records of peer review and quality assurance committees are 

not subject to discovery. However, original sources of information such as incident reports or 

occurrence reports are discoverable. No person in attendance at a meeting can be required to 

testify as to what transpired at the meeting. This prohibition does not apply to individuals who 

are a party to an action the subject matter of which was reviewed at the meeting or to any person 

requesting hospital staff privileges. 

Section 663-1.7 of the Hawaii Revised Statutes covers peer review committees created by a 

professional society, hospital, or clinic staff to maintain professional standards established in the 

organization’s bylaws. It also covers hospital or clinic quality assurance committees. Committee 

members and individuals who file complaints or appear as witnesses before these committees are 

immune from civil liability, as long as they acted without malice. Individuals who provide 

information at committee meetings are also immune from civil liability unless the person knew 

the information provided was false. Professional societies, hospitals, and clinics are generally not 

immune from liability, except for communicating any conclusion reached by their peer review or 

quality assurance committees to a similar organization, or to a governmental agency or board. 

Last, sections 671D-4 to 671D-11 cover professional review actions taken by a professional 

review body, as defined by the statute. Under these sections, the professional review body, its 

members and staff, and persons assisting the body with respect to a professional review action 

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may not be held liable for damages. There are exceptions to this provision for antitrust cases 

brought by the state and civil rights cases. Witnesses to the professional review body are not 

protected if they knowingly provide false information. Finally, professional review actions must 

be taken with the reasonable belief that the action would improve the quality of health care, after 

the physician involved was provided reasonable notice, and with the reasonable belief that the 

action was warranted by the facts. Actions that do not meet these basic standards are not 

protected. 

Idaho 

Idaho Code Sections 39-1392a to 1392f require hospitals have in-hospital medical staff 

committees which review the care provided by the medical staff for the purpose of reducing 

morbidity and mortality. The furnishing of information to medical staff committees or medical 

society committees or the subsequent use of this information by these committees will not 

subject any person, hospital, or agency to any liability or action for monetary damages or other 

legal or equitable relief. Persons knowledgeable about information presented to a committee may 

not disclose this information except as authorized by the Idaho State Board of Medicine, or for 

the sake of determining hospital privileges. All written records and all reports related to a 

committee hearing are the property of the hospital or medical society. This provision does not 

alter a patient’s right to access to his/her hospital chart. 

All written records of interviews, all reports, statements, minutes, memoranda, and physical 

materials relating to the review of any in-hospital medical staff or medical society committees are 

confidential and privileged. They are not subject to subpoena or discovery proceedings. 

The statute also provides for certain exceptions to the privilege and confidentiality protections. 

In a civil action against a physician or a hospital in a matter related to an investigation or review, 

the hospital or medical society can, under certain circumstances, disclose the action the 

committee took and the names and addresses of persons who have direct knowledge of the care 

provided. 

Illinois 

Section 85/10.2 of Title 210 of the Illinois Compiled Statutes provides that no hospital or 

individual who is a member, agent, or employee of the hospital, its medical or administrative 

staff, or the hospital board shall be liable for civil damages as a result of peer review activities, 

quality review, morbidity or mortality studies, or professional discipline activities. There is an 

exception to this immunity if the challenged review activities constitute "willful and wanton 

misconduct." 

Illinois Compiled Statutes at 225 ILCS 60/5 provides immunity to persons serving on 

committees whose purpose is internal quality control to reduce morbidity and mortality or 

improve patient care. These committees may be organized by a hospital or a professional 

association. Any person serving on such committee or providing service to such committee may 

not be liable for civil damages as a result of acts, omissions, or decisions of the committee. The 

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immunity does not apply to acts involving willful or wanton misconduct. People furnishing 

information to these committees are also protected from any action for damages or other relief. 

Under 735 Illinois Compiled Statute 5/8-2101, information, interviews, reports, statements, 

memoranda, or other data of these committees are privileged and can be used only for statutorily 

specified purposes including medical research, evaluation, and improvement of quality care. 

Such information is not admissible as evidence or discoverable in any action. The claim of 

confidentiality, however, cannot be used to deny a physician in a state privileging action access 

or use of data upon which a privileging decision was based. 

Two 1998 cases clarify these confidentiality and privilege provisions. In Doe v. Illinois Masonic 

Medical Center (705 NE 2d. 436), the court confirmed that promoting peer review is not the only 

purpose of the Medical Studies Act; it exempts documents used by hospitals and other providers 

in the course of research from disclosure as well. Thus, the hospital’s institutional review board 

was a committee and documents relating to the experimental pre-implantation genetic testing 

procedure used by the hospital to reduce the incidence of cystic fibrosis were protected from 

discovery in a malpractice case. In Chicago Trust Company v. Cook County Hospital (698 N.E. 

2d. 641), the court ruled that documents created by a hospital in response to an accidental patient 

discharge were discoverable because the documents were not created, prepared, or generated by 

the hospital’s oversight committee. 

Indiana 

Sections 34-30-15-1 through 34-30-15-21, Indiana Code Annotated, provide immunity and 

confidentiality protections for peer review committees. Peer review committees are defined in 

section 34-6-2-99 to include committees organized by a state or local organization of health care 

providers, or the governing board or professional staff of a health care facility. Peer review 

committees, as defined in the statute, evaluate the qualifications of health care providers, patient 

care rendered by health care providers, and the merits of complaints against health care providers. 

All communications to a peer review committee are privileged and proceedings of a peer review 

committee are confidential. Peer review committee personnel and participants are not allowed to 

reveal any communication, records, or determination of a peer review committee. However, the 

governing board of a hospital or professional health care organization may disclose the final 

action taken with regard to a health care provider. No person in attendance at a peer review may 

disclose any information acquired during the course of a proceeding. Furthermore, records or 

determinations of a peer review committee are not subject to subpoena or discovery, nor are they 

admissible as evidence, except in certain cases. Information discoverable from original sources is 

not immune from discovery. A professional health care provider, a peer review committee, a 

governing board of a hospital or other professional health care organization may use information 

obtained by a peer review committee for legitimate internal business purposes, including 

reduction of morbidity and mortality. 

Peer review committee personnel are protected from liability for any act, statement, or 

proceeding made in good faith in regard to evaluation of patient care. Personnel of a peer review 

committee are also immune from civil actions arising from any determination made in good faith. 

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In addition, the immunity protection applies to a peer review committee, an organization, or any 

person who, in good faith furnishes records, information or assistance to a peer review 

committee, unless the person knowingly furnishes false records or information. 

Iowa 

Iowa Code Sections 135.40 to 135.42 specifically apply to morbidity and mortality studies 

conducted by the Iowa Medical Society or any of its allied medical societies, or any in-hospital 

staff committee. 

Persons, hospitals, or other organizations that provide information, reports, interviews or other 

data for such studies are provided immunity from civil liability. This same protection also 

applies to any person or group which releases or publishes the findings and conclusions of such 

studies. The findings of morbidity and mortality studies may only be used or published for the 

purpose of advancing medical research or education, except that a summary may be released for 

general publication. All information, interviews, reports, statements, memoranda, data, findings 

and conclusions from these studies are not to be used, offered or received in evidence in any legal 

proceedings. The Code does not exempt from discovery primary medical or hospital records. 

Iowa also has more general peer review statutory protection. Section 147.135 provides immunity 

to individuals from civil liability arising in connection with service on a peer review committee, 

providing information to such a committee, or filing a complaint with one. Peer review records 

are privileged and confidential and not subject to discovery or admissible in evidence, with some 

exceptions. A person present at a peer review committee meeting may not testify about the 

proceeding, other than a license disciplinary action or action brought by a licensee who was the 

subject of the review and whose competence is at issue. 

Kansas 

Sections 65-177 to 65-179 of the Kansas Statutes Annotated allow the secretary of health and 

environment to conduct medical research studies for the purpose of reducing morbidity or 

mortality from maternal, perinatal, and anesthetic causes. These studies can be conducted by the 

secretary’s staff or other qualified persons, agencies or organizations. All data provided for these 

studies must be treated as confidential and be used only for the purpose of medical research. The 

research files, and opinions expressed about the data are inadmissible as evidence, but statistical 

findings of the study are admissible. Also, this section does not affect a patient's right to access 

his/her medical record or to have the record entered into evidence. The statute prohibits 

interviews with patients named in a report or their relatives, but authorizes the publication of 

final reports or statistical compilations so long as the names of individuals and institutions are 

not identified. Physicians, hospitals or other persons who furnish data for these research studies 

are not subject to any action for damages or other relief. There is no explicit grant of immunity to 

members of a committee involved in such a study. 

Section 65-4915 protects peer review committees, which include committees of state or local 

professional associations, organized medical staff, or health maintenance organizations that 

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function to evaluate and improve quality of health care or to reduce morbidity or mortality. 

Reports, statements, records, proceedings, and findings of these peer review committees are 

privileged and are not subject to discovery or subpoena and are inadmissible as evidence in any 

proceeding. Information contained in these records is also not discoverable in the form of 

testimony by an individual who participated in the peer review process. These protections do 

not apply to licensing or disciplinary proceedings of a health care provider. 

Sections 65-4909 and 65-442 provide immunity to these same individuals and organizations for 

performance of their functions, provided they acted in good faith and without malice. 

Kentucky 

Section 311.377 of the Kentucky Revised Statutes Annotated protects members, participants, or 

employees of committees of any licensed hospital, health maintenance organization, organized 

medical staff, medical society, or designated affiliated medical association for good faith actions in 

reviewing and evaluating the competency of conduct of other health care personnel. The 

proceedings, records, opinions, conclusions, and recommendations of any committee, medical 

staff, or other entity are confidential and privileged. Furthermore, they are not subject to 

discovery, subpoena, or introduction into evidence in any civil action or in any administrative 

proceeding. The statute does not restrict from discovery any evidence, document, or record 

which is subject to independent discovery. No person will be permitted or compelled to testify 

concerning his/her testimony or the testimony of others except that a defendant in a lawsuit may 

testify about such matters. Testimony and records related to the review may be presented in a 

statutory or administrative proceeding related to the duties of the review entity. 

Louisiana 

Louisiana Revised Statutes Section 13:3715.3 provides immunity from damages for peer review 

committees, committee members, and organizations sponsoring these committees. This 

immunity applies as long as the action or recommendation was made without malice and in the 

reasonable belief that the action or recommendation is warranted by the facts. Employees, 

physicians, hospitals, organizations, or institutions furnishing information, data, reports, or 

records to any of these committees are not liable in damages for providing information. All 

records, notes, data, studies, analyses, exhibits, and proceedings of the committee are 

confidential. They are not available for discovery or court subpoena except in lawsuits brought 

by a physician for termination of staff privileges. Records or documents which are otherwise 

discoverable from original sources are discoverable. 

Two cases have further clarified the qualified immunity given to review committee members. In 

the 1994 case Smith v Our Lady of the Lake Hospital, Inc. (639 So. 2d. 730), the court found 

that qualified immunity protects committee members from liability on damages only, not from 

litigation in general. Furthermore, qualified immunity protects individuals not entities. The 

surgeon involved in the case, who sought to reinstate his hospital privileges, was allowed to sue 

the hospital for injunctive relief. 

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Also Smith v. Our Lady of the Lake Hospital, Inc. confirmed that peer review actions must be 

taken without malice in order for qualified immunity to apply. However, the court determined 

that a competitor's participation in peer review alone was not enough to infer malice. Also, the 

fact that the medical review was carried out by a professional society committee rather than an 

internal committee of the surgeon's peers did not add up to malice. 

Finally, in the 1998 case Zamanian v. Christian Health Ministry (715 So. 2d. 57), the "good 

faith" requirement for qualified immunity was interpreted to mean that committee members had 

reasonable grounds for believing that a statement is correct, but did not require ultimate proof 

that the statement was true. Moreover, mere allegations of bad faith were not enough to refute 

qualified immunity without further evidence of personal animosity. 

Maine 

Title 24, Maine Revised Statutes Sections 2502, 2510-A, 2510-B, and 2511 protect professional 

competence committees (as defined by the statute) whose study and actions aim to maintain and 

improve the quality of care rendered by a health care entity or physician, reduce morbidity and 

mortality, or establish and enforce professional standards. Members of professional competence 

committees or professional review committees are immune from civil liability as long as their 

actions are taken without malice. 

Title 32, Maine Revised Statutes Sections 2599, 3293 and 3296 contain provisions relevant for 

review committees. A physician licensed in Maine who is a member of a medical review, peer 

review, or disciplinary committee is immune from civil liability for undertaking or failing to 

undertake an act. The committee must be established either as a requirement of accreditation by 

the Joint Commission on Accreditation of Hospitals, by a state or county professional society, 

or the Board of Licensure in Medicine. All proceedings and records of proceedings of medical 

staff review committees are confidential and exempt from discovery. 

Records of professional competence committees are privileged and confidential. With limited 

exceptions, they cannot be subject to subpoena or admitted as evidence in any civil, judicial or 

administrative proceeding. Professional competence review records may be used in a proceeding 

in which a physician contests a professional competence review action taken against him/her, or 

in an action in which the review committee uses the documents in its own defense. Furthermore, 

a professional competence committee may furnish records to other professional review bodies, 

the physician who is the subject of the review, and his/her attorney, agents or representatives. 

Last, professional competence committees may release a physician’s professional status 

information . 

In the 1996 case Benjamin v. Aroostook Medical Center (937 F. Supp. 957), the court 

interpreted this immunity provision as protecting members of professional competence 

committees for liability for any report of information made available to a licensure board. 

Members were determined to be shielded not only from claims for damages but from any suit. 

The same decision further defined “malice” as “actual malice” or ill will, or “implied 

malice”—“reckless disregard for the truth or falsity of slanderous element of statement.” 

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Maryland 

Sections 14-501 to 14-504, Maryland Health Occupations Code Annotated, protect medical 

review committees that function to evaluate and improve the quality of health care or to 

discipline health care providers. Members of a medical review committee acting in good faith or 

persons who furnish information to or participate in a medical review committee are immune 

from civil suit. 

Proceedings, records, and files of a medical review committee are confidential and are not 

discoverable or admissible as evidence in any civil action arising out of matters that are being 

reviewed and evaluated by the committee. This protection does not apply to documents 

otherwise subject to discovery, or to civil actions brought by a party to a review committee 

proceeding who claims to be aggrieved by a decision of the review committee. 

During the 2000 legislative session, the Maryland Legislature added Maryland Health General 

Code Sections 13-1001 to 13-1007. This section establishes a Maternal Child Health Committee 

to review cases of maternal deaths and issue recommendations for the prevention of maternal 

mortality. This committee is considered a medical review committee and is entitled to the 

protections provided for under section 14-501 of the Health Occupations Code. 

Massachusetts 

Massachusetts Annotated Laws Chapter 231, Section 85N protects members of a professional 

society or an appointed committee thereof, or members of a committee of a hospital medical staff 

or a health maintenance organization from civil liability as a result of acts, omissions, or 

proceedings of such committees, as long as they acted in good faith. Such members are also 

protected from liability for acts, omissions, or proceedings performed within the scope of their 

duties for a nonprofit corporation, the sole voting member of which is a physicians’ professional 

society. Peer review records may be discovered and testimony of witnesses present at the 

committee proceedings may be used in actions pursuant to Chapter 231, Section 85N. In such 

cases, neither the witness nor members of a committee may be questioned regarding the witness’ 

testimony before the committee or the identity of any person furnishing information or opinions 

to the committee. 

Section 1 of Chapter 111 defines a medical peer review committee as a committee of a state or 

local professional society of health care providers, or of a medical staff of a hospital or health 

maintenance organization established for the purpose of evaluating or improving the quality of 

health care services. Confidentiality of the proceedings, reports, and records of a medical peer 

review committee are protected by Chapter 111, Section 204 from subpoena, discovery, or 

introduction into evidence in any judicial or administrative proceeding, except for proceedings 

conducted by the board of registration in medicine. Also under Chapter 111, Section 204, no 

person who was in attendance at a medical review committee meeting is permitted or required to 

testify in any judicial or administrative proceeding, other than a proceeding before a board of 

registration, regarding the proceedings or findings of the committee. However, documents 

available from original sources are not immune from discovery simply because they were 

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presented in a medical review proceeding. Witnesses may testify to matters known independent 

of the committee’s proceedings. 

In 1998, a Massachusetts court ruled that hospital incident reports were a necessary byproduct 

of a medical review committee’s work and thus were shielded from discovery. (Carr v. Howard 

689 N.E. 2d. 1304) 

Michigan 

Section 331.531, Michigan Compiled Laws, offers protection from civil or criminal liability to 

persons, organizations, or entities acting as a review entity. Persons, organizations, or entities 

are also offered immunity for providing information or data to a review entity. These protections 

do not apply if the persons, organizations, or entities acted with malice. A review entity is 

defined, in part, as a duly appointed peer review committee of a state or county association of 

health care professionals, a health care facility, or a health care association. Section 331.532 

authorizes the publication of the committee’s findings or proceedings for the limited purposes of 

advancing health care research or health care education, maintaining the standards of the health 

care professions, or disciplining a health care provider. Section 331.533 requires that a review 

entity remove a patient’s name and address from the record before releasing its findings or 

proceedings. Also, under this section, an entity’s findings and proceedings are considered 

confidential and are not discoverable and are not to be used as evidence in any civil action or 

administrative proceeding. 

Section 333.21513 requires hospitals to organize their medical staff for the purpose of enabling 

effective peer review to reduce morbidity and mortality and improve care. Under section, 

333.21515, the records, data and knowledge collected by individuals and committees conducting 

peer review are confidential and are not available for court subpoena. 

Minnesota 

Minnesota Statutes Sections 145.61 to 145.67 cover review organizations including a committee 

of a hospital, clinic, state or local professional association, or a health maintenance organization. 

These committees must have a purpose described in the statute. Covered committees include, 

among others, those established to reduce morbidity or mortality, develop or review professional 

standards, or determine whether action should be taken against a professional's staff privileges or 

professional association membership. Review organizations and their members and employees 

are not liable for damages or other relief for their review activities or recommendations unless 

they were motivated by malice. This protection also applies to a person, firm, or corporation 

which provides information to a review organization, unless the person knew or had reason to 

believe the information was false. 

All data and information acquired by a review organization is confidential except to the extent 

necessary to carry out the purpose of the review. The proceedings and records are not subject to 

discovery or introduction into evidence in any civil action against a professional arising out of the 

matter which is the subject of review. This information is protected from subpoena and 

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discovery, except for professionals seeking data relating to their medical staff privileges.­

Documents or records from original sources are not immune from discovery. Also, no personshall disclose what transpired in a review meeting. An exception is made for disclosuresnecessary to further the committee's purpose. Persons who were members of or witnesses to thereview committee may testify in other actions provided that they are not questioned about theirtestimony before the committee or opinions formed as a result of the proceedings.­

Some recent cases clarify these immunity and confidentiality provisions. Doctor's Medical Clinicv. Jackson (581 N.W. 2d. 30, 1998) established that a hospital and members of its review 

committee were immune from liability for equitable relief in an action where a physician 

challenged the revocation of his privileges. 

In re: Fairview University Medical Center (590 N.W. 2d. 150, 1999) reaffirmed the 

confidentiality protections granted to review organization documents, ruling that confidentiality 

applies to all documents in peer review organization files—including those from other sources. 

The court further ruled that the Board of Medical Practice complaint committee could not 

subpoena a review organization's records because it did not qualify for the exception to 

confidentiality provided to disclosures necessary to carry out functions of the review 

organization. 

Mississippi 

Mississippi Code Annotated Sections 41-63-1 to 41-63-9 apply to medical review committees of 

a hospital, state or local medical society, health maintenance organization or other health care 

facility established to evaluate and improve the quality of health care services or the competence 

of health care practitioners. Hospitals, review committees, and their members are not liable in 

damages for any action or recommendation taken by the committee if they act without malice. 

Physicians, nurses, hospitals, and other institutions who provide medical information to the 

committee are also immune from liability. 

The proceedings and records of any medical review committee are confidential and are not subject 

to discovery or introduction into evidence in lawsuits arising out of matters which are the subject 

of evaluation and review by the committee. These protections do not apply in any legal action 

brought by a medical review committee to restrict or revoke a physician’s license to practice 

medicine or hospital staff privileges, or for review actions alleged to be malicious. In addition, 

records from original sources are admissible. Persons attending a committee meeting may not be 

permitted or required to testify about committee findings or other committee matters. This 

provision does not prohibit witnesses or committee members from testifying about other matters 

within their knowledge as long as they are not questioned about their testimony to the committee 

or their opinions formed as a result of the committee proceedings. These provisions limiting 

discovery do not apply to legal actions brought by a committee to restrict or revoke a physician's 

privileges, nor do they apply to legal actions brought by aggrieved physicians against a 

committee member in which malice is alleged. 

Sections 41-63-23 through 41-63-29 also provide protections from discovery or introduction into 

evidence for accreditation and quality assurance materials of health care organizations. Persons 

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involved in the preparation, evaluation or review of these materials are not permitted nor can 

they be required to testify in any civil action as to any evidence, findings, or recommendations. 

Information or records from original sources are admissible. These provisions do not apply in 

any legal action brought by a health care entity to restrict or revoke a physician’s license to 

practice medicine or hospital staff privileges, or for review actions alleged to be malicious. 

A 1998 case Claypool v. Mladineo (724 So. 2d. 373) further defined the limits on privilege for 

granted to peer review committees. The court stated that generally records and transcripts of 

peer review proceedings were confidential, but that confidentiality did not apply to otherwise 

discoverable material. Furthermore, the plaintiff in the case was entitled to review committee 

documentation that would tell him where to find this otherwise discoverable information. Also, 

persons present at the committee meeting could testify regarding matters not specifically 

prohibited by the statute; and the review committee was obligated to provide the plaintiff with 

names and addresses of those in attendance at the committee meetings in order to schedule 

depositions of those persons. 

Missouri 

Revised Statutes of Missouri Section 537.035 covers peer review committees appointed by a 

state, county, or local society of health care professionals, the medical staff of a hospital or other 

health facility to evaluate or monitor the quality of health care services. Each committee member, 

person, and hospital governing board who participates in the operation of a peer review 

committee is immune from civil liability for acts performed in good faith without malice within 

the reasonable scope of committee inquiry. This protection also applies to those who testify 

before or provide information to the committee. 

The proceedings, findings, deliberations, reports, and minutes of the committee are not subject to 

discovery or subpoena nor are they admissible into evidence in any judicial or administrative 

action for failure to provide appropriate care. Information otherwise discoverable or admissible 

from original sources is not covered by these prohibitions. The provisions limiting discovery 

also do not apply in any judicial or administrative action brought by a peer review committee to 

deny, revoke, or restrict staff privileges or license, or when the committee is sued for carrying out 

its responsibilities. No person attending a peer review proceeding may testify about committee 

matters. But, member, agent, employee or witness to the committee may testify regarding 

matters within his/her knowledge as long as he/she is not questioned regarding his/her testimony 

to the committee or opinions formed as a result of the committee proceeding. 

In Health Midwest Development Group, Inc. v. Daugherty (965 S.W. 2d. 841, Supp. 1998) 

physician-patient privilege did not preclude discovery of hospital peer review committee records 

in a physician's action against a hospital contesting the restriction of his staff privileges. 

However, identifying information must be removed from patient records. 

In Dixon v. Darnold (939 S.W. 2d. 66) the court ruled that a party opposing discovery of peer 

review records based on the privilege provisions of the statute must show how discovery of the 

documents violates peer review privilege. A simple assertion of privilege is not sufficient. 

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Montana 

Section 37-2-201 of the Montana Code immunizes members of peer review committees or 

professional standards review committees of a health care professional society from civil suit, if 

they act without malice and in the reasonable belief that their actions or recommendations are 

warranted. The proceedings and records of such a committee are not subject to discovery or use 

as evidence in any proceeding. However, documents available from original sources are 

discoverable. Persons present at a committee meeting cannot be questioned about committee 

proceedings, although such a person may testify about matters they learned about apart from the 

meeting. Immunity is extended to those in a nonprofit corporation engaged in peer review, 

medical ethics review, or professional standards review. Section 37-3-404 provides immunity to 

those who provide information to the state board of medical examiners as required by 37-3-401, 

37-3-402, or 37-3-403. 

Section 50-16-102 gives immunity to anyone giving information relating to infant morbidity and 

mortality to the state health department, a medical association, or hospital or medical society 

committee, or a nationally organized medical society or research group. The identity of persons 

who are the subject of mortality studies is confidential, and infant mortality data and studies may 

not be used in legal proceedings. 

Sections 50-16-201 to 50-16-205 grant access to hospital records to medical staff committees 

organized to reduce morbidity and mortality. Committee data and records are privileged and 

confidential, and are not admissible as evidence in any judicial proceeding. Committee data and 

records may be published only for the purpose of evaluating medical care, therapy and treatment 

for research or statistical purposes. The committee may not disclose the identity of any patient 

whose records have been studied. These confidentiality provisions do not limit the 

discoverability of patient hospital records. 

Nebraska 

Section 25-12,121 of the Revised Statutes of Nebraska gives immunity to hospital medical staff 

committees, their members and agents, for action for damages if such an action is related to a 

committee recommendation concerning hospitalization or confinement in an extended care 

facility. In addition, peer review proceedings and records of a state or local health professional 

association are confidential, and the records and proceedings are not subject to discovery or 

admissible in evidence, under Section 25-12,123; however, records otherwise available from 

original sources are not immune from discovery or use in a civil action merely because they were 

presented during committee proceedings. This section also applies to health practitioner peer 

review committees of state or local health care professional societies. No committee member or 

witness may testify about his or her testimony before the committee or about committee 

opinions, but may testify as to matters within his/her knowledge. A court may, however, order 

disclosure of such committee proceedings, minutes, records, reports, or communications for good 

cause. 

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Immunity for peer review committee members is based on Section 71-147.01. It protects 

members of peer review committees of state or local professional associations from liability, if 

they act without malice and in the reasonable belief that such action or recommendation is 

warranted by the facts known to them. Nebraska law gives particular protection to morbidity 

and mortality proceedings. Sections 71-3401 to 3403 deal with studies conducted by the 

Nebraska State Medical Association or the Department of Health to reduce morbidity and 

mortality. The statute immunizes from civil suits any person providing information for such a 

study or releasing the findings of such a study to advance medical research or education. The 

identity of patients must be kept confidential. None of the information, interviews, reports, 

statements, or memoranda furnished for the study, and none of the study findings, can be 

introduced as evidence in any legal proceeding, unless confidentiality is waived by the interested 

parties. 

Section 71-7903 provides that information and communications originating in peer review 

committees are privileged communications and are not discoverable unless the privilege is waived 

by the patient and a court orders the disclosure of such proceedings or communications. Privilege 

does not extend to medical records kept with respect to a patient in the ordinary course of 

business of operating a clinic, organization, or association of practitioners or providers, or to 

production of evidence relating to the treatment of any patient in the ordinary treatment course. 

Nevada 

Sections 49.117 through 49.123 of the Nevada Revised Statutes protect review committees. 

Review committees are defined as committees organized by a hospital, other medical facility or a 

medical society to evaluate and improve the quality of care. Review committees may refuse to 

disclose their proceedings, records and testimony presented before them. Any member of the 

committee, person whose work was reviewed by the committee or witness to the committee may 

claim this privilege. With limited exceptions, this privilege is presumed unless all parties entitled 

to claim privilege sign a written waiver of privilege. 

Section 49.265 of the Nevada Revised Statutes further exempts from discovery the proceedings 

and records of review committees of medical societies. A person attending a committee meeting 

may not be compelled to testify concerning the proceedings. However, statements of persons 

who are parties to a later lawsuit relating to the committee’s action are subject to discovery, as 

are statements made by any person requesting staff privileges at a hospital. There are no 

statutory immunity protections for peer review activities related to quality of care or morbidity 

or mortality reviews. 

A 1997 case limited the types of documents immune from discovery. In Columbia/HCA 

Healthcare Corp. v. Eighth Judicial District Court ex. rel. County of Clark (936 P.2d. 844) the 

court ruled that hospital occurrence reports, which were factual reports about an incident, 

contained the type of information that would be obtained through traditional discovery. 

Therefore, if a plaintiff could not obtain the information contained in the occurrence report from 

other sources, the plaintiff should be denied access to the occurrence report. 

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New Hampshire 

Members of professional standards review committees are afforded immunity for good faith 

actions taken by the committee. For physicians and nurses this includes committees organized 

by a state or federal agency, or a society or association affiliated with the American Medical 

Association, the American Nurses Association, or the Medical Care Foundation. Section 507:8-

C, New Hampshire Revised Statutes. 

Under Section 151:13-a of the New Hampshire Revised Statutes, hospitals, trustees, medical 

staff members, employees, and attendees at a hospital committee reviewing matters related to 

care and treatment or to morbidity or mortality cannot be held liable for providing information to 

the committee, and the committee records are privileged and confidential and not discoverable or 

admissible into evidence, except in the case of a legal action brought by a quality assurance 

committee to revoke or restrict a physician’s license or hospital staff privileges, or in a 

proceeding alleging repetitive malicious action and personal injury brought against a physician, 

then a committee’s records shall be discoverable. The hospital board of directors or trustees 

may waive this privilege and release information in conjunction with an administrative or judicial 

proceeding. Since a hospital’s governing board may waive the privilege, negative implication is 

that no one else may do so. 

Section 329:29 provides confidentiality protection to records, proceedings, findings and 

deliberations of medical review committees of county or state medical societies or committees of 

the board of registration in medicine. The records are not discoverable or admissible as evidence 

in a legal proceeding. A medical review committee may provide information to a hospital review 

committee, including a hospital morbidity and mortality committee, subject to the privileges and 

immunities set forth in 151:13-a. 

In Smith v. Alice Peck Day Memorial Hospital, 148 F.R.D. 51 (D.N.H. 1993), quality assurance 

privilege was inapplicable in litigation challenging the hospital’s revocation of a physician’s staff 

privileges. The ordinary record of a patient’s treatment remains admissible into evidence, even 

though a hospital QA committee may have studied the record and issued a privileged report 

based on data from the treatment record. In re “K” (1989) 132 NH 4, 561 A2d 1063. 

New Jersey 

Sections 2A:84A-22.8 and 2A:84A-22.9 of the New Jersey Statutes protect utilization review 

committees of hospitals or extended care facilities. They provide immunity for committee 

members and limited confidentiality for committee information. 

Under Section 2A:84A-22.10 members, staff or consultants of a hospital review committee or 

local, county or state medical society whose function is to improve the quality of health care are 

immune from liability for their recommendations or actions made within the scope of the review, 

as long as they act without malice. 

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Section 26:1A-37.2 establishes confidentiality protection for information held by the Department 

of Health and procured in connection with research studies approved by the Public Health 

Council for the purpose of reducing morbidity and mortality. Such information may not be 

disclosed to anyone not participating in the study, unless patient-identifying information is 

removed. 

New Mexico 

Sections 41-9-2 to 41-9-6 of the New Mexico Statutes provide immunity to organizations of 

health care providers established by state or local associations to gather patient care information 

for the purpose of improving the quality of care, reducing morbidity and mortality, obtaining or 

disseminating statistics and information about treatment or prevention, and other miscellaneous 

purposes. Persons providing information to the organization are immune from a lawsuit unless 

they have reason to know that the information is false. Organization members, employees, and 

advisors are immune from a lawsuit if they act without malice and in the reasonable belief that 

their actions are warranted. 

The information acquired by a protected organization shall not be disclosed except to the extent 

necessary to carry out the organization’s purpose or in a judicial appeal of an action by the 

organization. However, records otherwise available from original sources are not immune from 

discovery or use in a civil action. Committee members may not disclose what happened at any 

meeting except where necessary to further organization purposes. Members of and witnesses to 

the organization may testify regarding matters within their knowledge as long as they are not 

asked about opinions formed as a result of the organization’s hearing. 

The 1998 case, Giron v. Corrections Corporation of America (14 F. Supp. 2d. 1245) established 

that records relating to a mortality and morbidity review are confidential and not discoverable in a 

medical malpractice action. 

New York 

Section 6527 of the Education Law covers hospital review committees, committees of a local, 

county, or state medical society with the responsibility of evaluating and improving the quality 

of health care, as well as the society itself or an individual performing a quality assurance review 

function. Members of the committee cannot be held liable for any committee-related 

recommendation or action, if they act without malice and in the reasonable belief that the act or 

recommendation was warranted, based on the disclosed facts. Similar immunity is afforded to 

individuals and entities providing information or recommendations concerning the qualifications, 

conduct, or practice of a physician to a government agency, medical society, or hospital. 

The proceedings and records relating to the committee’s review are not subject to discovery, and 

persons attending a committee meeting may not be required to testify about the meeting. An 

exception to this prohibition is made for statements of a person attending a meeting who is later 

party to a lawsuit, the subject matter of which was reviewed at the meeting. 

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Section 206(1)(j) of the New York State Public Health Law provides immunity to the health 

commissioner and designees conducting morbidity/mortality and quality improvement in medical 

care audits. No information is admissible as evidence in any action in any court and is 

confidential. 

Section 2805-j of the New York State Public Health Law establishes medical, dental and podiatric 

malpractice prevention programs and quality assurance committees for their oversight. Persons 

who provide information to the program or participate in the quality assurance committee are 

immune, as are hospitals and persons acting on behalf of the hospital who take or do not take 

action as a result of a review, provided that nothing shall relieve any hospital of liability in an 

action for malpractice based on an act or failure to act as a result of a review conducted. Section 

2805-m provides for confidentiality of records, documentation, or committee actions. No person 

in attendance at committee meetings shall be required to testify as to what transpired at the 

meeting. Prohibition relating to discovery of testimony does not apply to statements made by 

any person in attendance of meetings who is a party to an action or proceeding, the subject 

matter of which was reviewed at the meeting. 

North Carolina 

North Carolina law protects medical review committees of a hospital or appointed by a state or 

local professional society, or a committee of a peer review corporation or organization for the 

purpose of evaluating the quality of health care, cost of, or necessity for hospitalization, and 

medical staff credentialing. Section 131E-95 of the General Statutes of North Carolina grants 

immunity to committee members for actions taken without malice or fraud. It also protects 

committee proceedings and records and materials considered or produced during the review from 

discovery or introduction into evidence in civil suits resulting from matters that are the subject of 

evaluation and review. No person can be required to testify about the matters presented to the 

committee or its findings, recommendations, evaluations, opinions, or other actions. However, 

information, documents, or records otherwise available from original sources are not protected 

from discovery. A member of the committee or person who testifies before the committee may 

testify in a civil action, but cannot be asked about his testimony before the committee or 

opinions formed as a result of the committee hearings. Information that is confidential and not 

subject to discovery or use in civil actions as outlined above may be released to a professional 

standards review organization performing accreditation or certification functions. This type of 

information is limited to what is reasonably necessary and relevant to the standards review 

organization’s determination to grant or continue accreditation or certification. The information 

released retains its confidentiality and is not subject to discovery or use in civil actions. 

In Shelton v. Morehead Mem. Hosp., 318 N.C. 76, 347 S.E. 2d 824 (1986) information from 

original sources was not immune from discovery merely because it was presented during the 

medical review committee proceedings, and members of a medical review committee were not to 

be prevented from testifying regarding information learned from other than committee sources, 

even though that information might have been shared by the committee. 

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Section 90-21.22 permits the North Carolina Medical Board to enter into agreements with the 

North Carolina Medical Society and its local medical society components for the purpose of 

conducting peer review activities including investigation, review and evaluation of records, 

reports, complaints, litigation and other information about practices and practice patterns of 

physicians licensed by the Board, including programs for impaired physicians. The purpose of 

the programs shall be to identify, review, and evaluate the ability of physicians to function in 

their professional capacity and to provide programs for treatment and rehabilitation. Any 

confidential patient information and other nonpublic information is confidential and not 

discoverable in civil cases. Persons participating in good faith in the peer review programs shall 

not be required to disclose information in civil suits and peer review activities conducted in good 

faith are sanctioned by the State. 

Section 90-21.22A protects medical review committees formed for the purpose of evaluating 

quality of, cost of, or necessity for health care services, including provider credentialing. 

Members of such committees who act without malice or fraud shall not be subject to liability for 

damages in civil actions because of acts, statements, or proceedings performed within the scope 

of the functions of the committee. The committee’s proceedings, records and materials it 

produces, and materials it considers are confidential and not considered public records and shall 

not be discoverable in civil actions. No person in attendance at a committee meeting can be 

required to testify in civil actions as to evidence or matters produced or presented during the 

proceedings of the committee, or as to findings, recommendations, evaluations, opinions, or other 

actions of the committee or its members. Committee members may testify in civil actions, but 

cannot be asked about their testimony before the committee or any opinions formed as a result of 

committee hearings. 

North Dakota 

Section 23-34-03 of the North Dakota Century Code states that peer review records including 

data, information, reports, documents, findings, compilations and summaries, testimony, and any 

other records generated by, acquired by, or given to a peer review committee are privileged and 

not subject to subpoena or discovery or introduction into evidence in any civil or administrative 

action, except records gathered from an original source that is not a peer review committee, 

testimony from a person as to matters within that person’s knowledge, provided the information 

was not obtained as a result of the person’s participation in a professional peer review; or peer 

review records subpoenaed in an investigation conducted by an investigative panel of the board of 

medical examiners or subpoenaed in a disciplinary action before the board of medical examiners. 

Section 23-01-15 established confidentiality for information, reports, and other data used in 

connection with a study conducted by or with the state department of health for the purpose of 

reducing morbidity or mortality. This information is inadmissible in a judicial or administrative 

proceeding. No research participant may disclose this confidential information, and no patient 

named in a report or a patient’s relative may be interviewed without the prior consent of the 

attending physician and surgeon. 

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Ohio 

Section 2305.25 of the Ohio Revised Code contains immunity protections for peer review or 

professional standards review committees of hospitals or state or local medical societies. 

Committee members, employees, and persons providing information to the committee are 

immune from lawsuits if their official actions are carried out without malice and in the reasonable 

belief that the action is warranted by the facts. 

Under Section 2305.251, proceedings and records are not subject to discovery or use as evidence, 

and no person is permitted or will be required to testify about committee matters, including the 

findings, recommendations, or actions of the committee. These protections only extend to civil 

suits arising out of the matters which are at issue before the committee. Documents available 

from original sources are not immune from discovery simply because the committee saw them. 

Similarly, witnesses may testify about matters discussed before the committee if the witness had 

independent knowledge of those matters. This permission to testify does not extend to any 

opinion formed as a result of the committee meeting. Section 2305.24 extends similar 

confidentiality protections to hospital quality assurance and utilization review committees. 

Oklahoma 

Title 63, Section 1-1709, of the Oklahoma Statutes protects studies for the purpose of reducing 

morbidity or mortality conducted by the State Board of Health, the Oklahoma State Medical 

Association, or any committee or allied society thereof; the American Medical Association, or 

other national organization approved by the State Board of Health, or any committee or allied 

medical society thereof, or any in-hospital staff committee. Immunity extends to persons and 

organizations that provide information for such a study or publish the findings and conclusions. 

The findings may be released to advance medical research and medical education in the interest of 

reducing morbidity or mortality, and a summary of the studies may be released for general 

publication if the names of patients are not revealed. 

Data, information, and reports furnished for the study, as well as the findings and conclusions, 

are privileged and may not be used or offered or received in evidence in legal proceedings, unless 

waived by the interested parties. Section 1-1709 also gives immunity to physicians and others 

serving on hospital utilization review committees for their decisions made in that capacity, 

provided they act in good faith. 

Section 1-1709-1 has been amended and relates to peer review information which includes 

records, documents and information generated during the course of a peer review process, but 

does not include the medical records of a patient whose health care is being reviewed, incident 

reports and like documents regarding services being reviewed, regardless of their title or caption, 

the identity of persons who have personal knowledge regarding facts and circumstances 

surrounding the patient’s care, factual statements regarding the patient’s care from individuals 

who have personal knowledge of the facts and circumstances if the statements were generated 

outside the peer review process, the identity and copies of all documents and raw data created 

elsewhere and considered during the peer review process, whether available elsewhere or not, 

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and credentialing data regarding the health care professional who provided the health care services 

being reviewed or who is the subject of a credentialing process. 

The peer review process means any process, program or proceeding, including a credentialing 

process utilized by a health care facility and, as amended, includes county medical societies that 

assess, review, study or evaluate credentials, competence, professional conduct or health care 

services of a health care professional. 

Peer review information shall be privileged except that health care facilities or a county medical 

society are permitted to provide relevant peer review information to the agency or board which 

licensed the health care professional who provided the services being reviewed in the peer review 

process with notice to the health care professional. Immunity from discovery is not offered in 

certain circumstances in civil actions. No person involved in a peer review process may be 

permitted or required to testify regarding the process in any civil proceeding or disclose by 

written discovery requests any peer review information. 

Title 76, Section 24 provides immunity to professional review bodies organized to maintain 

standards of conduct and competence for various professionals, including physicians. 

Professional review action means an action or recommendation taken or made by a professional 

review body which adversely affects a person’s ability to perform a profession, but shall not 

include actions taken or recommendations made by private professional review bodies against a 

person who does not have a reasonable connection to the body’s sponsoring organization which 

is defined as a professional association or institution through which persons practice a 

profession. Anyone supplying information in good faith to the professional review organization 

shall not be liable in any way. Protection does not extend to actions for violation of civil rights or 

antitrust. 

Oregon 

Section 41.675 of the Oregon Revised Statutes (1998) applies to committees of hospitals, health 

care facilities, and professional societies concerned with medical research, quality assurance, or 

the training, supervision, or discipline of physicians. 

A person serving on a committee protected by the statute or providing information to the 

committee is immune from a lawsuit arising from any good faith action taken. Committee written 

reports, notes, and records are not admissible as evidence, except for those records dealing with 

the hospital care received by a litigant. The records are also admissible in lawsuits brought by 

physicians contesting a restriction or termination of staff privileges. Committee members and 

persons providing information to the committee may not be examined concerning the committee’s 

proceedings or findings. 

Pennsylvania 

Title 63 of the Pennsylvania Statutes Sections 425.2 to 425.4 contains peer review provisions. 

The statute applies to a hospital committee or review organization established by a state or local 

professional society to evaluate and improve the quality of health care, reduce morbidity and 

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mortality, or promote cost containment. Section 425.3 grants immunity from lawsuits based on 

committee activities to committee members, employees, advisors and consultants, provided they 

acted without malice. 

Under Section 425.4, review committee proceedings and records are not subject to discovery and 

use as evidence, and no person may testify about committee matters, including the findings of the 

committee. These protections only extend to civil suits arising out of matters at issue before the 

committee. Documents available from original sources are not immune from discovery simply 

because the committee saw them. Similarly, witnesses may testify about matters discussed 

before the committee if the witness had independent knowledge of those matters. This 

permission does not extend to any opinion formed as a result of the committee meeting. 

Rhode Island 

Sections 5-37.3-4 and 12-17-25 of the General Laws of Rhode Island provide immunity to peer 

review boards, their members and those furnishing information to the committee, provided they 

act without malice and in the reasonable belief that the action was warranted and within the scope 

of the board's functions. 

The proceedings and records of peer review committees and boards are non-discoverable and 

inadmissible as evidence. Documents available from original sources are not immune from 

discovery simply because the committee saw them. Under Section 5-37.3-7, no person 

attending a committee meeting may testify about committee matters, including the findings of the 

committee. However, witnesses may testify about matters discussed before the committee if the 

witness had independent knowledge of those matters. This permission to testify does not extend 

to any opinion formed as a result of the committee meeting. 

Exceptions to the provisions regarding privilege and witness testimony are allowed in lawsuits by 

the peer review board to restrict or revoke a physician's staff privileges, and for instances in 

which members of the peer review board are sued for actions taken by them. In such cases, any 

personally identifiable, confidential, health care information may not be disclosed without 

authorization. Furthermore, the imposition or notice of a restriction of privileges or licensure by 

a peer review board is discoverable. 

South Carolina 

Members of a duly appointed committee of a state or local professional society formed to 

maintain professional standards are immune from monetary liability under Section 40-71-10 of 

the South Carolina Code, if they act without malice and their actions are based on reasonable factfinding. The section specifically includes morbidity and mortality committees appointed by the 

Department of Health and Environmental Control. The statute does not mention immunity for 

persons who provide information or otherwise cooperate with the committee. 

Section 40-71-20 provides that all committee proceedings and data and information it acquires 

shall remain confidential unless a respondent being reviewed requests public disclosure. The 

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proceedings and documents are protected from discovery, subpoena, or use as evidence in civil 

actions, except upon appeal from the committee action. Documents otherwise discoverable do 

not become confidential simply because they were presented to the committee. Testimony about 

committee matters is not allowed except when the witness learned about such matters apart from 

the committee meeting. Committees appointed by the Department of Health and Environmental 

Control are permitted to issue reports containing only non-identifying data and information. 

Section 44-30-50 provides liability immunity to members of review panels, licensing boards, 

consultants, and persons providing information in good faith under the Health Care Professional 

Compliance Act. Section 44-30-60 provides that proceedings, records, and information are 

confidential except that the expert review panel may notify a person or entity charged with 

monitoring the requirements of the Act, and must notify the appropriate licensing board and 

Department of Health and Environmental Control of any noncompliance by a health care 

professional with the requirements of the expert review panel. The Department may take any 

action it deems necessary to protect the public health pursuant to the Act. 

South Dakota 

Section 36-4-25 of the South Dakota Codified Laws provides immunity for members of or 

consultants to a duly-appointed peer review committee comprised of physicians licensed to 

practice medicine or osteopathy, or to the medical staff or governing board of a licensed health 

care facility engaged in peer review activity. The immunity extends to any act of a member made 

without malice in the reasonable belief that it was warranted by the facts. 

Section 36-4-26.1 protects all reports, records, statements, minutes, and any other data of the 

committee from discovery or admissibility at trial. No person will be required to testify about 

what transpired at a committee meeting. The discovery protections do not prevent a physician 

from obtaining information that formed the basis for a denial of staff privileges or employment. 

Further, the discovery protections do not apply to deny a person or their counsel access to 

materials in defense of an action against that person. Section 36-4-26.1 does not apply to 

observations made at the time of treatment by a health care professional present during the 

patient’s treatment or to patient records prepared during the treatment and care rendered to a 

patient who is a party to an action or proceeding, the subject matter of which is the care and 

treatment of the patient. No member of any committee who has participated in peer review 

deliberations involving the subject matter of the action may testify as an expert witness for any 

party in an action for personal injury or wrongful death. Notwithstanding membership on a 

committee, a health care professional observing or participating in the patient’s treatment and 

care may testify as a fact or expert witness concerning that treatment and care, but may not be 

required to testify to anything protected by 36-4-26.1. 

Tennessee 

Section 63-6-219 of the Tennessee Code Annotated protects a medical review committee or peer 

review committee of a state or local professional association or society, including impaired 

physician peer review committees, programs, malpractice support groups and their staff 

personnel, or a committee of any licensed health care institution, or its medical staff, or any 

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committee of a medical care foundation or HMO, PPO, individual practice association or similar 

entity, with the responsibility to evaluate and improve the quality of health care or to determine 

that health care services rendered were indicated, were performed in compliance with the 

applicable standard of care, that the cost of health care rendered was reasonable, and to evaluate 

or review the diagnosis or treatment or the performance of medical or hospital services. Immunity 

extends to committee members, staff members, consultants, and persons who provide 

information to the committee, provided they acted in good faith and without malice and on the 

basis of facts reasonably known or believed to exist. Immunity extends to entities, committees or 

individuals attempting to provide assistance directly related to and including alcohol or drug 

counseling and intervention through an impaired professional program to any licensee or 

applicant for license. Physicians’ health programs and physicians’ health peer review 

committees shall be immune from liability for providing intervention, referral, and other support 

services to minor children or spouse of physicians. 

Information furnished to a protected committee is declared to be privileged. Committee records 

and proceedings, which are broadly defined, are confidential and not available through subpoena 

or discovery proceedings. Documents and records otherwise available from original sources 

remain available, however. 

Texas 

Under section 160.007 of the Texas Occupations Code , all proceedings and records of a medical 

peer review committee are confidential, and communications to such a committee are privileged. 

Unless disclosure is allowed or required by law, records, determinations, and communications of 

a medical peer review committee cannot be subpoenaed, and are non-discoverable and 

inadmissible. The statute provides an exception allowing records to be disclosed to another 

medical peer review committee, a government agency, the physician reviewed by the committee, 

or an accreditation body. Records may also be used in an anti-competitive action or civil rights 

proceeding, or an action arising from the committees proceedings in which the committee or a 

member of the committee is the defendant. 

Under section 160.010, no cause of action accrues against members, agents, or employees of a 

medical peer review committee from any act, statement, determination, or recommendation made 

without malice in the course of peer review. Similar immunity extends to an individual who 

participates in medical peer review activity or furnishes information to a medical peer review 

committee. 

Under Section 161.032 of the Texas Health and Safety Code, records and proceedings of a 

medical committee are confidential and not subject to subpoena or admissible at trial. Medical 

committees are defined in Section 161.031. This definition includes, among others, committees of 

a medical organization or hospital. 

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Utah 

Section 58 13-4 of the Utah Code gives immunity to health care providers serving on committees 

of hospital or professional associations organized to evaluate and improve the quality of health 

care, or review professional and ethical standards. Immunity from liability is also granted to 

those providing information to such a committee. Immunity only applies to actions taken and 

information furnished in good faith without malice. Health care providers covered by this section 

are presumed to be acting in good faith and without malice absent clear and convincing evidence 

to the contrary. 

Sections 26-25-1 through 26-25-4 authorize the Department of Human Services, medical 

societies, university medical centers, and professional associations to conduct studies for the 

purpose of reducing morbidity and mortality, or evaluating and improving hospital care. The 

statute gives immunity to persons who provide information for a study or who publish findings 

and conclusions. The information provided may only be used or published to advance medical 

research or reduce morbidity and mortality. Identification of the persons studied must be 

eliminated from any published versions of the findings. Information furnished for these studies 

and study findings and conclusions are privileged communications and not discoverable or 

admissible in legal proceedings. 

Vermont 

Sections 1441 to 1443, of Title 26 Vermont Statutes Annotated, protect peer review committees 

that are established by a hospital, HMO, state or local professional association, or other health 

care provider to evaluate and improve the quality of health care, to determine that health services 

rendered were professionally indicated, to ensure that health services are performed in 

compliance with the applicable standard of care, or that the cost of health care rendered was 

reasonable by health service providers. Committee members, employees, agents, consultants, 

and persons who assist the committee are immune from monetary liability for committee 

business if they act without malice and in the reasonable belief that the action is warranted. The 

proceedings, reports, and records of committees are not subject to discovery or use as evidence in 

any civil action arising out of the matters being reviewed by the committee. No person attending 

a committee meeting may testify about committee business or its findings, but may testify as to 

matters within their knowledge. Documents not generated by the committee that are available 

from the original sources and testimony based on independent knowledge are accessible even 

though such matters are considered by the committee. The proceedings, reports, records, 

supporting information and evidence of a peer review committee provided by the committee to a 

board may be used by the board for disciplinary purposes, but shall not be subject to public 

disclosure. 

Virginia 

Section 8.01-581.13 of the Virginia Code provides immunity from civil liability to actively 

practicing health professionals engaged in peer review, provided they act in good faith and 

without malicious intent. This review must be done as a member or agent of an entity 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

30­
established by federal or state law, a hospital, or an association, society, or academy affiliated 

with one of a number of health professional associations or a governmental agency. 

Section 8.01-581.16 extends similar immunity to hospital committees, boards, groups, 

commissions, and other entities established pursuant to federal or state law or JCAHO 

requirements, by public or private hospitals, or to committees acting with a governmental agency 

to review and evaluate the adequacy and quality of professional services. Committee members 

and consultants are immune from civil liability for any committee business not done in bad faith 

or with malicious intent. 

Medical staff committee, utilization review committee, board, group, commission, other entity, 

and nonprofit entity providing a centralized credentialing service proceedings, minutes, records, 

and reports are partially exempt from discovery under Section 8.01-581.17, unless good cause 

arising from extraordinary circumstances justifies disclosure. 

Privilege is not extended to hospital medical records kept in the ordinary course of business of 

operating a hospital or related to the hospitalization or treatment of any patient in the ordinary 

course of hospitalization. Accreditation and peer review records of the American College of 

Radiology and the Medical Society of Virginia are considered privileged communications. 

Section 8.01-44.1 provides immunity from civil liability to members of committees, boards, 

groups, commissions, or other entities established pursuant to federal or state law or regulation 

which function to authorize, review, evaluate, or make recommendations on the nature, conduct, 

activities, or procedures involved in or related to programs or research protocols conducted under 

supervision of faculty or staff members of any hospital, college, or university, including 

experiments involving human subjects when committee business is conducted in good faith and 

without malicious intent, or if a committee member knows or should know that the program or 

protocol is in violation of Chapter 5.1 of Title 32.1. Immunity does not apply to those persons 

engaged in the actual conduct of the programs or protocols. 

Washington 

Sections 4.24.240 and 4.24.250 of the Revised Code of Washington provide immunity to health 

professionals, their employees, and health care entities and facilities for their peer review 

committee activities. The statute immunizes committee members, employees, investigators, and 

persons who supply information to the committee from liability for any good faith official 

action. 

The proceedings, reports, and written records of such committees or of the protected individuals 

are not subject to subpoena or discovery except in cases arising out of a restriction or revocation 

of privileges. 

West Virginia 

Sections 30-1-16 and 30-3C-1 through 30-3C-3 of the West Virginia Code protect committees 

established by a state or local health professional society to reduce morbidity and mortality, to 

improve the quality of health care, to establish and enforce cost containment guidelines, or to 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

31­
review qualifications and performance of health professionals. Immunity extends to the 

committee itself, and to persons who provide information to the committee, review organization 

members, and employees, providing they acted without malice and in a reasonable manner. 

The proceedings and records of the review organization are protected from subpoena, discovery, 

and admissibility as evidence in any lawsuit arising out of the matters being reviewed by the 

organization. No person attending a meeting may testify about committee matters, although he 

or she may testify about matters otherwise within his or her knowledge. Information and 

documents available from original sources are not protected. An individual may execute a waiver 

authorizing release of contents of his or her file pertaining to his or her acts or omissions, and the 

waiver removes confidentiality and privilege. Upon further review by any other review 

organization, judicial review of any finding or determination of a review organization, or in a civil 

action filed by an individual whose activities have been reviewed, any testimony, documents, 

proceedings, records, and evidence adduced before the review organization are available to the 

further review organization, the court, and the individual whose activities have been reviewed. 

The court shall enter a protective order to provide for confidentiality of records provided to the 

court by the review organization and all papers and records relating to the proceedings before the 

reviewing court. In Young v. Saldanha, 189 W. Va. 330, 431 S.E. 2d 669 (1993), to effect a 

waiver of the privilege of confidentiality attendant to information and records which were the 

subject of health care peer review, an individual must formally indicate intent to waive the 

confidentiality provision by executing a valid waiver. 

Wisconsin 

Section 146.37 of the Wisconsin Statutes provides immunity to any program that reviews or 

evaluates health care services to improve the quality of health care, to avoid improper utilization 

of services of health care providers or facilities, or to determine the reasonable charges for such 

services, or who participates in obtaining health care information under chapter 153. Persons 

who participate in the review program are immune from civil damages for any official actions 

made in good faith. 

Under Section 146.38, records of an organization’s or individual’s investigations, inquiries, 

proceedings, and conclusions may not be used in any civil action for personal injuries; however, 

information, documents, or records presented during peer review may not be construed as 

immune from discovery merely because they were so presented. A person who testifies during 

review or participates in review cannot testify in a lawsuit about any information obtained from 

the review process, but may testify as to matters within his or her knowledge. The statute 

specifies that the committee may release its findings if patient identification is withheld unless 

the patient grants permission to disclose identity in certain circumstances. The findings may also 

take the form of a statistical report. 

Wyoming 

Sections 35-17-101 through 106 of the Wyoming Statutes apply to professional standard review 

organizations, defined as medical organizations of a local, county, or state medical society 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

32­
performing any review function, and to hospital medical staff quality assurance committees. 

Members of the organization, as well as the entity itself, are not liable for civil damages for 

official acts, except for intentional, malicious, or grossly negligent acts or omissions resulting in 

harm. Persons who provide information to a review organization are immune unless they know 

the information they provide is false or they provide information unrelated to the duties of the 

organization. 

All reports, findings, proceedings, and data of the organization are confidential and privileged and 

exempt from discovery or introduction into evidence in any civil action. No person attending a 

meeting may testify about committee matters. However, information documents and records 

available from independent sources are not protected, and a committee member or witness may 

testify about matters otherwise within his or her knowledge, as long as he/she is not asked about 

his/her testimony before the committee or opinions formed as a result of the committee hearing. 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

33­
List 1­

Statute CitationsAlabama................................. Code of Ala. §§ 6-5-333, 22-21-8, 34-24-58 

Alaska.................................... Alaska Stat. §§ 18.23.010 to .070 

Arizona.................................. Ariz. Rev. Stat. Ann. §§ 36-2401 to -2404, 36-445 to -445.03 

Arkansas................................ Ark. Stat. Ann. §§ 20-9-501 to -503, 16-46-105(a) 

California ............................... Cal. Civil Code §§ 43.7 to .8, 43.97; Cal. Evidence Code 

............................................... §§ 1156 to 7 

Colorado ................................ Colo. Rev. Stat. §§ 12-35.5-203, 12-36.5-101 to -105 

Connecticut............................ Conn. Gen. Stat. §§ 19a-17b, 19a-25 

Delaware................................ Del. Code Ann. tit. 24 §§ 1731A(h), 1768 

District of Columbia.............. DC Code Ann. §§ 32-501 to -505 

Florida.................................... Fla. Stat. §§ 766.101, 395.0193 

Georgia................................... Ga. Code Ann. §§ 31-7-131 to -133, 31-7-140 to -143 

Hawaii.................................... Haw. Rev. Stat. §§ 663-1.7, 624-25.5, 671D-4 to 671D-11 

Idaho...................................... Idaho Code §§ 39-1392a to -1392f 

Illinois.................................... 210 ILCS 85/10.2; 225 ILCS 60/5; 735 ILCS 5/8-2101 

Indiana ................................... Ind. Code Ann. §§ 34-30-15-1 to -21, 34-6-2-99 

Iowa....................................... Iowa Code §§ 135.40 to .42, 147.135 

Kansas ................................... Kan. Stat. Ann. 65-177 to -179, 65-4909, 65-4915, 65-442 

Kentucky............................... Ky. Rev. Stat. Ann. § 311.377 

Louisiana................................ La. Rev. Stat. Ann. § 13:3715.3 

Maine..................................... Me. Rev. Stat. tit. 32 §§ 2599, 3293, 3296; tit. 24 

............................................... §§ 2502, 2510A, 2510-B, 2511 

The American College of Obstetricians and Gynecologists 34 

Copyright © 2001 
Maryland............................... Md. Health Occ. Code Ann.§§ 14-501 to -504, General Health 

............................................... Code Sections 13-1001 to -1007 

Massachusetts....................... Mass. Ann. Laws ch. 111 §§ 1, 204; ch. 231 § 85N 

Michigan................................ Mich. Complied Laws §§ 331.531 to .533, 333.21513, 333.21515 

Minnesota.............................. Minn. Stat. §§ 145.61 to .67 

Mississippi............................ Miss. Code Ann. §§ 41-63-1 to -9, 41-63-23 to -29 

Missouri ................................ Rev. Stat. of Mo. § 537.035 

Montana ................................ Mont. Code Ann. §§ 37-2-201, 37-3-401 to -404, 50-16-102 , 

............................................... 50-16-201 to -205 

Nebraska................................ Neb. Rev. Stat. §§ 25-12,121, 25-12,123, 71-147.01, 71-3401 to 

............................................... -3403, 71-7903 

Nevada................................... Nev. Rev. Stat. §§ 49.265, 49.117 to .123 

New Hampshire..................... N.H. Rev. Stat. Ann. §§ 151:13-a, 329:29, 507:8-C 

New Jersey............................ N.J. Rev. Stat. §§ 2A:84A-22.8 to -22.10, 26:1A-37.2 

New Mexico .......................... N.M. Stat. Ann. §§ 41-9-2 to -6 

New York .............................. N.Y. Educ. Law § 6527, N.Y. Public Health Law §§ 206(1)j, 

............................................... 2805-j, 2805-m 

North Carolina....................... N.C. Gen. Stat. §§ 131E-95, 90-21.22, 90-21.22A 

North Dakota......................... N.D. Cent. Code §§ 23-01-15, 23-34-01 to 34-06 

Ohio....................................... Ohio Rev. Code Ann. §§ 2305.24 to .25, 2305.251 

Oklahoma............................... Okla. Stat. tit. 63 § 1-1709, 1-1709-1, tit. 76 § 24 

Oregon ................................... Or. Rev. Stat. § 41.675 

Pennsylvania.......................... Tit. 63 Pa. Stat. §§ 425.2 to .4 

Rhode Island.......................... R.I. Gen. Laws §§ 5-37.3-4, 5-37.3-7, 12-17-25 

South Carolina ....................... S.C. Code Ann. §§ 40-71-10, 40-71-20, 44-30-50, 44-30-60 

The American College of Obstetricians and Gynecologists 

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35­
South Dakota......................... S.D. Codified Laws §§ 36-4-25, 36-4-26.1 

Tennessee .............................. Tenn. Code Ann. § 63-6-219, tit. 47 ch. 25 

Texas...................................... Tex. Occ. Code 160.007, 160.010, Tex. Health & Saf. Code § 

............................................... 161.031 to .032 

Utah....................................... Utah Code Ann. §§ 26-25-1 to -4, 58-13-4, 158-13-5 

Vermont................................. Vt. Stat. Ann. tit. 26 §§ 1441 to 1443 

Virginia................................... Va. Code Ann. §§ 8.01-581.13, 8.01-581.16. to .17, 8.01-44.1, 

............................................... ch. 5.1, tit 32.1 

Washington............................ Wash. Rev. Code §§ 4.24.240, 4.24.250 

West Virginia ......................... W. Va. Code §§ 30-3C-1 to -3: 30-1-16 

Wisconsin .............................. Wis. Stat. §§ 146.37, 146.38 

Wyoming ............................... Wyo. Stat. §§ 35-17-101 to -106 

Current as of January 2000 unless otherwise noted. 

The American College of Obstetricians and Gynecologists 

Copyright © 2001 

36­
Appendix E 

Examples of Data Abstraction 

Forms for Medical Records 

Here are three examples of data abstraction forms. 

The first is an example of a brief semi-structured medical record 

abstraction form. 

The second is an abstraction form used by the New York State 

Department of Health, and the third is the form used by the 

Florida Department of Health. 
Example 1

Strategies to Reduce Pregnancy-Related Deaths 

Example of semi-structured medical 

record abstraction form 

CASE # 

BACKGROUND: 

Age, race/ethnicity, date of woman’s birth, EDC, date of delivery


or pregnancy termination, date of death, est gestational age.


LISTED CAUSE OF DEATH:

from death certificate


PAST MEDICAL HISTORY:

PRENATAL, LABOR & DELIVERY HISTORY:

Gravidity, parity


Admissions, symptoms, diagnoses, treatment, course of disease


POSTPARTUM HISTORY:

If applicable


FINDINGS:

E.g., autopsy or coroner’s report


Reviewer’s cause of death


Rationale for relation or lack of relation to pregnancy


CONCLUSION:

Pregnancy-related or not

Example 2 

Reproduced with permission from the New York State Department 

of Health. 
NEW YORK STATE DEPARTMENT OF HEALTH 

CENTER FOR COMMUNITY HEALTH 

DIVISION OF FAMILY HEALTH 

BUREAU OF WOMEN’S HEALTH 

NEW YORK STATE MATERNAL MORTALITY REVIEW 

Case No. 

Form MRAT 
Medical Record # 

Date of Death _______/_______/________ 

month day year 

Cause of Death 

(as stated on death certificate) 

Date of Birth≠ ______/______ /______ 

month day year 

Age at death ______

Pregnancy Check Box Yes No No response

Gestation at time of

delivery or death weeks days

Gravida ____ Parity ____ ____ ____ ____

Death before 24 wks gestation

Still pregnant 

Abortion/mole 

Ectopic gestation 

Death after 24 wks gestation 

Antepartum 

Intrapartum 

Postpartum 0-7 days 

Postpartum 8 – 42 days 

Postpartum > 42 days 

Status of Infant(s) 1 2 

Live Birth 

Stillbirth* 

Neonatal death* 

*cause of death if known________________________ 
Marital Status 

Single 

Married 

Divorced/Separated 

Widowed 

Place of Birth ________________________ (on death certificate) 

Racial/Ethnic group (Check all that apply) 

White 

AfricanAmerican 

Latina 

(Hispanic) 

Asian 

Native 

American 

Occupation _____________________________________ 

Did she work during pregnancy? Yes No Unknown 

Please comment on social and family circumstances

(e.g. living situation, language, access to care, substance abuse, domestic violence, unplanned or

unintended pregnancy, etc.)
Pregnancy Risk Factors 

a. Moderate Risk


[ ] Maternal age less than 17 or greater than 35

[ ] Race - non-white

[ ] Anemia - Hgb less than 11g

[ ] HIV positive

[ ] Smokes more than 1/2 pack per day

[ ] Substance abuse (including alcohol) -- low level

[ ] Prior cesarean section

[ ] Cardiac - Class I, II, or mitral valve prolapse

[ ] Epilepsy

[ ] Chronic medical condition

[ ] Sought prenatal care after 20 weeks

b. High Risk


[ ] Insulin Dependent Diabetes

[ ] Cardiac- Class III, IV, or arrhythmia

[ ] Rh Sensitization (Titer >1/8)

[ ] Uterine abnormality or incompetent cervix

[ ] Hypertension (>160/95) or requiring medication

[ ] Renal disease (chronic, serious)

[ ] more than 4 moderate risk factors

c. Very High Risk


[ ] Drug addiction/ alcoholism

[ ] AIDS

[ ] 2 or more high risk factors

What was the source of payment for perinatal care of the deceased 

Medicaid/Medicare 

HMO 

Other insurance 

(specify______________________) 

Self-pay 

Other 
MEDICAL HISTORY Antenatal 

Was there any relevant past obstetric and medical history? 

(e.g. chronic illnesses, previous pregnancy complications) 

Contraceptive History

Relevant history of method(s) used in the year before index pregnancy. If hormonal

contraception,

please give the name and duration of use

Name of Method Duration 

Previous Pregnancies (including abortions, ectopic pregnancies) 

Year Wks. Gestation Method of Delivery LB/SB/NND* 

*LB= Live Birth SB= Stillbirth NND= Neonatal Death 

Indicate source of prenatal information 

[ ] full prenatal care record 

[ ] prenatal care summary sheet 

[ ] admission history 

[ ] none 

Was gestational age assessed before 20 weeks by ultrasound? 

Yes No Unknown 

LMP ____/______/_______ 

EDC ____/______/_______ 
Were there any antenatal hospital admissions ? 

Yes No 

if yes , please specify dates and reasons 

MEDICAL HISTORY Intrapartum 

Mode of delivery 

Spontaneous 

Assisted vaginal 

Caesarean section 

If Caesarean section, please specify 

Elective 

Planned Emergency* 

Unplanned Emergency** 

Peri/Post mortem*** 

* Patient was in labor (or induction had failed) and was appropriately prepared for 

anaesthetic 

** Desirable preparation was not possible 

*** Terminally ill patient on cardio-respiratory support 

Please specify any complications that occurred during the course of delivery. 
Please give details of the events leading to this death 

Was an autopsy performed? 

Yes No Unknown 

How would you classify this case? 

____ pregnancy associated death 

____ pregnancy related death 

____ direct maternal death 

____ indirect maternal death 
OVERALL ASSESSMENT OF CARE 

Were the care and services provided by the hospital and/or clinicians in accordance with 

professionally recognized standards? 

Yes No 

Was there any failure in clinical management or occurrence of sub-standard care which 

caused or contributed to this death? 

Yes No 

Occurrence of Sub-Standard Care 

Antenatal 

Contribution to Outcome 

Yes No Doubtful 

Major Minor Irrelevant 

Intrapartum 

Contribution to Outcome 

Yes No Doubtful 

Major Minor Irrelevant 

Postpartum Yes No Doubtful 

Contribution to Outcome Major Minor Irrelevant 

In your opinion, was the mortality preventable? 

Yes No 
Example 3 

Reproduced with permission from the Florida Department of 

Health. 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

DATA SOURCES Attachment 

(Check each record which was used for this abstraction) 

(Also, please transfer to Abstracted Data Sheet) 

 Prenatal Record (Specify below): 

 Complete 

 Partial 

 Labor and Delivery Record 

(including Immediate Postpartum) 

 6 Week Postpartum Record 

 Record of Terminal Event 

 Medical Examiner’s Report 

 Autopsy Report 

 Toxicology Report 

(Specify Record in which it was located) 

________________________________ 

 Pathology Report 

(Specify Record in which it was located) 

________________________________ 

 Healthy Start Care Coord. Record 

 EMS Record 

 Law Enforcement Record 

 Home Care Record 

 Other Hospital Records 

(Not Related to Delivery or Terminal Event) 

 Social Service Record 

 Other (Specify)_______________________ 

Revised June 25, 1999 Data Sources, 1 Page Only 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

OUTPATIENT VISIT A ttachment 

(Please fill out for each visit. Note reasons for any lapses in care.) 

Date/Time: 

Place: 

Provider: 

Payer Source: 

Reason for Visit: 

Condition (Include vital signs, 

weight, etc.) 

Psychosocial Issues Identified: 

Education: 

Procedures/Labs: 

Family Planning: (type) 

Follow up: 

Revised June 25, 1999 Outpatient Attachment, One Page per Visit 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

POSTPARTUM CARE Attachment 

(Please fill out for each visit. Note reasons for any lapses in care.) 

Date/Time: 

Place: 

Provider: 

Payer Source: 

Reason for Visit: 

Condition (Include vital signs, 

weight, etc.) 

Psychosocial Issues Identified: 

Education: 

Procedures/Labs: 

Family Planning: (type) 

Follow up: 

Revised June 25, 1999 Postpartum Attachment, One Page per Visit 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

Check Source: 

DEMOGRAPHICS 

(Not from Death Certificate) 

1. PAMR CASE NUMBER 

2. AGE AT LAST BIRTHDAY 

4. MATERNAL PLACE OF BIRTH 5. OCCUPATION 

� United States (50 states including DC) � Unemployed 

� Puerto Rico � Managerial & Professional 

� Virgin Islands � Technical, Sales, Administrative Support 

� Guam � Service Occupations 

� Haiti � Farming, Forestry, Fishing 

� Canada � Student 

� Cuba � Housewife 

� Mexico � No Occupation or None 

� Remainder of the World (Specify) ______________ � Precision Production, Crafts & Repair, Operators, 

Fabricators, Laborers 

� Unknown/Not Classifiable � Other (Specify)________________ 

6. MARITAL STATUS � Unknown 

� Married 7b. ETHNICITY 

� Living as Married � African - American 

� Never Married (Single) � Indian 

� Divorced � Chinese 

� Separated � Japanese 

� Widowed � Hawaiian 

� Unknown/Not Classifiable � Other Entries 

7a. RACE � Filipino 

� White � Haitian 

� Non-white � Other Asian or Pacific Islander 

8. EDUCATION � Unknown/Not Classifiable 

Elementary/Secondary College � Hispanic (Specify by checking appropriate box below) 

� 0 � 7 � 1 year � Mexican 

� 1 � 8 � 2 years � Puerto Rican 

� 2 � 9 � 3 years � Cuban 

� 3 � 10 � 4 years � Central or South American 

� 4 � 11 � ≥ 5 years � Other and Unknown Hispanic 

� 5 � 12 � Other � Not Classifiable 

� 6 

Prenatal Record____ Healthy Start_____ Other(Specify)____________________ 

Revised June 25, 1999 Demographics, 1 Page Only 
PAMR Case #_____


FLORIDA DEPARTMENT OF HEALTH


PREGNANCY ASSOCIATED MORTALITY REVIEW


DATA ABSTRACTION FORM


Check Source of Information: 

MEDICAL HISTORY 

Note: #’s 9 & 10 Omitted 

11. GENERAL HISTORY 

Problem Patient 

Hx 

Family 

Hx 

Developed 

During Most 

Recent PG 

Comments 

a. Diabetes 

b. Hypertension 

c. Heart Disease 

d. Rheumatic Fever 

e. Mitral Valve Prolapse 

f. 

g. Gall Bladder/Liver 

h. Neuro/Mental/Emotional Health 

i. 

j. Disease 

k. Phlebitis/Varicosities 

l. 

m. Thyroid Dysfunction 

n. Major Accidents 

o. History of Blood Transfusion 

p. Drug Allergies 

q. RH Sensitized 

r. 

s. 

t. Surgery 

u. Operations/Hospitalizations 

(Describe) 

v. Breast Disease/Mammography 

w. Anesthetic Complications 

x. History of Abnormal Pap 

y. Uterine Abnormality 

z. In Utero DES Exposure 

aa. Street Drugs 

bb. Cancer 

cc. Other Signs of Toxemia (Specify) 

dd. Evidence of Disability (Specify) 

ee. Other (Specify) 

Prenatal record____ Healthy Start_____ Other(Specify)________ 

Kidney/UTI 

Epilepsy 

Hepatitis/Liver 

STD/AIDS 

Tuberculosis 

Asthma 

Gynecological 

Revised June 25, 1999 Medical History, Page 1 of 6 
PAMR Case #_____


12. IMMUNIZATION HISTORY (If not documented, check here____) 

a. Were childhood immunizations 

completed? 

 Yes  No  Unknown 

b. Were any immunizations received 

as an adult? (Specify which immunizations 

were received as an adult) 

 Yes  No  Unknown 

c. Were any immunizations received 

in the year prior to the woman’s 

death? (Specify which immunizations were 

received as an adult) 

 Yes  No  Unknown 

13. SEXUAL HISTORY (If not documented, check here____) 

a. Age (in years) at first intercourse: ______ years 

b. Lifetime number of sexual partners: ______ 

High Average Low 

c. Risk of Hepatitis B?  Blood 

Transfusion 

 Multiple Sexual 

Partners 

 IV Drug User 

 Sex for Money 

 > 1 Sexual 

Partner 

 Monogamous 

 No Risk Factors 

d. Risk of HIV?  Blood 

Transfusion 

 Multiple Sexual 

Partners 

 IV Drug User 

 Sex for Money 

 > 1 Sexual 

Partner 

 Monogamous 

 No Risk Factors 

14. OBSTETRICAL HISTORY 

a. Type of Contraception Most Recently Used (If not documented, check here ______) 

(Specify date last used)___________________ 

 None  Diaphragm  Female Sterilization 

 Spermicides  Condom  Natural Family Planning 

 Periodic Abstinence  Pill (Specify type)__________________  Basal Body Temperature 

 Withdrawal  IUD  Rhythm 

 Cap  Depo-Provera  Combination (Specify) __________ 

 Sponge  Norplant  Other (Specify) ___________________ 

b. Was the patient breastfeeding in last 24 

months? 

c. Did the patient have previous birth over 9 

lbs.? 

 Yes  Yes 

 No  No 

 Unknown  Unknown 

d. Describe Menstrual Cycle. (If not documented, check here ______) 

 Regular with No Spotting  Other Irregularities (Specify) _________________________ 

 Regular with Spotting  Unknown 

 Skips Menses on a Regular Basis Age started: _________years 

Revised June 25, 1999 Medical History, Page 2 of 6
PAMR Case #_____


e. Problems with previous pregnancies (Specify trimester) 

Trimester 

Problem First Second Third Comments 

Bleeding 

Diabetes 

Hyperemesis 

Hypertension 

Low birth weight 

Toxemia 

Delivery (Specify)__________ 

Other (Specify)______________ 

f. Does the patient request contraception?  Yes  No 

If yes, specify type (use list in question 14a) ______________________________________________ 

15a. WEIGHT 

a. Patient’s last reported weight prior 

to the most recent pregnancy: _________________ lbs. 

b. Recent weight change other than 

pregnancy induced.  Yes  No 

c. Describe the patient’s weight.  Obese 

(Preconceptual weight 

20% or more above 

ideal for height) 

 Underweight 

(10% or more under 

ideal weight for height) 

 Within Normal 

Limits 

15b. HEIGHT _________inches 

16. REASON FOR INITIAL APPOINTMENT: (For example, is visit for prenatal, postpartum or for a 

health complaint? 

17. CURRENT MEDICATIONS 

List all drugs documented as prescribed up to 3 months prior to the most recent pregnancy. Also 

include any medications if prescribed in the postpartum period. Include name of drug as written in 

record, dose, route, schedule for taking medication and date prescribed. (e.g. Penicillin 250 mg, PO, QID, 

date prescribed) 

Drug Date Prescribed Reason 

a. 

____/____/____ 

b. 

____/____/____ 

c. 

____/____/____ 

d. 

____/____/____ 

e. 

____/____/____ 

Include type and length of symptoms, treatment and follow up plans if noted.) 

Revised June 25, 1999 Medical History, Page 3 of 6
PAMR Case #_____


18. PRIOR HOSPITALIZATIONS 

Date(s) Length of Stay Reason for Admission 

_____/_____/_____ 

_____/_____/_____ 

_____/_____/_____ 

19. SUBSTANCE USE 

Does the medical history include assessment of maternal substance use, e.g. smoking, alcohol, or 

illicit drugs? 

 Yes  No  Unknown 

20. TOBACCO USE 21. ALCOHOL USE 

 Yes  No  Unknown  Yes  No  Unknown 

If yes, then: If yes, then: 

b. Type of tobacco (Cigarettes, Cigars, Oral) __________ a. Type of alcohol (Beer, Liquor, Wine) ______________ 

c. Packs smoked per day ___________________ b. Drinks per week 

d. Number of years smoked _________________ c. Age at which drinking began _______________ 

e. Age at which smoking began ______________ d. Addiction to alcohol? 

 Yes  No  Unknown 

22. OTHER SUBSTANCES USED (Check all substances used by this patient and indicate addiction problems in last 6 months) 

Substance How Ingested When Used in Relation to PG 

 Amphetamines  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Barbiturates  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Cocaine/Crack  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Hallucinogens  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Heroin  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Marijuana/Cannabis  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

________________________ 

Revised June 25, 1999 Medical History, Page 4 of 6
PAMR Case #_____


22. OTHER SUBSTANCES USED (Cont.)(Check all substances used by this patient and indicate addiction problems in last 6 

months) 

Substance How Ingested When Used in Relation to PG 

 Methadone  PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Methamphetamine or 

Crystal 

 PO  IV  Before  After 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 Inhaled  Unknown  During  Unknown 

 Herbs (Specify)_________________ 

_______________________ 

 Other (Specify)_____________ 

 PO  Other____ 

 Unknown 

 Before 

 During 

 After 

 Unknown 

 Known addiction in the 6 

months prior to the most 

recent pregnancy 

 PO 

 Inhaled 

 IV 

 Unknown 

 Before 

 During 

 After 

 Unknown 

23. HIV 

a. Was there documentation that the patient 

was offered an HIV test? 

b. Patient’s response to the offer of HIV testing: 

 Yes  No  Accepted (Complete c,d,e)  Refused 

c. Was there documentation that the patient 

was offered pre-test counseling? 

d. Was there documentation that the patient was 

offered post-test counseling? 

 Yes  No  Yes  No 

e. Results of HIV testing:  Positive  Negative 

24. PSYCHOSOCIAL ASSESSMENT 

a. Was a Psychosocial Assessment made on this 

patient? 

b. Was a caseworker available to this 

program/facility for assessment/follow-up? 

 Yes  Yes 

 No  Unknown  No  Unknown 

c. Did a caseworker see this patient? d. Did a caseworker develop a case management 

plan for problems noted below? 

 Yes  Yes 

 No  Unknown  No  Unknown 

Revised June 25, 1999 Medical History, Page 5 of 6
PAMR Case #_____


e. Problems identified by medical, nursing or social work personnel. 

(If not documented, check here_____) 

Problem Identified Care Plan Referral Services Received 

 Family Violence  Yes  No  Yes  No  Yes  No 

 Chronic illness (Specify)_______________  Yes  No  Yes  No  Yes  No 

 Communication barriers  Yes  No  Yes  No  Yes  No 

 Crime/legal problems  Yes  No  Yes  No  Yes  No 

 Depression  Yes  No  Yes  No  Yes  No 

 Disability (Specify)_____________________  Yes  No  Yes  No  Yes  No 

 Disturbed relationship with a child  Yes  No  Yes  No  Yes  No 

 Substance use (Tobacco, Drugs, or Etoh)  Yes  No  Yes  No  Yes  No 

 Employment/educational needs  Yes  No  Yes  No  Yes  No 

 Housing inadequate/homeless  Yes  No  Yes  No  Yes  No 

 Frequent moves (>3 times in last 2 months)  Yes  No  Yes  No  Yes  No 

 Inadequate support systems  Yes  No  Yes  No  Yes  No 

 Late life pregnancy (Age >39 years)  Yes  No  Yes  No  Yes  No 

 Mother abused as a child  Yes  No  Yes  No  Yes  No 

 Need for financial support  Yes  No  Yes  No  Yes  No 

 Poor nutrition/hunger  Yes  No  Yes  No  Yes  No 

 Single mother  Yes  No  Yes  No  Yes  No 

 Suicidal ideation  Yes  No  Yes  No  Yes  No 

 Teen mother (Age < 18 years)  Yes  No  Yes  No  Yes  No 

 Transportation problems  Yes  No  Yes  No  Yes  No 

 Stress  Yes  No  Yes  No  Yes  No 

 Difficulty keeping appointments  Yes  No  Yes  No  Yes  No 

 Unsafe neighborhood  Yes  No  Yes  No  Yes  No 

 Hazardous work exposure 

 Other (Specify)__________________________ 

 Yes 

 Yes 

 No 

 No 

 Yes 

 Yes 

 No 

 No 

 Yes 

 Yes 

 No 

 No 

 None 

f. Comments on Medical History: 

Revised June 25, 1999 Medical History, Page 6 of 6
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

PRENATAL CARE 

 Complete  Partial 

25. TYPE of PRIMARY PRENATAL 

PROVIDER (Check one only) 

26. PAYER SOURCE 

(Check one only) 

 Family Physician  Medicaid HMO 

 Obstetrician  Medipass 

 Certified Nurse Midwife  Private Insurance 

 Licensed Midwife  Managed Care Organization (HMO, PPO, IPA, etc.) 

 Alternative Provider (Specify)______________________ 

 Physician Assistant 

 Self pay 

 Other (Specify)__________________________________________ 

 Nurse Practitioner (ARNP)  No Source Data 

 Other (Specify)_______________________________________ 

 None 

 No Source Data 

27. PRENATAL CARE RECEIVED BY MOTHER 

 Yes  No  No Source Data 

28. DATE PRENATAL CARE BEGAN _____/_____/_____ # gestational weeks = _______ 

29. LAST DATE OF PRENATAL CARE _____/_____/_____ # gestational weeks = _______ 

30a. PRIMARY LOCATION OF PRENATAL CARE (Check one only) 

 Private Office  Health Department  Neighborhood Clinic 

 Hospital Clinic  Family Planning Center  Other (Specify)_____________________ 

 Birthing Center  HMO Clinic  No Source Data 

30b. REFERRED FOR SPECIALIST CARE  Yes  No 

If yes, Type of Specialist_______________________Reason______________________Date_________ 

31a. NUMBER OF PRENATAL VISITS (Enter exact number) 

Documented # of Prenatal Visits______  No Source Data 

31b. PREGNANCY PLANNED?: (Mark one) 

 Intended  Unintended  No Source Data 

32. DATE OF LAST MENSTRUAL PERIOD 

____/_____/____ 

33. EDD DATE 

____/____/____ 

34. Sonogram EDD DATE 

___/____/___ 

Date Sonogram Done 

____/____/____ 

Gestational weeks_______ 

35. GRAVIDA ______ 

(Give figures during the last pregnancy.) 

36. PARA (Give figures during the last pregnancy.) 

______/______/______/_________ 

Full Term Preterm Abortions Living Children 

Revised June 25, 1999 Prenatal Care, Page 1 of 8 
PAMR Case #_____


37. MATERNAL GENETIC PROBLEMS 

(Describe) 

38. INFANT GENETIC PROBLEMS 

(Describe) 

39. PREVIOUS PREGNANCIES (Do NOT include 

pregnancy most proximal to the mother’s death) 

40. PREVIOUS PREGNANCIES 

a. Date _____/_____/_____ a. Date _____/_____/_____ 

b. Pregnancy Outcome b. Pregnancy Outcome 

 Spontaneous 

Abortion 

 Still Birth  Spontaneous 

Abortion 

 Still Birth 

 Therapeutic 

Abortion 

 Live Birth  Therapeutic 

Abortion 

 Live Birth 

 Ectopic  Ectopic 

c. If live birth, please specify birthweight. 

______lbs. 

c. If live birth, please specify birthweight. 

______lbs. 

d. Current Status of Infant. d. Current Status of Infant. 

 Living  Living 

 Deceased  Deceased 

 Unknown  Unknown 

e. Maternal Complications e. Maternal Complications 

 Yes  No  Yes  No 

f. If yes to complications, please specify below. f. If yes to complications, please specify below. 

41. PREVIOUS PREGNANCIES 42. PREVIOUS PREGNANCIES 

a. Date _____/_____/_____ a. Date _____/_____/_____ 

b. Pregnancy Outcome b. Pregnancy Outcome 

 Spontaneous 

Abortion 

 Still Birth  Spontaneous 

Abortion 

 Still Birth 

 Therapeutic 

Abortion 

 Live Birth  Therapeutic 

Abortion 

 Live Birth 

 Ectopic  Ectopic 

c. If live birth, please specify birthweight. 

______lbs. 

c. If live birth, please specify birthweight. 

______lbs. 

d. Current Status of Infant. d. Current Status of Infant. 

 Living  Living 

 Deceased  Deceased 

 Unknown  Unknown 

e. Maternal Complications e. Maternal Complications 

 Yes  No  Yes  No 

f. If yes to complications, please specify below. f. If yes to complications, please specify below. 

Revised June 25, 1999 Prenatal Care, Page 2 of 8

PAMR Case #_____


43. HIV 

a. Was there documentation that the patient 

was offered an HIV test? 

b. Patient’s response to the offer of HIV testing: 

 Yes  No  Accepted (Complete c,d,e)  Refused 

c. Was there documentation that the patient 

was offered pre-test counseling? 

d. Was there documentation that the patient was 

offered post-test counseling? 

 Yes  No  Yes  No 

e. Results of HIV testing:  Positive  Negative 

44. LABORATORY SCREENING TEST 

INITIAL LABS If Abnormal,

(WHEN INDICATED) 

DATE/ 

WKS (WERE RESULTS 

NORMAL?) 

Results Specify Actions Repeat Results 

a. HCT/HGB (Specify)  Yes  No 

b. HbsAG  Yes  No 

c. Syphilis  Yes  No 

d. Rh Antibody Screen  Yes  No 

e. Blood type  Yes  No 

f. Rubella  Yes  No 

g. Gonorrhea  Yes  No 

h. PAP smear  Yes  No 

If Abnormal, OTHER LABS 

DATE/ 

WKS (WERE RESULTS 

NORMAL?) 

Results Specify Actions Repeat Results 

i. (Specify) 

j. Group B Strep  Yes  No 

k. GTT (If abnormal screen)  Yes  No 

l. test  Yes  No 

m. Urinalysis  Yes  No 

n. Chlamydia  Yes  No 

o. MSAFP  Yes  No 

p. Other (Specify) __________  Yes  No 

q. Other (Specify) __________  Yes  No 

If Abnormal, OPTIONAL LABS DATE/ 

WKS (WERE RESULTS 

NORMAL?) 

Results Specify Actions Repeat Results 

r. Wet Mount & KOH  Yes  No 

s. Herpes Culture  Yes  No 

t. Screen  Yes  No 

u. HGB Electrophoresis  Yes  No 

v. Platelets  Yes  No 

w. FTA-ABS if  Yes  No 

x. Syphilis Screen  Yes  No 

y. Urine C & S  Yes  No 

z. Other (Specify) __________  Yes  No 

HCT/HGB 

TB 

Drug 

Revised June 25, 1999 Prenatal Care, Page 3 of 8

PAMR Case #_____


aa. Other (Specify) __________  Yes  No 

bb. Other (Specify) __________  Yes  No 

cc. Other (Specify) __________  Yes  No 

45. COMMENTS 

46. PROCEDURES 

PROCEDURES 

(Include date/weeks/any other info.) 

RESULTS 

 Ultrasounds: 

1........................................................... 

2........................................................... 

3........................................................... 

4........................................................... 

 Non Stress Test 

............................................................ 

............................................................ 

 Oxytocin Trial (CST) 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

 Amniocentesis 

............................................................ 

............................................................ 

 Amnioinfusion 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

 Colposcopy.......................................... 

 Alternative Therapies (Specify) 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

............................................................ 

47. PSYCHOSOCIAL ASSESSMENT 

a. Was a Prenatal Psychosocial Assessment 

performed? 

b. Was a caseworker available to this 

program/facility for assessment/follow-up? 

 Yes  Yes 

 No  No 

 Unknown  Unknown 

c. Problems identified by medical, nursing or social work personnel during prenatal care 

(If same as in Medical History, check here ______and go to Part d.) 

Problem Identified Care Plan Referral Services Received 

 Battered during pregnancy  Yes  No  Yes  No  Yes  No 

 Chronic illness (Specify)_______________  Yes  No  Yes  No  Yes  No 

 Communication barriers  Yes  No  Yes  No  Yes  No 

 Crime/legal problems  Yes  No  Yes  No  Yes  No 

Revised June 25, 1999 Prenatal Care, Page 4 of 8

PAMR Case #_____


c. Problems identified by medical, nursing or social work personnel during prenatal care (cont.) 

Problem Identified Care Plan Referral Services Received 

 Depression  Yes  No  Yes  No  Yes  No 

 Disability (Specify)_____________________  Yes  No  Yes  No  Yes  No 

 Disturbed relationship with a child  Yes  No  Yes  No  Yes  No 

 Substance use (Tobacco, Drugs, Etoh)  Yes  No  Yes  No  Yes  No 

 Employment/educational needs 

 Housing inadequate/homeless 

 Frequent moves (>3 moves/last 2 months) 

 Inadequate support system 

 Late life pregnancy (Age > 39 years) 

 Mother abused as a child 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

 No 

 No 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

 No 

 No 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

 No 

 No 

 Need for financial support  Yes  No  Yes  No  Yes  No 

 Poor nutrition  Yes  No  Yes  No  Yes  No 

 Single mother  Yes  No  Yes  No  Yes  No 

 Suicidal ideation (Age < 18 years)  Yes  No  Yes  No  Yes  No 

 Teen mother  Yes  No  Yes  No  Yes  No 

 Transportation problems  Yes  No  Yes  No  Yes  No 

 Hazardous exposures at work 

 Other (specify)__________________________ 

 Other (specify)__________________________ 

 Other (specify)__________________________ 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

 Yes 

 Yes 

 Yes 

 Yes 

 No 

 No 

 No 

 No 

d. Did a caseworker see the mother? e. Did a caseworker develop a case management 

plan for problems noted above? 

 Yes  Yes 

 No  No 

 Unknown  Unknown 

f. COMMENTS 

48. MEDICATIONS PRESCRIBED DURING PREGNANCY 

List all drugs documented as prescribed. Include name of drug as written in record, dose, route, 

schedule for taking medication and date prescribed. (e.g. Penicillin 250 mg, PO, QID, date prescribed) 

Drug Date 

Prescribed 

Comments 

a. ____/_____/_____ 

b. ____/_____/_____ 

c. ____/_____/_____ 

d. ____/_____/_____ 

Revised June 25, 1999 Prenatal Care, Page 5 of 8

PAMR Case #_____


48. MEDICATIONS PRESCRIBED DURING PREGNANCY (Cont.) 

e. ____/_____/_____ 

f. ____/_____/_____ 

g. ____/_____/_____ 

49. PRE-PREG WEIGHT/HEIGHT 50. PREGNANCY OBSERVED WEIGHT GAIN 

a. Weight______lbs. 

b. Height______in. 

 Unknown 

 Unknown 

_____lbs. during _____weeks 

51. NUTRITIONAL FACTORS PRESENT DURING PREGNANCY 

Deviation in weight Care Plan Referral Services Required 

 Obesity (preconceptual weight 20% or 

more above ideal weight for height) 

 Yes  No  Yes  No  Yes  No 

 Excessive weight gain (> 8 

lbs./month) 

 Yes  No  Yes  No  Yes  No 

 Low pre-pregnancy weight 

(10% or more under ideal weight for height) 

 Yes  No  Yes  No  Yes  No 

 Inadequate weight gain 

during pregnancy (less than 2 

lbs./month after first trimester 

 Yes  No  Yes  No  Yes  No 

52. REFERRALS to health or human services programs during pregnancy (Please check all that apply) 

 Healthy Start 

Services 

 Genetic Evaluation  Employment Office  Other Drug 

Treatment Programs 

 Nurse Home 

Assessment/Followup 

 Family Planning  Homemaker or 

Home Health Aids 

 Child Protective 

Services 

 Other Case 

Management 

 Transportation  Smoking Cessation 

Program 

 Other (Specify) 

_______________________ 

 WIC  Housing Authority  Mental Health 

Services 

 Other (Specify) 

________________________ 

 Dietitian or 

Nutritional 

Counseling 

 Group Shelters: 

Homeless or 

Battered (Circle One) 

 Methadone 

Maintenance 

Program 

 None 

53. REFERRALS to community based organizations during pregnancy (Please check all that apply) 

 Childbirth 

Education 

 Community Health 

Worker 

 Narcotics 

Anonymous 

 Other (Specify) 

______________________ 

 Breastfeeding 

Support Group 

 Local Church 

Organization 

 Alcoholics 

Anonymous 

 Other (Specify) 

_______________________ 

 Peer Group Support  United Way  None  Other (Specify) 

________________________ 

 Parenting 

Hotline/Support 

Groups 

 Food Bank 

Revised June 25, 1999 Prenatal Care, Page 6 of 8

PAMR Case #_____


54. PRENATAL RISK ASSESSMENT 

a. Was prenatal risk assessed?  Yes  No  Refused 

Screen 

 Unknown 

b. What system was used to assess 

risk? 

 Creasy 

 Healthy 

Start 

 Hollister 

 Propras 

 Other 

 None 

___________ 

c. Specify level of risk based on 

system used to assess risk. 

 Low  Moderate  High  Very High 

55. HEALTHY START 

a. What was the patient’s Healthy Start Score?_________ 

b. Was the patient at risk, but not 

referred? 

 N/A  Yes  No  Unknown 

c. What factors determined the referral status of this patient? 

 Score >4  Other Factors  Self Referred 

d. Did the patient refuse the program?  N/A  Yes  No  Unknown 

e. Was care coordination indicated?  N/A  Yes  No  Unknown 

f. Was care coordination received?  N/A  Yes  No  Unknown 

56. HEALTHY START RISK FACTORS (from Prenatal Screen) 

 Age Less than 18  Feel Unsafe 

 Age More than 39  Hungry 

 Race = Black  Tobacco 

 Unmarried  Drug or Alcohol Use 

 Less than High School Education  Timing of Pregnancy 

____Earlier 

 Prepregnancy Weight Less than 110 lbs.  Previous Poor Outcome 

 Problems Keeping Appointments  Illness Requiring Ongoing Care 

 Moved More than 3 Times in One Year  Trimester of Entry to Care = 2nd 

61. PRENATAL EDUCATION (Note: 

At any time during the prenatal period, were any of the following topics documented in writing as 

having been discussed? (Check all that apply) (If not documented, check here____) 

 Avoidance of alcohol, drugs, tobacco, 

and over-the-counter medications 

 Sexuality during pregnancy 

 Signs of labor 

 Harmful environmental exposures  Signs of preterm labor 

 Healthy Start  Stress 

 Labor and delivery process  Signs of complications of pregnancy 

 Obstetrical anesthesia and analgesia  Relaxation techniques during pregnancy 

 Physical activity and exercise during 

pregnancy 

 Rights and responsibilities of the pregnant woman 

 Physical and emotional changes during 

pregnancy 

 Risk of HIV infection and risk reduction behaviors 

 Nutrition education including 

appropriate dietary intake, RDA 

during normal pregnancy, and 

appropriate weight gain 

 Infant sleep position and bedding 

 Fetal movement 

 Other (Specify) _________________________________________________ 

____Later ____Not at All 

#’s 57-60 Omitted) 

Revised June 25, 1999 Prenatal Care, Page 7 of 8

PAMR Case #_____


FLORIDA DEPARTMENT OF HEALTH


PREGNANCY ASSOCIATED MORTALITY REVIEW


DATA ABSTRACTION FORM


Prenatal Care Visits Attachment 

Date Weeks Fundal Ht. Weight BP FHT Procedures Comments 

Revised June 25, 1999 Prenatal Care, Page 8 of 8 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

HOSPITALIZATION #___ 

Note: Complete for each hospitalization, add number above, and insert into chronological order. 

62. LEVEL OF HOSPITAL 

 Level 1  Level 2  Level 3 

63. DATE OF ADMISSION 64. TIME OF ADMISSION 

_____/_____/_____ _____ AM or PM 

(Circle one) 

65. ADMITTING DIAGNOSIS/CONDITION: Include vital signs/BP and admission history. 

If during postpartum period, include weeks/days post delivery _________ 

66. If patient was admitted as a TRAUMA patient, then state the cause of the trauma and the 

location where the injury occurred. If automobile trauma, include info. on use of seat belts. 

67. TRANSPORTATION TO HOSPITAL (Check one only) 

 EMS Team/Ambulance (If checked, fill out transport 

abstraction tool) 

 Bus or Cab 

 Family’s or Friend’s Auto  EMS Helicopter (If checked, fill out transport abstraction tool) 

 Drove Self  Other (Specify) _______________________________________ 

 Walked  Unknown 

68. FINAL DISPOSITION OF PATIENT 

 Deceased on Arrival  Transferred to Another Hospital 

 Deceased before Discharge  Other (Specify) _______________________________________ 

 Home  Unknown 

 Skilled Nursing Facility 

69. PAYER SOURCE FOR HOSPITALIZATION 

 Medicaid HMO 

 Medipass 

 Private Insurance 

 Managed Care Organization (HMO, PPO, IPA, etc.) 

 Self pay 

 Other (Specify) ______________________________________ 

 No Source Data 

Revised October 2, 2000 Hospitalization, Page 1 of 7 
PAMR Case #_____


70. PHYSICAL EXAM ON ADMISSION (If abnormal, describe) 

Normal Abnormal No Source Data Comments 

a. Head   

b. Eyes   

c. Ears   

d. Nose   

e. Throat/Palate/Mouth   

f.   

g. Heart   

h. Abdomen   

i.   

j.   

k. Spleen   

l.   

m. Kidneys   

n. Bladder   

o. Genitalia   

p. Neurologic   

q. Skeletal   

r.   

s.   

t.   

u. Skin   

v. Color/Appearance   

w. Other (Specify)__________   

71. Was the patient pregnant 

on admission? 

72. Did the patient deliver up 

to 1 hour prior to admission 

or was there a precipitous 

delivery? 

73. Was a pregnancy test 

performed on admission? 

 Yes  Yes  Yes N/A 

 No  No  No 

 Unknown  Unknown  Unknown 

74. If pregnant, describe status and outcome. 

 In Labor  Cervical Dilation  WNL for Stage of Pregnancy 

 Ruptured Membranes  Cervical Effacement  Outcome _______________ 

75. If pregnant, which methods were used to evaluate labor/delivery status? 

 OB on call  ER physician  Ultrasound at_____________ 

 L & D personnel  FHT by ________________  Other___________________ 

Comments: 

 

 

 

 

 

Lungs  

 

 

Stomach  

Liver  

 

Umbilical  

 

 

 

 

 

Extremities  

Spine  

Trunk  

 

 

 

# weeks__________ 

Revised October 2, 2000 Hospitalization, Page 2 of 7

PAMR Case #_____


76. TESTS DONE DURING THIS HOSPITALIZATION (If abnormal, please comment) 

a. Urine Tests Date Results 

 Guaiac 

 Urinalysis 

 Urine Microscopic 

 Urine Culture 

 Drug screen 

 Other____________ 

b. Stool Specimens Date Results 

 Blood Present 

 Culture 

c. X-rays Date Results 

 Skull 

 Chest 

 Abdomen 

 CAT Scan (Give type) 

 MRI 

 Other _____________ 

d. Other Tests Date Results 

 EKG 

 EEG 

 Ultrasound 

 Other ___________________ 

e. Cultures Date Results 

 Blood (Aerobic/ Anaerobic) 

 Throat 

 Mycobacterium 

 Wound 

 Uterine 

 Cervical for 

Gonorrhea 

 Cervical for 

Chlamydia 

 Group B Strep 

 Other ___________________ 

f. Blood Tests Date Results 

 Hep B Surface 

Antigen 

 HIV 

 GTT 

 ANA Titer 

 CD4 Level 

 CBC 

Revised October 2, 2000 Hospitalization, Page 3 of 7

PAMR Case #_____


Blood Tests (cont.) Date Results 

 T3/T4/TSH 

 Clotting Factors 

 Platelets 

 Electrolytes 

 Liver Enzymes 

 BUN 

 Other _____________ 

77. MEDICATIONS DURING HOSPITALIZATION 

Please indicate all types of medication given during hospitalization. 

 Antimetic/antinausea  Aspirin substitute  Oral contraceptives 

 Antacids  Combinations  Sedatives/tranquilizers 

 Anti-cancer medication  Diuretic  Steroids/hormones 

 Anti-convulsant  Hypnotic  Vaginal medication 

 Anti-histamine  Hypothyroid medication  Vitamins 

 Anti-hypertensive  Insulin  Anti-HIV 

 Anti-inflammatory  Iron  Blood product 

 Antibiotic  Laxative/suppositories Magnesium Sulfate: Time started and 

amount:_______________________ 

Other (Specify)___________________________ 

 Aspirin  Narcotics  Unknown 

78. ATTENDING PHYSICIAN/CLINICIAN 

DURING HOSPITALIZATION 

79. CONSULTING PROVIDERS DURING 

HOSPITALIZATION 

 Internist  ARNP  Internist  Specialist 

(Specify)_________________ 

 Family 

Physician 

 Physician Assistant  Psychiatrist  Other 

(Specify)_________________ 

 Obstetrician  Student  Special Nursing 

Case Management 

 None 

 CNM  Other (Specify)______________  Social Worker 

80. PSYCHOSOCIAL ASSESSMENT 

a. Was a caseworker available on the unit for 

psychosocial assessment during 

hospitalization? 

b. Did a caseworker contact the mother during 

hospitalization? 

 Yes  Yes 

 No  Unknown  No  Unknown 

c. Problems identified by medical, nursing or social work personnel during hospitalization: 

(If not documented, check here_____) 

Problems Identified Care Plan Referral Services Received 

 Battered during pregnancy  Yes  No  Yes  No  Yes  No 

 Bereavement support family  Yes  No  Yes  No  Yes  No 

 Chronic illness (Specify)_______________  Yes  No  Yes  No  Yes  No 

 Communication barriers  Yes  No  Yes  No  Yes  No 

 Crime/legal problems  Yes  No  Yes  No  Yes  No 

 Depression  Yes  No  Yes  No  Yes  No 

 Disability (Specify)_____________________  Yes  No  Yes  No  Yes  No 

 Disturbed relationship with a child  Yes  No  Yes  No  Yes  No 

Revised October 2, 2000 Hospitalization, Page 4 of 7

PAMR Case #_____ 

c. Problems identified by medical, nursing or social work personnel during hospitalization (Cont.) 

Problem Identified Care Plan Referral Services Received 

 Drug or alcohol abuse  Yes  No  Yes  No  Yes  No 

 Employment/educational needs  Yes  No  Yes  No  Yes  No 

 Housing inadequate/homeless  Yes  No  Yes  No  Yes  No 

 Inadequate support systems  Yes  No  Yes  No  Yes  No 

 Late life pregnancy (Age >39 years)  Yes  No  Yes  No  Yes  No 

 Mother abused as a child  Yes  No  Yes  No  Yes  No 

 Need for financial support  Yes  No  Yes  No  Yes  No 

 Poor nutrition  Yes  No  Yes  No  Yes  No 

 Single mother  Yes  No  Yes  No  Yes  No 

 Suicidal ideation  Yes  No  Yes  No  Yes  No 

 Surviving children  Yes  No  Yes  No  Yes  No 

 Teen mother (Age <18 years)  Yes  No  Yes  No  Yes  No 

 Transportation problems  Yes  No  Yes  No  Yes  No 

 Other (specify)_________________________  Yes  No  Yes  No  Yes  No 

 Other (Specify)_________________________  Yes  No  Yes  No  Yes  No 

 None 

81. WEIGHT RECORDED ON ADMISSION 82. HEIGHT RECORDED ON ADMISSION 

 Yes If yes, state weight in 

pounds___________ 

 Yes If yes, state height in 

inches___________ 

 No If no, estimate weight in 

pounds___________ 

 No If no, estimate height in 

inches____________ 

 Unknown  Unknown 

Comments: 

83. NUTRITIONAL FACTORS PRESENT DURING ADMISSION 

Deviation in weight Care Plan Referral Services Received 

 Obesity (preconceptual weight 20% or 

more above ideal weight for height) 

 Yes  No  Yes  No  Yes  No 

 Underweight (10% or more under 

ideal weight for height) 

 Yes  No  Yes  No  Yes  No 

 Weight loss during 

hospitalization 

 Yes  No  Yes  No  Yes  No 

 Difficulty eating or 

swallowing 

 Yes  No  Yes  No  Yes  No 

 Need for a special diet. (Specify 

type of diet)_________________ 

 Yes  No  Yes  No  Yes  No 

Revised October 2, 2000 Hospitalization, Page 5 of 7

PAMR Case #_____


84. Was a nutritional 

assessment documented in 

the chart? 

85. Was a referral to a 

registered dietitian 

ordered? 

86. Did the dietitian see the 

mother? 

 Yes  Yes  Yes 

 No  No  No 

 Unknown  Unknown  Unknown 

87. DISCHARGE PLANNING 

a. Hospitalization 

Outcome 

 The patient 

expired. 

Date__________ 

Time__________ 

 The patient 

was discharged 

home. 

Date__________ 

Time__________ 

 The patient 

was discharged 

elsewhere. 

Date__________ 

Time__________ 

 Unknown 

b. If patient expired, summarize the events leading her death. 

c. Is there documentation of follow-up 

/evaluation for children whose mother died 

during hospitalization? 

If yes, describe. 

 Yes  No  Unknown 

d. Is there documentation of social services for 

family of deceased mother? 

If yes, describe (i.e. assistance with funeral 

arrangements, referrals to community, etc.) 

 Yes  No  Unknown 

e. Was a discharge plan documented in the 

records? 

 Yes  No  Unknown 

f. Was a follow-up medical visit scheduled?  Yes  No  Unknown 

g. With whom was the follow-up visit scheduled? 

 Private Physician  Outpatient Clinic  Transferred to 

Another Hospital 

 Other 

(Specify)__________________ 

Revised October 2, 2000 Hospitalization, Page 6 of 7

PAMR Case #_____


88. REFERRALS: To outpatient follow-up care with health or human services programs before 

discharge. (Check all that apply) 

 Healthy Start 

Services 

 Genetic Evaluation  Employment Office  Other Drug 

Treatment Programs 

 Nurse Home 

Assessment/Followup 

 Family Planning  Homemaker or 

Home Health Aids 

 Child Protective 

Services 

 Other Case 

Management 

 Transportation  Smoking Cessation 

Program 

 Other 

(Specify)_________________ 

 WIC  Housing Authority  Mental Health 

Services 

 Other 

(Specify)_________________ 

 Dietitian or 

Nutritional 

Counseling 

 Group Shelters: 

Homeless or 

Battered (Circle one) 

 Methadone 

Maintenance 

Program 

 None 

Comments: 

Revised October 2, 2000 Hospitalization, Page 7 of 7

PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

TRANSPORT 

89. REASON FOR TRANSFER 

Date/time: 

90. MATERNAL CONDITIONS 

OBSTETRIC 

CONDITION 

MEDICAL 

COMPLICATIONS 

SURGICAL 

COMPLICATIONS 

 Premature rupture of 

membranes 

 Serious infection  Trauma requiring ICU or 

surgical correction 

 Premature labor  Severe heart disease  Procedure that may induce 

labor 

 Severe pre-eclampsia  Poorly controlled diabetes  Acute abdominal emergency 

 Hypertensive disorder  Thyrotoxicosis  Other (Specify)_____________________ 

 Third trimester bleeding  Renal disease with 

deteriorating function or 

increased hypertension 

 Other (Specify)____________________  Drug overdose 

 Other (Specify)____________________ 

91. FETAL CONDITIONS (Describe) 92. NEONATAL CONDITIONS (Describe) 

93. WHO MANAGED THE TRANSPORT? 94. TRANSPORT VEHICLE 

 Attending Physician  Ground Ambulance 

 Another Clinician  Fixed-wing Aircraft 

 Other (Specify)____________________________________  Helicopter 

 Other (Specify)_____________________________________ 

95. TIMING OF EMS (Circle AM or PM) 96. LEVEL OF HOSPITAL 

a. ______AM/PM Call Received 

b. ______AM/PM Depart for Referring Facility 

c. ______AM/PM Arrive at Referring Facility 

d. ______AM/PM Depart for Receiving Facility 

e. ______AM/PM Arrive at Receiving Facility 

Referring Facility 

 Level 1  Level 2  Level 3 

Receiving Facility 

 Level 1  Level 2  Level 3 

Revised October 2, 2000 Transport, Page 1;

of 2;
PAMR Case #_____;

97. PROCEDURES BEFORE TRANSPORT (Describe) 

 Tocolytic agents  Hemodynamic stabilization 

 Anticonvulsants  CPR 

 Antihypertensive drugs  Other (Describe) 

98. PROCEDURES IN TRANSPORT (Describe) 99. VITAL SIGNS IN TRANSPORT (Describe) 

100a. Is there documentation of family/children? Yes  No  Unknown 

100b. Is there documentation of bereavement support? Yes  No  Unknown 

101. WAS THIS TRANSPORT FOR RPICC SERVICES? 

 Yes  No  Unknown  N/A 

Comments 

Revised October 2, 2000 Transport, Page 2;

of 2;
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

LABOR & DELIVERY and IMMEDIATE POSTPARTUM 

(Supplement wi th Hospitaliz ation Tool as needed.) 

102. LOCATION OF BIRTH 

 Hospital  EMS Transport 

 Home  Non EMS Transport 

 Birthing Center  Other (Specify) _______________________________________ 

 No Source Data 

103. PAYER SOURCE FOR L & D 

 Medicaid HMO  Self pay 

 Medipass  Other (Specify) _______________________________________ 

 Private Insurance  No Source Data 

 Managed Care Organization (HMO, PPO, IPA, etc.) 

104. TRANSPORTATION TO HOSPITAL OR BIRTHING CENTER 

 EMS Team/Ambulance (If yes, complete transport 

abstraction form) 

 Bus or Cab 

 Family or Friends Auto  EMS Helicopter 

 Drove Self  Other (Specify) _______________________________________ 

 Walked  Unknown 

105. LEVEL OF DELIVERY HOSPITAL 

 Level 1  Level 2  Level 3 

106a. DATE OF ADMISSION 106b. TIME OF ADMISSION 

_____/_____/_____ __________ AM or PM (Circle one) 

106c. WEIGHT ON ADMISSION 106d. HEIGHT ON ADMISSION 

______pounds ______inches 

107. ADMISSION 

DIAGNOSIS/ 

CONDITION: 

(Include vital signs & BP, 

/reflexes/LOC, urine) 

___________________ 

___________________ 

___________________ 

___________________ 

REASON FOR 

ADMISSION:_______ 

___________________ 

___________________ 

___________________ 

___________________ 

___________________ 

108. ONSET OF LABOR 

(Include any information regarding 

symptoms/actions prior to admission, 

i.e. timing of contractions) 

_________________________ 

_________________________ 

_________________________ 

_________________________ 

AM or PM 

(Circle one) 

109. STATUS UPON ARRIVAL TO DELIVERY SITE 

 Stage 1 of Labor  Cervical Dilation ______________cm 

 Stage 2 of Labor  Cervical Effacement ____________% 

 Stage 3 of Labor 

 Scheduled C–Section 

 Delivered Place of delivery: _________________ 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 1 of 7 
PAMR Case #_____ 

110. MEMBRANES 

a. Did membranes rupture spontaneously prior 

to the onset of labor? 

b. Were membranes artificially ruptured? 

 Yes: Time__________ AM or PM (Circle one) 

 No  Unknown 

 Yes: Time___________ AM or PM (Circle one) 

 No  Unknown 

c. Were the membranes ruptured for a period of time longer than 24 hours prior to delivery? 

 Yes  No  Unknown 

111. PRIMARY PROVIDER FOR L & D 

 Family Physician 

 Obstetrician 

 Licensed Midwife 

 Physician Assistant 

 EMS Team 

 Law Enforcement 

 Student (Specify) 

 Other (Specify) 

 Certified Nurse 

Midwife 

 Nurse Practitioner  None  Alternative 

Practitioner (Specify) 

112. OTHER PROVIDERS THAT ASSESSED MOTHER 

 Internist  Obstetrician  Perinatologist  Specialist (Specify) 

 Other (Specify) _________  None  Doula _________________ 

113. DURATION OF LABOR 

First Stage: # of hrs._______ Second Stage: # of hrs._______ Third Stage: # of hrs._______ 

 Normal (3-20 hours) 

 Abnormal (<3 or >20 hours) 

 Unknown 

 Normal (0-2 hours) 

 Abnormal (> 2 hours) 

 Unknown 

 Normal (0-30 minutes) 

 Abnormal (>30 minutes) 

 Unknown 

114. SIGNIFICANT MEDICAL PROBLEMS DEVELOPED OR EXACERBATED DURING 

LABOR & DELIVERY 

Medical Problem Comments (Specify Problem, Date/Time developed and Treatment) 

 Neuro/Psychiatric Diseases 

 Cardiovascular Disease 

 Respiratory Disease 

 Gastrointestinal Disease 

 Exacerbation of 

Endocrinologic/Metabolic 

 Renal Disease 

 Gynecological 

 Musculoskeletal 

 Exacerbation of Oncologic 

Disease 

 Exacerbation of 

Genetic/Congenital Disorder 

 Autoimmune/Rheumatologic 

 Hematologic 

 Trauma/Physical Injury 

 Other Problems 

(Specify)________________________________ 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 2 of 7

PAMR Case #_____ 

115. SIGNIFICANT OBSTETRIC PROBLEMS DURING LABOR & DELIVERY 

Obstetric Complications Placental Complications 

 Pregnancy 

Induced HTN 

 Uterine 

Hemorrhage 

(>500cc) 

 Extension of 

Episiotomy 

 Chorioamnionitis  Amniotic Fluid 

Embolism 

 Anesthesia 

Complication 

 Cervical/Vaginal 

Laceration 

 Multiple 

Pregnancy 

 Other 

 Abruptio  Retained 

Placenta 

 Praevia  Manual 

Removal of 

Placenta 

 Accreta  Other (Specify) 

______________ 

116a. LABS (Include admission/discharge pertinent findings. For extensive labs/procedures, use Hospitalization lab sheet. Or use back) 

Procedures: Ultrasound Report on admission: 

116b. PLACENTA REPORT: 

117a. PRESENTATION  Vertex  Breech  Other 

117b. TYPE OF DELIVERY (Check one only) If Undelivered, check here_______ 

 Primary C-Section-Planned 

 Primary C-Section-Unplanned 

 Secondary C-Section-Planned 

 Secondary C-Section-Unplanned 

 Vaginal 

 Assisted Vaginal (Specify)___________________________ 

117c. DELIVERY DATE:__________ TIME:________ AM or PM (Circle one) 

118. REASON FOR C-SECTION (Check all that apply) 

 Repeat  Diabetes  Placenta Previa 

 Abruptio  Failed Induction  Prematurity 

 Breech  Failure to Progress/Descend  Pre-eclampsia 

 Congenital Anomalies  Fetal Distress  Other (Specify)_____________________ 

 Cord Prolapse  Herpes  Unknown 

 CPD  Malpresentation (other than breech)  Not a C-Section Delivery 

119. TYPE OF ANESTHESIA FOR DELIVERY (Check all that apply)  NONE 

 Local  Epidural  Narcotic Analgesia 

(Specify)____________________________ 

 Prudenal  Spinal/Saddle Block  Sedatives (Specify)________________ 

 Paracervical  General Anesthesia  Other (Specify)_____________________ 

120a. MEDICATIONS DURING L & D (Check all that apply)  NONE 

 Demerol  Cephalosporin  Gentamycin  Blood products 

(Specify)___________________________ 

 Morphine 

 Apresoline 

 Vistaril 

 Erythromycin 

 Ergotrate 

 Penicillin 

 Heparin 

 Lasix 

 Kanamycin 

 Other (Specify)___________________________ 

 Other (Specify)___________________________ 

 Phenergan 

 Oxytocin to 

Augment 

Labor 

� Oxytocin 

to 

Stimulate 

Labor 

� Oxytocin 

After 

Delivery 

� Mg 

Sulfate: 

Time 

started_____ 

Amt:_______ 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 3 of 7

PAMR Case #_____ 

120b. STATUS OF BABY: (Check one only) Gestational Weeks_________ 

 Fetal Demise Weight ___________ Length _______ Head ______ 

Comments/Description of fetus: _____________________________________________________ 

Was bereavement support documented?  Yes  No  Unknown 

 Live Birth Weight ___________ Length _______ Head ______ 

Data on Infant Documented in Mother’s Chart 

Apgars:_____/_____/_____ 

Resuscitation Efforts:  No  Yes, by ________________________ 

Transferred:  Newborn Nursery  Newborn Intensive Care  Other (Specify)______________________ 

Is there documentation that mother saw or held infant?  Yes  No 

Comments: 

121. REFERRALS for postpartum or other care (Check all that apply) Check here if none________ 

 Obstetrician  Specialist (Specify) __________________________________ 

 Perinatologist  Other (Specify) _______________________________________ 

 Internist 

122. OTHER 

a. Did mother expire during L & D?  Yes  No  Unknown 

(If yes, describe events) 

b. Is there documentation of follow-up/evaluation of children whose mother died during L & D? 

 Yes  No  Unknown 

(Describe) 

c. If mother died, is there documentation of grief loss counseling to surviving family members? 

 Yes  No  Unknown 

(Describe) 

Other comments regarding delivery: 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 4 of 7

PAMR Case #_____ 

123. VITAL SIGNS POSTPARTUM: (Include temp., pulse, resp. and B/P. Expand on any abnormal findings.) 

1 hour: Day 1: 

2 hour: Day 2: 

3 hour: Day 3: 

4 hour: On Discharge: 

124a. POSTPARTUM COMPLICATIONS 

 Hemorrhage (Amount_______ , H/H _______)  Postpartum infection 

 Hematoma formation  Other (Specify)_________________________________________ 

 Excessive vaginal bleeding  Other (Specify)_________________________________________ 

Treatments given for above problems: 

124b. OTHER SIGNIFICANT HEALTH CONDITIONS (List & describe below) 

125. NUTRITIONAL FACTORS PRESENT DURING ADMISSION 

Factor Care Plan Referral Services Received 

125a.  Weight loss during 

hospitalization 

 Yes  No  Yes  No  Yes  No 

125b.  Difficulty eating or 

swallowing 

 Yes  No  Yes  No  Yes  No 

125c.  Need for a special diet. 

(Specify type of diet)_______________________ 

 Yes  No  Yes  No  Yes  No 

125d. Was a nutritional 

assessment documented in the 

chart? 

125e. Was a referral to a 

registered dietitian ordered? 

125f. Did the dietitian see the 

mother? 

 Yes 

 No 

 Unknown 

 Yes 

 No 

 Unknown 

 Yes 

 No 

 Unknown 

126. PSYCHOSOCIAL ASSESSMENT 

126a. Did this mother exhibit long bouts of depression following birth?  Yes  No 

(If yes, describe below. Include treatments/referrals.) 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 5 of 7

PAMR Case #_____ 

126b. Was a case worker available on the unit for 

psychosocial assessment during hospitalization? 

126c. Did a case worker contact the 

mother during hospitalization? 

 Yes No 

 Unknown 

 Yes No 

 Unknown 

126d. Problems identified by medical, nursing or social work personnel during hospitalization: 

(If not documented, check here______) 

Problem Identified Care Plan Referral Service Received 

 Battered during pregnancy  Yes  No  Yes  No  Yes  No 

 Bereavement support family  Yes  No  Yes  No  Yes  No 

 Chronic illness 

(Specify)_______________________________ 

 Yes  No  Yes  No  Yes  No 

 Communication barriers  Yes  No  Yes  No  Yes  No 

 Crime/legal problems  Yes  No  Yes  No  Yes  No 

 Depression  Yes  No  Yes  No  Yes  No 

 Disability (Specify)__________________  Yes  No  Yes  No  Yes  No 

 Disturbed relationship with 

child 

 Yes  No  Yes  No  Yes  No 

 Drug or alcohol abuse  Yes  No  Yes  No  Yes  No 

 Employment/educational needs  Yes  No  Yes  No  Yes  No 

 Housing inadequate/homeless  Yes  No  Yes  No  Yes  No 

 Inadequate support systems  Yes  No  Yes  No  Yes  No 

 Late life pregnancy (>39 years)  Yes  No  Yes  No  Yes  No 

 Mother abused as a child  Yes  No  Yes  No  Yes  No 

 Need for financial support  Yes  No  Yes  No  Yes  No 

 Poor nutrition  Yes  No  Yes  No  Yes  No 

 Single mother  Yes  No  Yes  No  Yes  No 

 Suicidal ideation  Yes  No  Yes  No  Yes  No 

 Surviving children  Yes  No  Yes  No  Yes  No 

 Teen mother (< 18 years)  Yes  No  Yes  No  Yes  No 

 Transportation problems  Yes  No  Yes  No  Yes  No 

 Other (Specify)_______________________  Yes  No  Yes  No  Yes  No 

 None 

127. DISCHARGE PLANNING Date of Discharge_______ 

127a. Education documented during postpartum stay:  Yes  No (If yes, check below all that apply) 

 Breastfeeding  Infant Care  Family Planning  Self Care  Other (Specify)_____________________ 

127b. Length of Hospital Stay: ___________days 

Was mother breastfeeding?  Yes  No  Unknown 

127c. Did mother sign herself out against medical advice?  Yes  No  Unknown  N/A 

127d. 

Hospitalization 

Outcome 

 The patient expired. 

Date____________ 

Time____________ 

 The patient 

was discharged 

home. 

Date__________ 

Time__________ 

 The patient 

was discharged 

elsewhere. 

Date__________ 

Time__________ 

 Unknown 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 6 of 7

PAMR Case #_____ 

127e. If patient expired during postpartum period, summarize the events leading to her death. 

127f. Was a discharge plan documented in 

the records? 

 Yes  No  Unknown 

127g. Was a follow-up medical visit 

scheduled? Yes  No 

 Unknown 

127h. hom was the follow-up visit 

scheduled? 

 Private Physician 

 Outpatient Clinic 

 Hospital 

 Other (Specify)______________________________________ 

127i. REFERRALS: To outpatient follow-up with health or human services programs before 

discharge. (Check all that apply) 

 Healthy Start 

Services Nurse 

Home 

Assessment/ 

Follow-up 

 Other Case 

Management 

 WIC 

 Dietitian or 

Nutritional 

Counseling 

 Genetic Evaluation 

 Family Planning 

 Transportation 

 Housing Authority 

 Group Shelters: 

Homeless or 

Battered (Circle one) 

 Employment Office 

 Homemaker or Home 

Health Aides 

 Smoking Cessation 

Program 

 Mental Health 

Services 

 Methadone 

Maintenance 

Program 

 Other Drug 

Treatment Programs 

 Child Protective 

Services 

 Other 

(Specify)_____________________ 

 Other 

(Specify)_____________________ 

 None 

Comments: 

(Note: For mothers requiring extensive hospitalization after delivery, supplement with 

With w

Hospitalization tool to continue abstraction of postpartum period.) 

Revised October 2, 2000 L & D & Immed. Postpartum, Page 7 of 7 
PAMR Case #_____ 

FLORIDA DEPARTMENT OF HEALTH 

PREGNANCY ASSOCIATED MORTALITY REVIEW 

DATA ABSTRACTION FORM 

TER MIN A L EV EN T/A U TOPSY FOR M 

128a. DATE OF DEATH ____/____/____ 128b. TIME _______ AM or PM 

(Circle one) 

129. WHEN MOTHER DIED  1st Trimester  2nd Trimester 

 3rd Trimester  Labor & Delivery  Postpartum 

130. AGE AT LAST BIRTHDAY________ 

131. WHERE DID THE DEATH OCCUR? 132. WEIGHT AT 

TIME OF DEATH? 

133. HEIGHT AT 

TIME OF DEATH 

 Automobile 

 Birthing Center 

 Medical Transport 

 Home 

 Hospice 

 Hospital 

 Work 

 Other (Specify)_____________ 

__________lbs. 

 No Source Data 

_____inches 

 No Source Data 

134. RESUSCITATION ATTEMPT AT 

TERMINAL EVENT? 

135. LAW ENFORCEMENT INVOLVED 

WITH THIS DEATH? 

 Yes  No  No Source Data 

If yes, included: 

 Yes  No No Source Data 

If yes, reason: 

136. WHO CERTIFIED THE 

DEATH? 

137. WAS THE DECEASED 

SEEN BY MEDICAL 

PERSONNEL IN THE 24 

HOURS PRIOR TO 

DEATH? 

138. TO WHERE WAS THE 

DECEASED 

TRANSPORTED? 

 Attending Physician 

 Medical Examiner 

 Other (Specify)____________________ 

 Yes 

 No 

 No Source Data 

 Funeral Home 

 Hospital 

 Morgue 

 Other (Specify)_____________ 

139. NOTES 

140a. AUTOPSY OFFERED 140b. AUTOPSY PERFORMED 

 Yes 

 No 

 Yes By __________________________________________ 

 No Reason _______________________________________ 

Revised June 25, 1999; Terminal Event/Autopsy, Page 1 of 2;






PAMR Case #_____


141. MEDICAL EXAMINER CASE  Yes  No 

142a. AUTOPSY RESULTS 

142b. Was Toxicology Report included?  Yes  No  Result_______________ 

143. CAUSE OF DEATH 

Cause of Death from 

the Medical Record: ICD Code 

Cause of Death from 

Autopsy Report: ICD Code 

(a) Immediate 

(b) Underlying 

(c) Underlying 

(d) Underlying 

(a) Immediate 

(b) Underlying 

(c) Underlying 

(d) Underlying 

144. PROBABLE MANNER OF DEATH 

 Accident  Homicide 

 Natural  Suicide 

 Undetermined 

145a. Documentation of grief support for family  Yes  No 

b. Documentation of funeral assistance  Yes  No 

c. Documentation of support/referrals for remaining children  Yes  No 

Abstractor’s Comments: 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________;

_________________________________________________________________________________;

_________________________________________________________________________________;

_________________________________________________________________________________;

_________________________________________________________________________________;

Revised June 25, 1999 Terminal Event/Autopsy, Page 2 of 2 
PAMR #: Fictitious


PREGNANCY ASSOCIATED MORTALITY REVIEW 

Case Summary 

(Revised 6/99) 

CASE # Fictitious


Pregnancy Related


Interval between Date of Delivery and Date of Death: 0 days


INFORMATION FROM DEATH CERTIFICATE:


Demographics: 21, Jamaican, married, black, worked with plants, 12th grade education


Cause of Death: Complications of preeclampsia


Pregnancy Box Checked: Yes


Autopsy: Yes


Referred to Medical Examiner: No


COMMUNITY INFORMATION:


Community: Urban/Rural


Estimated distance from home to nearest Level III delivering facility: 5 miles


Case Summary Synopsis:


She was 21 years old, black, with 12 years of education, worked with plants, married, 

gravida 1, para 0. She died 4 hours after delivery; cause of death was complications of 

preeclampsia. Medical history was unremarkable. Entry for prenatal care was at 28 

weeks, with 8 visits to an obstetrician at a clinic. Prenatal history was significant for 

hypertension. She was started on Procardia during the third trimester. She was referred 

to WIC during the prenatal period. Delivery method was primary C/section performed by 

an obstetrician under general anesthesia. Obstetric complications included elevated BP, 

which was stabilized after delivery. Infant was 38 weeks gestation, weighed 7 pounds, 

and suffered no complications from the birth. Autopsy was done in the hospital. 

Significant findings included no anatomic cause of death. 

1. GENERAL HISTORY 

General History: Allergic to Penicillin 

No other problems documented 

Immunization History: No Source Data 

Sexual History: Sexually active at age 17 

No history of STDs or herpes 

Obstetrical History: 

a. Contraceptive: None 

b. Breastfeeding: N/A 

c. Births over 9 pounds: No 

d. Menstrual Cycle: Age 14, regular 

e. Previous Pregnancy Problems: N/A 

2. PRENATAL CARE RECORD (Partial, unable to access record) 

Provider: Obstetrician 

Page 1 of 5 
PAMR #: Fictitious 

Prenatal Care: Yes


Payer: Medicaid


First Visit: 1/18 at 28 weeks


Last Visit: 4/24 at 38 weeks


Location: Clinic


Number of Prenatal Visits: 8


Last Menstrual Period: 7/19/96


EDD by Dates: 4/22


EDD by Sonogram: Unknown


Gravida: 1 Para: 0


Maternal or Infant Genetic Problems: No Source Data


Previous Pregnancy History: N/A


HIV: Not on AZT


Laboratory Screening Tests: O+, RPR, GC, Antibody test, Chlamydia, sickle cell


within normal limits 

Other and Repeated Labs: H/H 11.3/35 at 32 weeks 

Procedures: AFP, Glucose within normal limits 

Medications: Started on Procardia 30 mg XL in third trimester for BP control 

Information on prenatal visits: 

Date Weeks Fundal Ht. Weight BP FHT Procedures Comments 

1/18 28-9 24cm 189 140/90 + F/u 2 weeks 

2/9 30 26 191 142/88 + Sono done F/u 2 weeks 

3/7 32 30 195 144/110 

140/90 

+ 24 hr. urine for 

protein & creatinine 

clearance 

3/16 33 31 199 138/92 + Started on procardia 

4/1 35 33 205 154/100 140 Urine n/n c/o headache, 

no edema 

4/8 36+ 35 204 140/98 152 Urine n/n +1 pedal 

edema 

4/15 37 36 205 154/98 142 Urine n/n +1 pedal 

edema 

4/24 38 36 206 142/92 136 +2 pedal 

edema, sent 

to hospital 

3. LABOR AND DELIVERY RECORD 

Location: Hospital


Payer: Medicaid


Level of Hospital: I


Date/Time of Admission: 4/24 at 11:30 a.m.


Admitting Diagnosis: Pregnancy induced hypertension


Onset of Labor: Unknown


Status upon Arrival: BP 140/90 – 150/95, bilateral pedal edema, mild hyperreflexia,


trace proteinuria. VE 4 cm, 100% effaced, vertex. 

Comments: Notation of swelling in face and hands 

Primary Provider for Labor and Delivery: OB 

Page 2 of 5 
PAMR #: Fictitious


Other Providers: Perinatologist


Duration in Labor: Unknown


Repeat labs: WBC 20.95 H/H 11/33, plts. 240,000


Type of Delivery: Primary C/section without labor trial, 4/24 at 1230


Reason: Preeclampsia


Anesthesia: General


Medications: MgSO4 for seizure precautions


Comments: During delivery BP normalized with diastolic < 110. On MgSO4 2


grams/hour for prophylaxis for preeclampsia. BP end of surgery 130/70. 

Status of Baby: Live Birth 

Weight: 3179 (7 pounds), Apgars 8/9 

Cord pH 7.39, baby transferred to newborn nursery 

After delivery, mother extubated and transferred to postpartum floor 

Postpartum Vital Signs: 

1300 pulse 120 resp. 40 BP 140/80 

1400 pulse 128 resp. 54 BP 138/78 

1500 pulse 130 resp. 40 BP 140/80 

1600 pulse 110 resp. 45 BP 135/78 

Medications: Plan to receive MgSO4 x 24 hours post C/section 

Summarization of events prior to demise: 

1630: On Desaturations noted to 80. Given face mask FIO2 with increase to 85 noted. 

Pulse 140, BP 150/100 respirations labored at 55. 

1635: OB called. Will be in hospital in 15 minutes. 

1640: Complaints of dizziness and shortness of breath. Coded. ER doctor at bedside. 

Intubated. Unable to revive after CPR and 4 rounds of ACLS medications. 

TERMINAL EVENT 

Date/Time of Death: 4/24 at 1730


Place of Death: Hospital


Weight: 200 pounds Height: 63 inches


Resuscitation: Attempted without success


Certifier of Death: MD


Medical Provider 24 Hours before Death: Yes


Autopsy: Yes, in hospital


Cause of Death: History of hypertension, preeclampsia, and obesity. No anatomic cause


of death found. 

Medical Examiner Case: No 

4. POSTPARTUM (AFTER DISCHARGE): N/A 

5. NUTRITION ISSUES 

Height: 63 inches


Pre-pregnancy Weight: 175 Recent Weight Change: unknown


Prenatal Weight Gain: 35 pounds by 38 weeks


Page 3 of 5 
PAMR #: Fictitious


Weight after Delivery: 200 pounds 

Nutritional Issues: Prenatal referral to WIC. No other documentation of nutritional 

issues. 

6. PRENATAL CARE 

Prenatal Care: Yes


First visit: 11/18 at 28 weeks


Last visit: 4/24 at 38 weeks


Location: Clinic


Number of Prenatal Visits: 8


7. SUBSTANCE USE 

Tobacco: Denied


Alcohol: Denied


Other substances: Denied


8. PRENATAL RISK ASSESSMENT 

Prenatal Healthy Start Screen given, scored 3. Referred for Healthy Start care based 

on other factors (obesity). Received 4 phone calls, 2 home visits and referral to WIC. 

9. SOCIAL SUPPORT 

Husband and sister noted as visitors. No family assessment or further mention of infant’s 

status noted in mother’s records. 

10. HOUSING 

No Source Data 

11. MENTAL HEALTH 

No Source Data 

12. FAMILY VIOLENCE OR NEGLECT 

No Source Data 

13. SOCIAL ISSUES 

No Source Data


Payer source: Medicaid


14. TRANSPORTATION 

No Source Data 

15. PROVISION OF SERVICES 

Referrals: 

Prenatal: WIC 

L&D: None 

Page 4 of 5 
PAMR #: Fictitious


Education: No documentation of prenatal education


Documentation of Bereavement/Grief Support to Family: Yes. Emotional support


given. Husband and sister in. Chaplain called for support.


16. ENVIRONMENTAL OR OCCUPATIONAL HAZARDS 

Employed in plant sales. Exposure unknown. 

17. FAMILY PLANNING


History of condom use prior to pregnancy.


18. MISCELLANEOUS INFORMATION 

Records abstracted: Labor and Delivery, Autopsy, Partial Prenatal, Healthy Start 

Unable to access records: Provider refused access to prenatal record. 

Page 5 of 5 
Appendix F 

Example of Questionnaire for 

Interviews after PregnancyRelated Deaths 

Reproduced with permission from the New 

York State Department of Health. 

This questionnaire was developed by the New York State 

Department of Health. 

Two versions of a questionnaire are included. The first can be 

used if the husband or partner is interviewed, and the second if 

another family member or friend is interviewed. 
Interview with husband or partner Client ID #:____________ 

Before we begin the interview, we really want to thank you again for your help in this research project. 

We know that speaking about _____may be emotional, and if at any time during the interview you 

would like to take a break or stop the interview, please just let me know. The reason we have asked you 

to participate in this study is that by speaking with you and others in similar circumstances, we will be 

better able to develop programs to prevent premature deaths in young women. I want to emphasize that 

everything we talk about today is completely confidential. There are no right or wrong answers in this 

survey, and it is perfectly fine if you don't know the answer to a question. If you don't understand a 

question, please ask me to explain exactly what I mean. We’ll begin with some questions about you and 

your relationship with ____ and then we’ll talk more specifically about ___. Unless there is something 

that you would like to ask me now, let's get started. 

______________________________________________________________________________ 

1. What was your relationship to _____? 

a) husband How long were you married? _______ years 

b) boyfriend 

c) live in partner/common law spouse 

d) other (specify)______________ 

2. What is your marital status? 

a) single, never married 

b) married 

c) widowed 

d) divorced 

e) separated 

3. How would you best describe your racial background? 

a) Caucasian 

b) Black 

c) Asian, Pacific Islander 

d) Native American 

e) Other 

4. 	 Are you of Spanish or Latino ancestry? 

____Yes _____No 

If no, go to question 7. 

5. 	If you were born outside of the United States, what country were you 

born in ________________________ 

6. How long did you know __________? _____months _______years? 

If the respondent was not the husband of ____, ask question 7, otherwise, go to question 9. 

7. 	Were either of you legally married to anyone else for the last year of her life? 

_____Yes _____No 

8. Was she ever married before? ______Yes ______No 

If no, go to question 10. 

9. How many times total was she married? _____________ 
10. Did you live together during the last year of her life? ______Yes _____No 

If yes, go to question 15. 

11. Where did you live in relation to _____ ? 

a) next door 

b) same apartment building or complex 

c) same street 

d) same neighborhood 

e) same city 

f) within the state 

g) different state 

h) different country 

12. During the last year of _____s life, how often did you see her?______________ 

13. How did you keep in contact with ________? (check all that apply) 

a) in person 

b) by telephone 

c) by mail 

d) other (please specify) _____________________ 

14. How would you describe your relationship with _____? 

a) very close 

b) somewhat close 

c) not close 

15. 	What is the highest grade or year of school that you have completed? 

___________________ 

16. Are you currently employed? ____Yes ____No 

If no, go to question 18. 

17. What is your occupation? _______________________ 

18. 	 Did you have a job in the last year of _____’s life? 

____Yes ____No 

If no, go to question 20. 

19. What was your occupation then? ____________________ 

20. 	Please tell me if you received money from any of the following sources 

to support yourself in the last year of _______ life. 

a) wages or pay from a job 

b) benefits such as AFDC__ Welfare__ General Assistance__ Food Stamps/SSI__ 

c) unemployment benefits 

d) child support or alimony 
e) Social Security 

f) Worker's Compensation 

g) Veteran's benefits or pensions 

h) family 

i) friends 

j) other 

21. 	Would you be willing to share with me an estimate or your annual 

income? _____Yes ____No 

If no, go to question 24. 

22. What was your total income for the past twelve months before taxes? 

Include all sources of income 

(Ranges in increments of $20,000 e.g <$20K, $20-$40K, $60-$80K, $80K+) 

$_____________________________ 

23. Was that similar to your income in the previous twelve months? 

___Yes ___No 

Now we would like to talk more specifically about ________. 

24. How did she describe her racial background? 

a) Caucasian 

b) Black 

c) Asian, Pacific Islander 

d) Native American 

e) Other (specify):________________ 

25. What was the first language she learned to speak as a child? 

a) English (skip to q27) 

b) Spanish 

c) Other (specify): __________________ 

26. Would you say that she: 

a) spoke English well 

b) spoke little English 

c) spoke no English at all 

27. What country was _____ born in? ____________________ 

If U.S., go to question 29. 

28. How long did ___ live in the United States? __________________ 

29. What was _____’s religion? 

a) Catholic 

b) Jewish 
c) Protestant 

d) Moslem/Muslim 

e) No religion (skip to q31) 

f) Other (specify): _______________ 

30. Was she active in her place of worship? ____Yes _____No 

31. Was _____ involved in other community organizations? ____Yes ____No 

32. 	What was the highest grade or year of school that _____ completed? 

______________________ 

33. What city or town did _____ live in for the last year of her life? _____________________ 

34. What type of housing did _____ live in for the last year of her life? 

a) private house 

b) apartment building or complex 

c) housing project 

d) homeless shelter 

e) residential program for drug or alcohol treatment 

f) institution please specify____________ 

g) homeless 

35. 	On a scale of one to five, how would you rate the safety of the neighborhood she lived in, 

with one being very dangerous and five being very safe? _____ 

Now I would like to ask you some questions about ____'s income 

36. In the year before she died, did _____ have a job? _____Yes _____No 

If no, go to question 38. 

37. What type of work was she doing? ________________________ 

38. 	 Again, I am going to list a number of ways that people support themselves. Please tell 

me if you know if _____ received money from any of the following sources to support herself 

in the last year of her life. 

a) wages or pay from a job 

b) benefits such as AFDC_, Welfare_, General Assistance_, Food Stamps_ or SSI_ 

c) unemployment benefits 

d) child support or alimony 

e) Social Security, Worker's Compensation, Veteran's benefits or pensions 

f) family 

g) friends 

h) other 

39. 	Would you be willing to share with me an estimate of _____s annual income? 

____Yes ____No 

If no, go to question 42. 
40. What was her total income for the last twelve months of her life before taxes? 

(Ranges in increments of $20,000 e.g <$20K, $20-$40K, $60-$80K, $80K+) 

$_____________________________ 

41. 	Was that similar to her income in the previous twelve months? 

______Yes _____No 

42. How did ____ die? 

______________________________________________________________________________ 

______________________________________________________________________________ 

43. 	Do you know if _____ was pregnant at any time during the last year of her life? 

____Yes _____No 

44. 	Did ___ have any chronic health problems (such as diabetes, hypertension)? 

___ Yes (describe _______________________________________ ) 

___ No 

45. Did ___ ever have a serious infection such as pneumonia, Lyme disease, TB or an 

STD? 

___ Yes If yes, specify _________________ 

___ No 

46. 	Did _____ have any disabilities? 

___ Yes (describe _______________________________________ ) 

___ No 

47. 	Was _____ ever diagnosed with mental illness? 

___ Yes (define ______________________ ) 

___ No 

If no, go to question 52. 

48. Did she receive treatment for the mental illness? ______Yes 

49. What type of treatment did she receive 

a) medication 

b) counseling 

c) electric shock therapy 

d) short-term hospitalization (<1 month) 

e) long-term hospitalization 

f) other (specify):_____________________ 

_____No


50. 	Do you know if _____ followed her doctor's treatment for her mental illness? 

______Yes _____No 
51. How long before _____ died did she develop mental illness? __________ 

52. Was there ever a time when _____ needed to go to the doctor or the hospital for any 

reason, but did not go? ______Yes _____No 

If yes, why didn't she go?______________________ 

Now I am going to ask you some questions about some things that _____ may or may not 

have done that could have affected her health. 

53. Did she ever smoke cigarettes? ______Yes _____No 

If no, go to question 56. 

54. Did she smoke cigarettes during the last year of her life? _____Yes _____No 

If no, go to question 56. 

55. 	Approximately how many cigarettes per day did _____ smoke during the last year of 

her life? _______ 

56. Did she drink alcohol? ______Yes _____No 

If no, go to question 58. 

57. Approximately how many alcoholic drinks did ____ have in average week during her 

last year of life? 

(A drink is one glass of wine, one wine cooler, one can or bottle of beer, one shot of liquor or 

one mixed drink) ____________________ 

58. Some women use drugs (prescribed or otherwise) for reasons other than to treat illnesses (e.g. 

stress, weight loss, socially). 	 Did _____ use drugs for similar reasons? 

______Yes _____No 

If no, go to question 62. 

59. Which of the following drugs did ___ use: (Circle all that apply) 

a) marijuana or hashish 

b) cocaine-nasal 

c) cocaine-injected 

d) crack, heroin 

e) PCP, angel dust, LSD 

f) barbiturates 

g) methadone 

h) prescription sedatives 
i) prescription diet pills 

h) Other non prescribed drugs (specify): ___________________________ 

60. How long had she been using drugs before she died? _____________ 

61. 	Did she use drugs during the last year of her life? ______Yes ______ No 

. 

Now I would like to talk about _____'s pregnancy history. 

62. 	How many times all together was _____ pregnant? ______ 

If none, go to question 75. 

63. 	How many children did she have altogether? ______ 

If none, (all pregnancies ended in spontaneous or induced abortion, go to q75) 

64. 	What were their ages and genders? (e.g. 13/M) 

_____________________________________ 

65. Did any of her pregnancies end in: (indicate how many of each) 

a) miscarriage (less than 5 months) 

b) abortion 

c) still birth / late miscarriage 

d) ectopic pregnancy (a pregnancy in her fallopian tubes) 

Now I would like to talk a bit about _____s children. 

66. 	Were all of her children living with her at the time of her death? ______Yes _____No 

If yes, go to question 68. 

67. What were the living arrangements of those children who lived away from _____? 

a) living with another relative 

b) living with a friend 

c) foster care 

d) adopted 

e) runaway 

f) living independently 

g) other (specify):_______________________ 

68. 	Have any of _____'s children been very sick or badly injured? 

______Yes _____No 

If no, go to question 72. 

69. Were they sick before or after her death? 

a) before 

b) after If after, go to question 75. 
70. Were they sick in the last year of her life? ______Yes _____No 

71. What illness(es) did he/she/they have? _________________________ 

72. 	Have any of _____'s children died? ______Yes _____No 

If no, go to question 75. 

73. When did he/she/they die ? 

a) before 

b) after 

74. What caused his/her/their death(s)? ______________________________________ 

_______________________________________________________________________ 

Now I have some questions about ____ last pregnancy of mm/dd/yy. 

75. 	Were you the father in that pregnancy (reiterate date mm/dd/yy)? 

____Yes ______No 

If no, ask question 76, but skip questions 77 through 83. 

76. Would you say that _____planned to get pregnant? 

a) planned 

b) did not plan 

77. Before ___ got pregnant, did the two of you use any birth control method to prevent 

pregnancy? 

____Yes ____No 

If no, go to question 79; If yes, skip question 79 

78. What method of birth control did you use? ______________________ 

79. Why were you not using birth control? _________________________ 

80. 	Did you want to have a child at the time? ___Yes ____No 

If yes, go to question 83. 

81. Why didn't you want to have a child?_____________________________ 

82. 	What did you want ____ to do about the pregnancy when you learned that she was 

pregnant? 

________________________________________________________________


83. 	Did the two of you make plans together to have a baby? 

____Yes ____No 
84. What was the outcome of _____'s last pregnancy of mm/dd/yy? 

a) fetal death 

b) live birth 

_full term baby 

_premature baby 

c) still birth (>20wks) 

d) miscarriage (<20wks) 

e) induced abortion 

f) ectopic pregnancy 

g) other (specify):________________ 

If the deceased had a live birth or a fetal death, continue with question 85. 

If she had any other outcome, go to question 87. 

85. 	Did ____ consider having an abortion or putting the child up for adoption? 

____Yes ____No 

86. 	If she considered abortion, what kept her from doing that? 

__________________________________________________ 

87. 	On a scale of 1 to 5, with 1 being strongly negative and 5 being strongly positive, 

what was _____'s reaction when she learned that she was pregnant?____________ 

88. 	Did ______ receive prenatal care during her pregnancy? 

_____Yes ____No 

If yes, go to question 90. 

89. Why didn't she receive prenatal care? ___________________________________ 

90. What month did she begin to receive that care? 

(If > 5 , why didn’t she receive care sooner?) ______________________________ 

____________________________________________________________________ 

91. Where did she go for prenatal care? 

a) Clinic 

b) HMO 

c) Private office 

d) Birthing Center 

e) Emergency room 

92. Do you know how many prenatal; visits she had altogether? 

a) 1-3 

b) 4-6 

c) 7+ 

d) don't know 
93. 	Did she find it difficult to keep her prenatal appointments? 

____Yes ____No 

If no, go to question 95. 

94. What was the reason for difficulty? 

a) child care 

b) job 

c) transportation 

d) illness 

e) other (specify):________________ 

95. How did she pay for prenatal visits? 

a) self pay 

b) private insurance 

c) friend/relative paid 

d) Medicaid / PCAP 

e) unable to pay 

f) other (specify):__________________ 

96. Did _____ receive WIC during her pregnancy? 

97. Did she experience any special medical problems during her pregnancy that made it 

necessary for her to see a specialist? 

____Yes ____No 

98. Many families and communities have traditions for pregnant women. Did ___ do 

any special things or see any special healers while she was pregnant? 

___Yes (specify):_______________ ____No 

If the deceased died during pregnancy, go to question 109 . ;

If the deceased died during birth, or before she was discharged from the hospital, skip questions;

103-108. 

99. What was the date of the baby's birth (or termination of pregnancy)? 

100. If this pregnancy ended in a birth/stillbirth, indicate delivery type: 

a) normal vaginal 

b) complicated vaginal 

c) c-section 

d) other (specify):_________________ 

101. If this pregnancy ended in abortion, indicate type: 

a) spontaneous miscarriage 

___/___/___

b) surgery for ectopic pregnancy 

c) abortion, licensed provider 

d) abortion, unlicensed provider 

e) other (specify):_______________ 

102. 	How many months pregnant was ____ at the time of delivery or termination of 

pregnancy? ________months 

103. After the pregnancy, did ____ keep her routine follow-up appointments? 

____Yes ____No 

104. Did ___ experience any medical complications after the baby was born/ the 

abortion? 

____Yes ___No 

If no go to question 109. 

105. Did ____ go to a doctor to treat the complications? _____Yes ______No 

If yes, go to question 109. 

106. Why didn't she go to a doctor to treat the complications? 

a) lack of money 

b) transportation 

c) child care 

d) other (specify):______________ 

107. Did the problems go away after treatment? ____Yes ___No 

108. Did ____ complain about excessive pain or discomfort after the baby was born/ the 

abortion? 

___Yes ____No 

109. 	The next set of questions is about events that may have happened to _____ in the 

last year of her life. I will read you a list of items and for each tell me whether or 

not it happened during this time in her life. 

a) 	Did she move apartments or houses? Y N 

If yes, how many times did she move? _________ 

b) Was she ever homeless? Y N 

c) Did she get very sad or depressed? Y N 

d) Did a close friend or family member become very sick or die? Y N 

e) Did she lose her job? Y N 

f) 	Did anyone hit, punch or kick her? Y N 

If yes, who?_________________ 

g) Was she the victim of a crime? Y N 

If yes, what type of crime?________________________ 

h) Was she arrested? Y N 

If yes, for what?____________________ 
i) Was she involved in a gang? Y N 

110. Did any other difficult event take place? please specify _____________________ 

111. Is there anything else you would like to share with me about _____? 

________________________________________________________________________ 

________________________________________________________________________ 

112. Finally, do you have any advice about helping families who experience a loss 

similar to yours? 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

Completed by: _______________________________ Date: _____/_____/_____ 
Interview for family member or friend Client ID#:_____________ 

Before we begin the interview, we really want to thank you again for your help in this research 

project. We know that speaking about _____may be emotional, and if at any time during the 

interview you would like to take a break or stop the interview, please just let me know. 

The reason we have asked you to participate in this study is that by speaking with you and 

others in similar circumstances, we will be better able to develop programs to prevent premature 

deaths in young women. 

I want to emphasize that everything we talk about today is completely confidential. There are 

no right or wrong answers in this survey, and it is perfectly fine if you don't know the answer to 

a question. If you don't understand a question, please ask me to explain exactly what I mean. 

Unless there is something that you would like to ask me now, lets get started. 

______________________________________________________________________________ 

1. What was your relationship to _____ 

a) mother 

b) father 

c) brother 

d) sister 

e) friend 

f) other (specify):_______________________ 

2. How would you best describe your racial background 

a) Caucasian 

b) Black 

c) Asian, Pacific Islander 

d) Native American 

e) Other (specify):___________________ 

3. Are you of Spanish or Latino ancestry? _____Yes _______No 

If no, go to question 6. 

4. What group best describes your ancestry, please be specific 

a) American 

b) African please specify country__________________ 

c) Caribbean please specify country__________________ 

d) Asian please specify country ________________ 

e) European please specify country ________________ 

6. If you weren’t born in the US, what country were you born in? ____________________ 
Now I would like to ask you some more questions about your relationship with _____. 

7. How long did you know _____? _____years ______ months 

8. Where did you live in relation to_______? 

a) next door 

b) same apartment building or complex 

c) same street 

d) same neighborhood 

e) same city 

f) within the state 

g) different state 

h) different country 

11. During the last year of her life, how often did you see _____? 

___________________________ 

12. How did you keep in contact with_______ (circle all that apply) 

a) in person 

b) by telephone 

c) by mail 

d) other (specify): _____________________ 

13. How would you describe your relationship with _____? 

a) very close 

b) somewhat close 

c) not close 

14. What is the highest grade or year of school that you have completed? 

___________________ 

15. Are you currently employed? 	 ____Yes ____No 

If no, go to question 17. 

16. What is your occupation _______________________ 

17. Did you have a job in the last year of _____s life? ____Yes ____No 

If no, go to question 19. 

18. What was your occupation then? ____________________ 

19. Please tell me if you received 	money from any of the following sources to support yourself 

in the last year of _____'s life. 

a) wages or pay from a job 
b) benefits such as AFDC_ Welfare_ General Assistance_ Food Stamps/SSI_ 

c) unemployment benefits 

d) child support or alimony 

e) Social Security 

f) Worker's Compensation 

g) Veteran's benefits or pensions 

h) family 

i) friends 

j) other 

20. Would you be willing to share with me an estimate or your annual income? 

____Yes ____No 

If no, go to question 23. 

21. 	What was your total income for the past twelve months before taxes? 

Include all sources of income 

(Ranges in increments of $4,999 e.g.15,000-19,999) 

$_____________________________ 

22. Was that similar to your income in the previous twelve months? 

Now we would like to talk more specifically about ________. 

23. How did she describe her racial background? 

a) Caucasian 

b) Black 

c) Asian, Pacific Islander 

d) Native American 

e) Other (specify):________________ 

24. Was she of Spanish or Latino ancestry? 

If no, go to question 26. 

26. What group best describes _____s ancestry, please be specific 

a) American 

b) African (please specify__________________ ) 

c) Caribbean (please specify__________________ ) 

d) Asian (please specify__________________ ) 

e) European (please specify___________________) 

27. 	What was the first language she learned to speak as a child? 

a)English 

b) Spanish 

c) Other (specify): __________________ 
28 Would you say that she 

a) spoke English well 

b) spoke little English 

c) spoke no English at all? 

29. 	What country was _____ born in? ____________________ 

If U.S., go to question 31. 

30. 	Did she live in the United States with or without official documentation? 

____Yes ____No 

31. What was _____s religion? 

a) Catholic 

b) Jewish 

c) Protestant 

d) Moslem/Muslim 

e) No religion 

f) Other (specify): _______________ 

32. Was she active in her place of worship (if applicable)? ____Yes ____No 

33. Was _____ involved in other community organizations? ____Yes ____No 

34. What was the highest grade or year of school that _____ completed? 

__________________________________ 

35. What city or town did _____ live in for the last year of her life? 

_________________________________ 

36. What type of housing did _____ live in for the last year of her life? 

a) private house 

b) apartment building or complex 

c) housing project 

d) homeless shelter 

e) residential program for drug or alcohol treatment 

f) institution (specify):____________ 

g) homeless 

37. On a scale of one to five, how would you rate the safety of the neighborhood she lived in, 

with one being very dangerous and five being very safe? ______ 

Now I would like to ask you some questions about ____'s income 

38. 	In the year before she died, did _____ have a job? ____Yes ____No 

If no, go to question 40. 
39. What type of work was she doing? ________________________ 

40. Again, I am going to list a number of ways that people support themselves. Please tell me if 

you know if _____ received money from any of the following sources to support herself in 

the last year of her life. 

a) wages or pay from a job 

b) benefits such as AFDC _, Welfare _, General Assistance _, Food Stamps or SSI_ 

c) unemployment benefits 

d) child support or alimony 

e) Social Security, Worker's Compensation, Veteran's benefits or pensions 

f) family 

g) friends 

h) other 

41. Would you be willing to share with me an estimate of _____s annual income? ____Yes 

____No 

If no, go to question 43. 

42. What was her total income for the last twelve months of her life before taxes? 

Include all sources of income. $_________________ 

43. Was that similar to her income in the previous twelve months? 

____Yes ____No 

44. How did ____ die? 

_____________________________________________________________________________________ 

_______________________________________________________________________ 

4Do you know if _____ was pregnant at any time in the last year of her life? 

_____Yes ____No 

46. Did _____ have any chronic health problems? ____Yes ____No 

47. Did ___ ever have a serious infection such as pneumonia, Lyme disease, TB, STD? 

48. Did ___ have any disabilities? 

49.	 Was _____ ever diagnosed with mental illness? ____Yes 

Define_________________________ 

49. Did she receive treatment for the mental illness? ____Yes 

50. What type of treatment did she receive 

a) medication 

b) counseling 

c) electric shock therapy 

____No


____No

d) short-term hospitalization 

e) long-term hospitalization 

51. Do you know if _____ followed her doctor's treatment for her mental illness? ____Yes ____No 

52. How long before _____ died did she develop mental illness? __________ 

53. Was there ever a time when _____ needed to go to the doctor or the hospital for any reason, but did 

not 	go? ____Yes ____No 

If yes, why didn't she go? _________________________ 

Now I am going to ask you some questions about some things that _____ may or may not have 

done that could have affected her health. 

55. 	Did she ever smoke cigarettes? 

____Yes ____No 

If no, go to question 58. 

56. 	Did she smoke cigarettes during the last year of her life? ____Yes ____No 

If no, go to question 58. 

57. Approximately how many cigarettes per day did _____ smoke during the last year of her life? ______ 

58. 	Did she drink alcohol? 

____Yes ____No 

If no, go to question 64. 

59. Approximately how much alcohol did ____drink per week during her last year of life? 

____________________ 

60. Some women use drugs for reasons other than to treat illnesses. Did ____ use drugs for similar 

reasons? 

____Yes ____No 

If no, go to question 64. 

61. How long had she been using drugs before she died? _____________ 

62. 	Did she use drugs during the last year of her life? ____Yes ___No 

If no, go to question 64. 

63. Which of the following recreational or street drugs did ____use: (Circle all that apply) 

a) marijuana 

b) cocaine-nasal 

c) cocaine-injected 

d) crack, heroin 

e) PCP 
f) barbiturates 

g) methadone 

h) other non prescribed drugs (specify):_______________ 

Now I would like to talk about _____'s pregnancy history. 

63. 	How many times all together was _____ pregnant? ______ 

If none, go to question 77. 

64. How many children did she have all together? ______ 

65. 	What were their ages and genders? (e.g. 13/M) 

_____________________________________ 

66. Did any of her pregnancies end in: (indicate how many of each) 

a) miscarriage (less than 5 months) 

b) abortion 

c) still birth 

d) ectopic pregnancy (a pregnancy in her fallopian tubes) 

Now I would like to talk a bit about _____s children. 

67. 	Were all of her children living with her at the time of her death? ______Yes _____No 

If yes, go to question 73. 

68. What were the living arrangements of those children who lived away from _____? 

a) living with another relative 

b) living with a friend 

c) foster care 

d) adopted 

e) runaway 

f) living independently 

g) other (specify):_______________________ 

69. 	Have any of _____'s children been very sick? ______Yes _____No 

If no, go to question 77. 

70. Were they sick before or after her death? 

a) before 

b) after If after, go to question 72. 

71. Were they sick in the last year of her life? ______Yes _____No 

72. What illness(es) did he/she/they have? _________________________ 
73. 	Have any of _____'s children died? ______Yes _____No 

If no, go to question 77. 

74. Did he/she/they die before or after her death? 

a) before 

b) after If after, go to question 76. 

75. Did he/she/they die during the last year of her life? ______Yes _____No 

76. What caused his/her/their death(s)?_________________________________________ 

Now I have some questions about ____ last pregnancy of mm/dd/yy. 

77. Would you say that _____ planned or did not plan to get pregnant? 

a) planned If planned, go to question 82. 

b) did not plan 

78. 	Do you know if _____ was using birth control before she got pregnant? 

____Yes (specify method if known):_________________ 

____No 

79. What was the outcome of this last pregnancy (dated mm/dd/yy)? 

a) fetal death 

b)	 live birth 

full term baby 

premature baby 

c) still birth (>20wks) 

d) miscarriage (<20wks) 

e) induced abortion 

f) ectopic pregnancy 

g) other____________________________________________________ 

If the deceased had a live birth or a fetal death and the answer to question 77 was "not planned", 

continue. If she had any other outcome, go to question 82. 

80. 	Did she consider having an abortion or placing the child up for adoption? 

____Yes ____No 

81. 	If she considered an abortion, what kept her from doing that? __________________ 

___________________________________________________________________ 

82. 	On a scale of one to five, with one being strongly negative and five being strongly positive, 

how did _________ react when she learned she was pregnant? _________ 

83. Did _____ receive prenatal care during her pregnancy? _____Yes ______No 
If no, go to question 90. 

84. 	Do you know what month of her pregnancy she began to receive that care? 

____Yes _______month ______No 

85. Where did she go for prenatal care? 

a) Clinic 

b) HMO 

c) Private office 

d) Birthing Center 

e) Emergency room 

86. Do you know how many prenatal; visits she had altogether? 

a) 1-3 

b) 4-6 

c) 7+ 

d) don't know 

87. 	Did she find it difficult to keep her prenatal appointments? 

____Yes ____No 

If no, go to question 89. 

88. What was the reason for difficulty? 

a) child care 

b) job 

c) transportation 

d) illness 

e) other (specify):________________ 

89. How did she pay for prenatal visits? 

a) self pay 

b) private insurance 

c) friend/relative paid 

d) Medicaid 

e) unable to pay 

f) other (specify):__________________ 

90. Did _____ receive WIC during her pregnancy? ___Yes ___No 

91. Did she experience any special medical problems during her pregnancy that made it 

necessary for her to see a specialist? 

____Yes ____No 

92. Many families and communities have traditions for pregnant women. Did ___ do any 

special things or see any special healers while she was pregnant? 

___Yes (specify):_______________ ____No 
If the deceased died during birth or before she was discharged from the hospital, skip questions 98 -

104. 

93. What was the date of the baby's birth or termination of pregnancy? ___/___/___ 

95. If this pregnancy ended in a birth/still birth of her child, indicate delivery type 

a) normal vaginal 

b) complicated vaginal 

c) c-section 

d) other (specify):_________________ 

96. If this pregnancy ended in an abortion, indicate type 

a) spontaneous miscarriage 

b) surgery for ectopic pregnancy 

c) abortion, licensed provider 

d) abortion, unlicensed provider 

e) other (specify):_______________ 

97. 	How many months pregnant was ____ at the time of delivery or termination of pregnancy? 

________months 

98. Did ____ keep her routine postpartum appointments? ____Yes ____No 

99. 	Did ___ experience any medical complications after the baby was born? 

____Yes ___No 

If no go to question 105. 

100. Did ____ go to a doctor to treat the complications? _____Yes ______No 

If yes, go to question 102. 

101. Why didn't she go to a doctor to treat the complications? 

a) lack of money 

b) transportation 

c) child care 

d) other (specify):______________ 

102. Did the problems go away after treatment? ____Yes ___No 

103. Did _____ have trouble sleeping after the baby was born? ______Yes ___No 

104. Did ____ complain about excessive pain or discomfort after the baby was born? 

___Yes ____No 
105. The next set of questions is about events that may have happened to _____ in the last year 

of her life. I will read you a list of items and for each tell me whether or not it happened 

during this time in her life. 

a) 	Did she move apartments or houses? Y N 

If yes, how many times did she move? ___________________ 

b) Was she ever homeless? Y N 

c) Did she get very sad or depressed? Y N 

d) Did a close friend or family member become very sick or die? Y N 

e) Did she lose her job? Y N 

f) 	Did anyone hit, punch or kick her? Y N 

If yes, who?_________________ 

g) Was she the victim of a crime?	 Y N 

If yes, what type of crime?________________________ 

h) 	Was she arrested? Y N 

If yes, for what?____________________ 

i) Was she involved in a gang? Y N 

106. Did any other difficult event take place? please specify________________________ 

107. Is there anything else you would like to share with me about _____ 

_________________________________________________________________________ 

_________________________________________________________________________ 

108. Finally, do you have any advice about helping families who experience a loss similar to yours? 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

_________________________________________________________ 

Completed by: _______________________________ 

Date: _____/_____/_____ 
Appendix G 

Extracts from “State Level 

Expert Review Committees— 

Are They Protected?” 

Excerpted, with permission from Ronald F. Wright, 

from Public Health Reports 1990:105;13-23. 

State Level Expert Review Committees— 

Are They Protected? 

Ronald F. Wright, J.D. 

Jack C. Smith, M.S. 

For years state maternal mortality review committees 

have made an important contribution to maternal health in our 

nation. More recently, however, many of these committees have 

become inactive. Representatives of the American College of 

Obstetricians and Gynecologists, State health departments, 

and State medical societies attribute the decline in committee 

activity in large part to legal concerns, such as the liability of 

committee members and the use of committee proceedings in 

litigation. 

State-level investigation of maternal deaths is the keystone to 

the national epidemiologic surveillance of maternal mortality 

conducted by the Centers for Disease Control, Public Health 

Service. Because State review committees traditionally carry out 

these investigative functions, the decline in committee activity 

has proved to be problematic. ... 

Although specific concerns regarding maternal mortality review 

committees prompted this report, the results apply more 

broadly to other expert committees, such as infant and perinatal 

mortality review committees, that are established to conduct 

morbidity and mortality investigations aimed at improving 

the public’s health. ... 
Strategies to Reduce Pregnancy-Related Deaths 

Background 

The 1990 Health Objectives for the Nation, promulgated by 

the Public Health Service, emphasized the need to reduce the 

maternal mortality rate in the United States.1 In recent decades, 

remarkable progress has been made in reducing deaths due to 

pregnancy and childbearing. However, because the maternal 

mortality rate has shown little decline in the 1980s,2 current 

projections for 1990 indicate that the intended objective of no 

more than five deaths per 100,000 live births for any county or 

for any ethnic group will not be met.3 

To further reduce maternal mortality, the Federal Government 

in 1987 initiated National Pregnancy Mortality Surveillance. 

This ongoing surveillance is conducted by the Division of 

Reproductive Health of the Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease Control 

(CDC), in collaboration and consultation with organizations 

representing both the public and private sectors of the health 

community. The purpose of the surveillance is to identify and 

describe more completely the number and characteristics of 

pregnancy-related deaths nationally and to use that information 

to develop and focus prevention strategies to improve maternal 

health. 

The investigative work done in States by maternal mortality 

review committees is integral to CDC’s National Pregnancy 

Mortality Surveillance.4 These committees typically operate 

as a standing committee of the State medical society and are 

composed of obstetricians, gynecologists, and other health 

professionals who have a clinical or epidemiologic interest in 

maternal health. 

Historically, maternal mortality review committees began to 

be established at the local and State level in the 1920s.5 In the 

1950s, the Committee on Maternal and Child Health Care of 

the American Medical Association (AMA) developed guidelines 

for state maternal mortality committees.6 Today many State 

committees operate under a protocol largely based on the 

AMA model. In general, these committees: 

■ Obtain cooperation from State medical societies. 

■ Develop liaison with State health departments. 

■	 Receive notice of maternal deaths from State offices of vital 

statistics (accompanied by a copy of the decedent’s death 

certificate). 
Appendix G 

■	 Collect relevant information pertaining to each maternal 

death from the physician in charge of the patient and from 

medical records and autopsy reports. 

■ Remove identifiers from records and assign a case number. 

■ Distribute information to committee members for analysis. 

■ Disseminate findings. 

A 1976 study showed that between 1968 and 1975, the number 

of States with active maternal mortality review committees 

declined from 45 to 38, and for those States that had functioning 

committees, the authors stated that “medicolegal concerns 

appear to have impeded case investigation or to have limited 

dissemination of findings in several States.”7 A 1988 study found 

that the number of States with active maternal mortality review 

committees had continued to decrease and attributed the 

decrease to the small number of maternal deaths in the States 

and to the reluctance of physicians to cooperate because of 

the current legal climate.8 

In conjunction with the new National Pregnancy Mortality 

Surveillance, CDC established a Maternal Mortality Working 

Group, composed of representatives of State health departments 

and medical societies who have a broad interest and expertise 

in maternal health, to provide consultation and guidance. 

Discussions with working group members revealed both 

concern and confusion regarding the current status of legal 

protection for all expert review processes at the State level, 

including maternal mortality review committees.9 The concern 

and confusion center on the statutory protection for committee 

members against liability and for committee records and 

proceedings against disclosure in litigation. ... 

Findings 

In the overwhelming majority of States, the legal risk of 

participating in expert review is negligible. The protections of 

State law are divided into two categories: confidentiality and 

immunity. Confidentiality laws protect from disclosure 

information gathered and created during the review process; 

some prevent the use of such information in a subsequent 

lawsuit. Immunity laws insulate participants from personal 

liability based on actions taken during the review process. 
Strategies to Reduce Pregnancy-Related Deaths 

Most States have confidentiality statutes protecting information 

involved in the review process from disclosure or use in 

subsequent litigation. Most statutes prevent disclosure of 

information in “discovery” proceedings; that is, the portion 

of a lawsuit in which parties may collect information pertinent 

to their claims or defenses. The most expansive protection not 

only prevents discovery of relevant documents but also makes 

such evidence inadmissible at trial. This broader protection 

would become helpful if a party to a lawsuit obtained a 

document through inadvertence or some other method 

outside the discovery process. In such a case, the document 

would have little value to a litigant because it would not 

become evidence in a trial. ... 

Most States also have statutes immunizing participants in the 

expert review process from civil liability. The most effective 

statutes protect both the members of the committee and any 

witness, provider of information, consultant, or employee of 

the committee. Most statutes will immunize conduct only if that 

conduct is “without malice,” or in other words, only when a 

person acts on the basis of a reasonable belief that it is the 

proper thing to do. 

Immunity protections are less important than confidentiality 

for maternal mortality review committees. Because no adverse 

action, such as restriction of staff privileges or loss of license, 

is normally taken against a physician as a result of a typical 

maternal mortality review committee finding, physicians have 

little risk of being sued personally because they served on such a 

committee. Nevertheless, immunity protections may be valuable 

as a guard against lawsuits in the unlikely event that one arises 

from some other source. ... 

Discussion 

The legal protection provided by State law to maternal mortality 

review committees depends on the extent to which State law 

recognizes the difference between maternal mortality review 

and peer review. Peer review normally takes place at the local 

level or within an institution such as a hospital. It evaluates 

medical treatment to assure the quality of the care given. Such 

an evaluation could be designed to enforce or improve the 

practices expected of persons with staff privileges to control the 

costs of medical care. Even when a State medical society or some 

entity of State government conducts peer review, the purpose of 

the review focuses on the qualifications of health care providers. 
Appendix G 

Maternal mortality review, on the other hand, does not consider 

the qualifications of any physician or the cost-effectiveness of a 

particular course of treatment. The committee need not (and 

often does not) know the name of the physician or the patient 

in the case. The findings of the committee do not result in loss 

of staff privileges or license or in any other form of discipline. 

Maternal mortality review takes place at a State level; its only 

aim is research to identify the most effective forms of treatment 

or prevention. To distinguish maternal mortality review and 

other forms of State-level, research-oriented review from peer 

review, in this report we use the terms “expert review” and 

“peer review.” 

Perhaps the greatest legal risk for expert review exists in States 

that have immunity and confidentiality statutes that are 

applicable only to peer review. ... Expert review committees 

often find protection under the same statute that applies to peer 

review. If “peer review” is defined broadly by a statute to include 

reviews for “improving the quality of health care” or “reducing 

mortality and morbidity,” expert review is probably also 

protected. On the other hand, if a statute protects peer review 

only for the purposes of assuring the quality of professional 

credentials or some other disciplinary purpose, expert review 

such as a maternal mortality review committee might be left 

with no special statutory protection. ... 

Legal structure of the committee. Expert review typically 

involves some cooperation between the State health department 

and the State medical society. The health department arranges 

for a committee of the medical society (or its designated 

representative) to receive records, such as death certificates 

and autopsy reports, relating to maternal deaths. Sometimes 

the medical society acts without any formal or informal 

authorization from the health department. A few State 

statutes...provide some protection to committees of local 

medical societies that is not available to committees of State 

medical societies. In those States, an affiliation with the local 

society would provide the most protection. 

Some statutes require that the committee be authorized by the 

health department before immunity and confidentiality will 

apply to the committee’s work. It is important to confirm with 

legal counsel that the group carrying out expert review has 

obtained the authorization required by law. Similarly, if the 

statute requires a particular type of proceeding, such as an 
Strategies to Reduce Pregnancy-Related Deaths 

actual meeting of the committee rather than a telephone 

conversation or correspondence, the statutory requirements 

should be followed to ensure that the committee does not lose 

its legal protection. 

Summary of confidentiality statutes. The typical confidentiality 

statute protects certain committee information from discovery 

in a civil suit. When parties to a lawsuit make a request during 

discovery for the committee to turn over protected information, 

the committee may refuse to do so. A smaller number of statutes 

protect committee information from subpoena, which is an 

order to appear at a legal proceeding. This protection prevents 

a party to a lawsuit from forcing another party to bring a 

document to trial, but it does not prevent the first party from 

using whatever documents or testimony he or she already 

possesses. 

The strongest statutes go beyond the exemption from discovery 

or subpoena and provide that committee information is 

inadmissible as evidence. Thus, if some committee information 

inadvertently leaks out, it still may not be used as evidence at 

trial. A few statutes provide simply that committee information 

is “privileged,” which implies an exemption both from discovery 

and from use as evidence. ... 

Confidentiality normally applies to all civil proceedings, but 

in a minority of states the protections apply to some types 

of lawsuits and not to others. For instance, in some States 

confidentiality only applies in lawsuits involving the same 

“subject matter” that was considered by the committee. In other 

words, if representatives of the patient whose case was being 

reviewed tried to discover committee documents, they would 

fail; however, if representatives of some other patient with a 

similar problem tried to obtain the same documents, they might 

succeed. Although this provision could limit significantly the 

protection offered, it will become relevant only in situations 

where committees hear two cases with enough similarity for the 

committee’s findings in one case to become useful in a lawsuit 

relating to the second case. Given the small number of cases 

reviewed by the typical maternal mortality review committee, 

such similar cases would be unlikely to occur. 

Many confidentiality statutes create an exception for 

information sought by a physician in a lawsuit challenging 

his or her loss of license or staff privileges. Under these statutes, 
Appendix G 

the physician may obtain committee information through 

discovery. However, since physician discipline normally does 

not result from maternal mortality review, this sort of lawsuit 

(and possible disclosure) is unlikely to happen. 

The committee information protected from discovery or 

admission as evidence includes both documents and testimony. 

The documents covered by statute are often described as 

“records” and “proceeding,” which include most of the 

documents normally involved in maternal mortality review, 

such as questionnaires filled out by physicians, notes regarding 

interviews, and memoranda analyzing the information gathered. 

Many statutes say that preexisting documents available from 

independent sources are discoverable even though such 

documents are presented to the review committee. This 

stipulation should pose no problem to review committees 

because the documents involved would be discoverable 

whether or not the committee used them. 

Testimony is also sheltered: parties may refuse to testify about 

what took place during committee proceedings. Under some 

statutes, witnesses are forbidden to testify about committee 

business even if they choose to do so. Some statutes allow 

testimony relating to matters discussed before the committee 

if the witness has some “independent” knowledge of those 

matters. For example, a witness present during treatment may 

describe to the committee what was seen and could also testify 

about the same matter in litigation. However, these same 

statutes always confirm that the witness may not testify about 

what actually transpired at a committee meeting or about an 

opinion formed as a result of the committee proceedings. 

Even when a statute is silent regarding testimony, such 

protection might be implied by other language in the law. 

When a statute protects “proceedings” of the committee from 

admission into evidence, presumably both documents and 

testimony revealing what happened in a committee meeting 

would be excluded from evidence. 

The final recommendations or findings of the committee are 

not always given the same protection as that given the records 

and proceedings of the committee. However, most States 

explicitly protect committee findings. Many committees will 

choose to publish their findings and will therefore be more 
Strategies to Reduce Pregnancy-Related Deaths 

concerned with admissibility than discovery. A few statutes 

require that all patient identifiers be removed from the final 

report. Even when not required by law, removal of names would 

be a prudent practice. 

Summary of immunity statutes. Immunity always extends 

to members of the review committee, and it often extends to 

witnesses and others who provide information. Virtually every 

statute limits immunity to those cases in which the physician 

acts “without malice.” A person acts without malice under the 

following circumstances: (a) he or she makes a reasonable effort 

to determine the true facts and (b) he or she reasonably believes 

that the action taken is appropriate. 

Personal lawsuits against committee participants normally 

are brought by physicians who are adversely affected by a 

peer review decision. Once again, because adverse effects to 

the physician who handled the case do not normally occur 

as a consequence of the review by the maternal mortality 

review committee, the risk of a committee participant being 

sued personally is low. 

Judicial interpretations of statutes. Whenever statutory 

language is unclear, the courts must interpret the meaning 

of the statute by trying to determine the intent of the legislature 

at the time it passed the bill. Therefore, maternal mortality 

review committees should remain informed about all court 

decisions in their State that interpret the relevant statute. A 

regular (perhaps an annual) consultation with legal counsel 

would offer the best information about such decisions. 

For many statutes, no judicial interpretations have appeared yet. 

Courts that have been asked to interpret statutes have tended 

not to read the statutes in an unexpected way. 

Perceptions of legal risk. The concerns of persons and 

organizations involved in the maternal mortality review process 

regarding legal risks generated the impetus for researching the 

protection afforded by State statutes. In some instances the 

perceptions of legal risks are accurate. For example, one may 

correctly perceive low legal risks when in fact there are low risks 

because statutory protection is strong, or one may correctly 

perceive higher legal risks when in fact there are higher risks 

because statutory protection is weaker. 
Appendix G 

On the other hand, not all of the perceptions of legal risk 

expressed by those involved in the maternal mortality review 

process are well-founded. That is, on examination of protective 

statutes, concerns of some persons about lawsuits may not be 

warranted. Conversely, complacency about legal risks by others 

may prove problematic. In any case, a clear understanding of 

State statutes and discussions with informed legal counsel must 

be part of an accurate assessment of legal risks. 

A survey of legal counsel associated with medical societies and 

health departments in several States revealed a relatively low 

level of concern in the legal community about legal risks. 

Although some were unfamiliar with the maternal mortality 

review process, legal counsel familiar with both the statutory 

protections and the review process reported no significant legal 

difficulties in the past and expressed little or no concern about 

the adequacy of coverage for future activities of the review 

committees. 

Impact of Federal law. The legal protection for expert review 

currently derives from State rather than Federal law. Two sources 

of Federal law—the antitrust laws and the Health Care Quality 

Improvement Act (HCQIA) of 1986—have a bearing on peer 

review but not on expert review. 

The antitrust laws prohibit conspiracies among competitors to 

reduce competition. A group of physicians using peer review in 

bad faith as a way to eliminate competitors (by stripping them 

of staff privileges or licences) might be liable under the antitrust 

laws.14 Antitrust suits are normally filed by a physician whose 

staff privileges or license is adversely affected by a peer review 

decision. Because expert review typically does not involve any 

decision relating to a physician’s privileges or license, the 

antitrust laws do not pose a significant legal threat to the 

expert review activities covered by this report. 

The HCQIA15 protects all participants in certain peer review 

activities from any civil damage action, provided they make 

a reasonable effort to obtain accurate facts and reasonably 

believe their action will further quality health care. This strong 

immunity statute will provide uniform legal protection for 

all States that do not “opt out” of its provisions. However, the 

HCQIA applies only to peer review activities with the purpose 

of physician discipline. Because the expert review activities 

covered by this report (including maternal mortality review) 
Strategies to Reduce Pregnancy-Related Deaths 

do not involve physician discipline, the HCQIA will not apply. 

Conversations with the persons in the Department of Health 

and Human Services responsible for drafting regulations under 

this statute confirm this interpretation of the statute. 

Implications for other forms of expert review. ...State statutes 

[have] direct relevance to public health policy. Recently, the 

National Academy of Sciences’ Institute of Medicine released a 

report addressing the future of public health in the United States 

and delineating Federal and State Government responsibilities 

for public health. The report concludes that “states are and must 

be the central force in public health” and recommends that 

“states review their public health statutes and make revision 

as necessary” to ensure an adequate statutory base for health 

activities.16 

The concept of expert review committees comprised of 

practicing clinicians, public health officials, medical school 

faculty, and other health professionals collectively focusing their 

expertise on a specific health problems is common to almost all 

States. Maternal mortality review committees are the premier 

example of such expert review committees. Yet the establishment 

of expert review committees is not limited to committees to 

investigate maternal deaths. For years it has been suggested 

that maternal mortality review committees should extend their 

activities to include maternal morbidity and perinatal mortality. 

In fact, “A Guide for Maternal Death Studies,”17 promulgated 

more than two decades ago by the AMA Committee on 

Maternal and Child Care, suggested that a similar guide be 

developed for organizing and operating an expert review 

committee to investigate perinatal deaths.6 Recently, the 1988 

report of the National Commission to Prevent Infant Mortality 

recommended that States “establish expert review panels to 

”18 investigate each infant death.

Although they have recognized the value of expert review 

committees, the medical and public health communities are 

aware that legal safeguards are necessary to protect committee 

members and the committee proceedings. More than 30 years 

ago, the AMA “A Guide for Maternal Death Studies” pointed 

out that laws protecting expert review committees vary from 

State to State and encouraged committees to seek advice from 

legal counsel whenever questions and concerns arose.6 In a 

recent article stressing the importance of having a review 

committee investigate maternal deaths, Sachs and coworkers 

5 
Appendix G 

pointed out that cooperation from clinicians and institutions 

requires legislation to protect the committee’s work from being 

misused in litigation.19 Similarly, the Department of Health and 

Human Services’ “Infant Mortality Review Manual,” which is a 

guide for investigating infant deaths, suggests that State statutes 

be examined to see if they adequately protect the data and 

opinions of the infant mortality review committee from 

admission as evidence in court.20 ... 

References 

1.	 U.S. Department of Health and Human Services: Promoting 

health/preventing disease: objectives for the nation. U.S. 

Government Printing Office, Washington, DC, fall 1980. 

2.	 Ellerbrock, T.V., Atrash, H.K., Hogue, C.J., and Smith, J.C.: 

Pregnancy mortality surveillance: a new initiative. 

Contemporary OB/GYN 31: 23-34 (1988). 

3.	 Centers for Disease Control: Progress toward achieving the 

1990 objectives for pregnancy and infant health. MMWR 37: 

405-413, July 8, 1988. 

4.	 Atrash, H.K., Ellerbrock, T.V., Hogue, C.J.R., and Smith, J.C.: 

The need for national pregnancy mortality surveillance. 

Family Plan Perspect 21: 25-26 (1989). 

5.	 Marmol, J.G., Scriggins, A.L., and Vollman, R.F.: History of 

the maternal mortality study committees in the United 

States. Obstet Gynecol 34: 123-138 (1969). 

6.	 Committee on Maternal and Child Care of the Council on 

Medical Services, American Medical Association: Report of 

officers. JAMA 162: 807 (1956). 

7.	 Grimes, D.A., and Cates, W.: The impact of state maternal 

mortality study committees on maternal deaths in the United 

States. Am J Public Health 67: 830-833 (1977). 

8.	 Entman, S.S., Atrash, H.K., Koonin, L.M., and Smith, J.C.: 

Maternal mortality surveillance (letter to the editor). Am J 

Public Health 78: 1499-1500 (1988). 

9.	 Owens, A.: Peer review: is testifying worth the hassle? 

Medical Economics 61: 167-173 (1984). 

14. Patrick v. Burget, 108 S.Ct.1658 (1988). 

15. 42.U.S.C. Sections 11101, 11111-11152 (West Supp. 1988). 

16. Institute of Medicine Committee for the Study of the Future 

of Public Health: The future of public health. IOM (88-02), 

Washington, DC, 1988, pp. 143, 146. 
Strategies to Reduce Pregnancy-Related Deaths 

17. Committee on Maternal and Child Care of the Council on 

Medical Services, American Medical Association : A guide for 

maternal death studies. Chicago, 1964. 

18. National Commission to Prevent Infant Mortality: Death 

before life: the tragedy of infant mortality. Washington, DC, 

1988, p. 32. 

19. Sachs, B.P., et al.: Hemorrhage, infection, toxemia, and 

cardiac disease, 1954-85: causes for their declining role in 

maternal mortality. Am J Public Health 78: 671-675 (1988). 

20. Infant mortality review manual. U.S. Department of Health 

and Human Services, Bureau of Maternal and Child Health 

and Resources Development, Washington, DC, 1988, p. 4. 
Appendix H 

Measures of PregnancyRelated Mortality 

Several measures can be used to quantify the various aspects of 

the risk of death from complications of pregnancy. Measures 

used to describe the actual risk of death are pregnancy-related 

mortality ratio and rates. Each of these measures has the same 

numerator: the number of pregnancy-related deaths in a year. 

Using different denominators allows calculation of the chance 

of dying due to complications of an individual pregnancy 

(pregnancy-related mortality ratio) and of the chance of a 

reproductive-aged woman dying of pregnancy complications 

(pregnancy-mortality rate): 

Ratio: Number of pregnancy-related deaths X 100,000 

Number of live births 

Rate: Number of pregnancy related deaths X 100,000 

Number of women of reproductive age 

Other measures, called proportionate mortality ratios, describe 

the contribution of pregnancy-related deaths to mortality. 

For these ratios, the deaths in the numerator are a subset— 

or proportion—of the deaths in the denominator. The 

proportionate mortality ratio indicates the extent to which 

pregnancy-related deaths contribute to mortality among women 

of reproductive age. The cause-specific proportional mortality 

ratio gives the contribution of different causes of pregnancyrelated mortality to the overall pregnancy-related mortality. 

Proportionate Number of pregnancy-related deaths X 100 

mortality ratio: Number of deaths to women 

of reproductive age 

Cause-specific Number of pregnancy-related X 100 

ratio: deaths due to specific cause 

Number of pregnancy-related deaths 

due to all causes 
Strategies to Reduce Pregnancy-Related Deaths 

To quantify the risk of death from a specific condition among 

women who have or develop that complication, cause-specific 

mortality rates can be calculated. Although this measure uses 

pregnancy-related deaths from the condition as the numerator, 

the denominator is the number of women with the condition 

of interest. These latter data are not always easy to obtain, 

although population-based hospital discharge may be used 

to count some conditions. 

Case-fatality Number of pregnancy-related deaths X 100,000 

rate: due to given condition 

Number of pregnant women with the 

same condition 
Appendix I 

Example of a Maternal Mortality 

Review Committee’s Report 

Reproduced with permission from the Massachusetts Department 

of Public Health. 
Number 1 May 2000 

Maternal Mortality and€

Morbidity Review in Massachusetts€

A Bulletin for Health Care Professionals 

Pregnancy-Associated Mortality: 

Medical Causes of Death, 1995-1998 

Purpose 

The purpose of this bulletin is to present Massachusetts-specific data related to maternal causes of 

death and maternal mortality ratios from 1995 through 1998, summarize case review findings, and 

suggest strategies for improving maternal outcomes. This bulletin covers deaths from medical 

causes associated with pregnancy (see page 2 for definitions). Future bulletins will address other 

causes of maternal deaths (e.g. drug overdose, homicide and other injuries), and additional 

epidemiological mortality and morbidity analyses. 

Background 

A maternal death is a sentinel event. During the last half of this century we have witnessed a 

dramatic decrease in maternal mortality in Massachusetts. Earlier work1

 documents a decline from 

50 per 100,000 live births in the early 1950s to 10 per 100,000 live births in 1985. During those 

same years, leading causes of maternal death shifted from infection, cardiac disease, pregnancyinduced hypertension and hemorrhage to injury (i.e., suicides, homicides and motor vehicle 

accidents) and pulmonary emboluS.2

 According to the National Center for Health Statistics, 

Massachusetts has the second lowest maternal mortality ratio in the U.S (3.3/100,000).3

 These 

unfortunate deaths teach important lessons to help prevent future mortality. They also provide clues 

for understanding maternal morbidity and improving women's health in general. 

In 1997, the Commissioner of the Massachusetts Department of Public Health (MDPH) appointed a 

Maternal Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the 

incidence of pregnancy complications, and make recommendations to improve maternal outcomes 

and prevent mortality. The work of the committee is protected under M.G.L. c.111, section 24A and 

24B, which assures the confidentiality of all records and proceedings.4

 The committee consists of 

obstetricians, certified nurse midwives, maternal fetal medicine specialists, a neonatologist and a 

pathologist (see Appendix A). This initiative follows the tradition of improving maternal health 

through case review begun by the Committee on Maternal Welfare of the Massachusetts Medical 

Society in 1941. That effort was chaired by Dr. John F. Jewett from 1953 to 1985.5

 Over time, 

definitions of maternal death have evolved and case finding methods have improved, but the goal of 

promoting maternal health has remained unchanged. 

1€
Defining a Maternal Death 

There is no standard definition of maternal mortality with respect to causes of death or timing of 

death in relation to pregnancy. Varying definitions used at state,6

 national and international levels 

make comparisons of mortality ratios across states and with national data quite difficult (see 

Appendix B for definitions). For example, the World Health Organization (WHO) and the National 

Center for Health Statistics (NCHS) define maternal deaths as occurring either during pregnancy or 

within 42 days after pregnancy termination. Individual states, however, have adopted various time 

intervals, from a minimum of 42 days to a maximum of 18 months postpartum. The WHO recently 

added a second category, called late maternal death, which includes deaths occurring between 42 

and 365 days following the end of pregnancy. Deaths caused by accidental or incidental causes or 

from cancer are excluded under many definitions. The MMMRC purposely chose a broad definition 

of maternal mortality to permit the most thorough retrospective investigation possible. 

Definition of Maternal Death Used in this Study 

For the purposes of this investigation, the definition of maternal mortality recommended by the 

Maternal Mortality Study Group, a national group jointly chaired by the Division of Reproductive 

Health at the Centers for Diseases Control and Prevention (CDC) and the American College of 

Obstetricians and Gynecologists (ACOG), was used.7

 In accordance with that definition, the term 

“pregnancy-associated" is used instead of “maternal” to reflect the inclusion of deaths occurring 

during pregnancy. 

Pregnancy-associated death: The death of a woman while pregnant or within one year of 

termination of pregnancy, irrespective of cause. 

Pregnancy-associated deaths are divided into three categories: 

1. Pregnancy-related. The death of a woman while pregnant or within one year of termination of 

pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or 

aggravated by her pregnancy or its management, but not from accidental or incidental causes .8 

2. Pregnancy-associated-but-not-pregnancy-related. The death of a woman while pregnant or 

within one year of termination of pregnancy due to a cause unrelated to pregnancy. 

3. Undetermined if pregnancy-related. The death of a woman while pregnant or within one year 

of termination of pregnancy, but the relationship of her death to pregnancy cannot be 

determined. 

The MMMRC further categorized deaths into those deaths that were caused by a medical condition, 

and deaths caused by intentional or unintentional injury. 

Pregnancy-Related Death: 

If this woman had not been pregnant, would she have died? 

2€
Mandatory Reporting of Maternal Deaths 

Massachusetts hospitals are obligated to report to the MDPH's Division of Health Care Quality the€

death of any woman during pregnancy or within 90 days of delivery or termination, regardless of the€

cause of her death. This regulation applies to deaths that occur in a hospital setting.€

Submit reports by telephone or Fax:€

Telephone: 617-753-8150€

Fax: 617-753-8165€

The Massachusetts Department of Public Health requires that “the death of a pregnant woman during 

any stage of gestation, labor or delivery or the death of a woman within 90 days of delivery or 

termination of pregnancy will be reported within 48 hours to the department by the hospital in which 

the death occurs [105 CMR 130.628(C)].” 1989 

Methods 

Case Finding 

Pregnancy-associated deaths occurring in Massachusetts from 1995 through 1998 were identified 

through mandatory facility reporting to the MDPH Division of Health Care Quality, and manual and 

automated reviews of death certificates. In addition to these traditional case-finding methods, the 

MMMRC employed an enhanced surveillance method linking birth certificates and fetal death 

certificates to death certificates of reproductive-age women. This approach has also been adopted 

by other states. These enhanced and improved surveillance methods in combination with the 

ACOG/CDC definition identified more deaths than previously reported. 

Case Review 

All available hospital medical records related to each woman's pregnancy and death, as well as her 

death certificate and certificates of infant birth or fetal death were obtained. A primary and 

secondary reviewer from the MMMRC analyzed all available documents and summarized each case 

for the entire committee without identifying patients, clinicians, or institutions. In addition, medical 

specialists in oncology, neurology and infectious disease were asked to review specific cases. 

During reviews, consensus was sought on answers to several questions: 

• Was the death pregnancy-related? 

• Was the death preventable? 

• What public health and/or clinical strategies might prevent future deaths? 

A “preventable death” is broadly defined as a death that may have been averted by one or more 

changes in the health care system related to clinical care, facility infrastructure, public health 

infrastructure and/or patient factors. 

Reviews were limited to attainable records, and the following medical records and documents were 

not reviewed by the committee: ambulatory care records not part of the hospital medical records; full 

reports of autopsies conducted by state medical examiners; hospital records for births or fetal deaths 

occurring outside of Massachusetts; and information about deaths or births occurring in non-hospital 

settings. These records may have provided additional insight. 

3€
Mortality Ratios, Causes, and Timing of Death9 

From 1995 through 1998, 88 women were identified (using the enhanced surveillance methods) who 

met the definition of a pregnancy-associated death. Three additional women were identified and 

their cases reviewed, but their deaths occurred more than one year following pregnancy and were 

therefore excluded from this analysis.10 Of the 88 deaths, 60 (68%) were caused by medical 

conditions, i.e. were not the result of an injury or drug overdose. The remaining 28 deaths were 

caused by intentional or unintentional injuries and will be reviewed and reported on in the future. 

Pregnancy-Associated Mortality Ratios11 

Using the enhanced case finding 

methodology, the pregnancy-associated 

mortality ratio over the four-year period was 

26.9 per 100,000 live births. Among the 60 

deaths caused by medical conditions, the 

pregnancy-related mortality ratio was 

5.8/100,000, and the pregnancy associated 

but not pregnancy-related mortality ratio 

was1.6/100,000 (data not shown). These 

ratios cannot be compared to other 

publications due to differences in definitions 

and case finding methodology. 

Distribution of Maternal Deaths Caused by Medical Conditions 

32% 

63% 

5% Pregnancy-related Among the deaths caused by medical 

conditions, 19 (32%) were pregnancy-related, Not pregnancy-related 38 (63%) were not related to pregnancy, and 

Undetermined in 3 (5%) cases it could not be determined 

whether or not the deaths were related to 

pregnancy based on available evidence. 

Distribution of Pregnancy-Related Medical Causes of Death 

Year 

Mortality (All Causes) 

N Ratio 

1995 21 25.4 

1996 19 23.4 

1997 25 30.8 

1998 23 28.0 

Total 88 26.9 

The leading medical cause of pregnancyrelated death was infectious disease (26%), 

followed by amniotic fluid embolism (21%) 

and pregnancy-induced hypertension (16%). 

Infectious diseases included septicemia, 

sepsis and varicella. Pregnancy-induced 

hypertension included HELLP syndrome 

(Hemolysis, Elevated Liver enzymes, and Low 

Platelets) and eclampsia. Other causes 

included cerebrovascular, cardiovascular and 

chronic conditions, and anesthetic 

complications. 

Infections 

26% 

Amniotic fluid 

embolism 

Other 

37% 

Pregnancy- 21% 

induced 

hypertension 

16% 

4€
Pregnancy-associated but not pregnancy-related medical causes of 

death 

Other 

11% 

Chronic Cancer 

Conditions 33% 

16% 

Cardiovascular 

16% 

Infections 

24% 

Timing of Medical Causes of Death 

The leading cause of pregnancy-associated 

but not pregnancy-related deaths was cancer 

(33%) followed by infectious diseases (24%), 

cardiovascular (16%) and chronic conditions 

(16%). Cancer deaths included melanoma, 

lymphoma, leukemia, brain tumors and other 

rare cancers. Two women had pre-existing 

diagnoses of cancer before they became 

pregnant. Infectious diseases included HIV, 

meningitis, encephalitis, pneumonia, and 

sepsis. Chronic conditions included asthma, 

diabetes, lupus and seizure disorders. Other 

causes included cerebrovascular and 

iatrogenic conditions. 

Thirty percent (n=18) of the deaths occurred either during pregnancy or within one week postpartum. 

Almost all (94.8%) of the pregnancy-related deaths and one-third (34.2%) of the deaths not related to 

pregnancy occurred within 42 days postpartum, a time coinciding with close contact with obstetrical 

providers. 

Number of Days 

All Related Not Related Undetermined 

N % N % N % N % 

<7 days 18 30.0 14 73.7 3 7.9 1 33.3 

7-41 days 15 25.0 4 21.1 10 26.3 1 33.3 

42-89 days 7 11.7 0 0.0 7 18.4 0 0.0 

90-364 days 20 33.3 1 5.3 18 47.4 1 33.3 

Total 60 100.0 19 100.0 38 100.0 3 100.0 

Preventable Deaths€

A "preventable death' is broadly defined as a death that may have been averted by one or more€

changes in the health care system related to clinical care, facility infrastructure, public health€

infrastructure and/or patient factors. These determinations were made with the benefit of€

retrospective review and current clinical practice guidelines at the time of the review rather than at€

the time of the death.€

Overall, 30% of the deaths (n=18) may have been preventable. Among the pregnancy-related€

deaths, 42% (n=8) may have been preventable, and among the deaths not related to pregnancy 26%€

may have been preventable (n=10). The preventability of 9 deaths (1 5%) could not be determined€

from the information available at the time of review, and 33 deaths (55%) were probably not€

preventable.€

5€
STRATEGIES TO SAFEGUARD MATERNAL HEALTH 

Maternal death case reviews provided meaningful information about when, how and why women 

died while pregnant or during the first year after the end of their pregnancy. Although infrequent, 

preventable deaths teach valuable lessons to avert future severe morbidity and deaths. Using 

composite case scenarios to provide a context for the reader, this section suggests strategies to 

safeguard maternal health for clinicians, hospital and ambulatory care facilities, as well as the entire 

public health community. These recommendations are intended to stimulate discussion among all 

those interested in improving maternal health and pregnancy outcomes and do not represent a 

comprehensive approach. 

Scenarios are composite vignettes drawn from two or more cases with key information changed to 

protect the identities of patients and providers. 

Strategies for Clinicians 

Varicella€

Scenario: A 30y/o woman with no known history of varicella was counseled to avoid exposure

during pregnancy. She had an uneventful labor and delivery. In the postpartum period she was

exposed and became symptomatic with varicella. Medical records did not indicate if she contacted

her provider or was offered VZIG. She became acutely ill, was hospitalized and eventually died of

disseminated varicella.

History of varicella. All pregnant women should be asked about their history of childhood diseases 

including varicella. History of varicella is an excellent indication of immunity. 

Counseling. Pregnant and postpartum women without evidence of varicella infection by history or 

seropositivity should be counseled to avoid contact with persons with chickenpox or shingles. In 

addition, these susceptible women should be instructed to call their obstetrical provider soon after 

any varicella exposure during pregnancy and postpartum periods. Susceptible pregnant women 

should be counseled to receive their first dose of varicella vaccine in the postpartum period 

Varicella Prevention: 

• VZIG for pregnant and postpartum women. Susceptible pregnant women who are exposed 

to varicella infection should be given varicella zoster immune globulin (VZIG) within 96 hours of 

exposure. Given the short time frame for administration of VZIG after exposure, verifying 

seronegativity may not be possible. VZIG may be given at any time during pregnancy and is free 

to all MA residents (see Appendix C). Postpartum women have the option of receiving VZIG or 

varicella vaccine for prophylaxis. 

• VZIG for infants. Infants whose mothers had an onset of varicella symptoms within five days 

before delivery and up to 48 hours after delivery, should also receive VZIG. 

• Varicella vaccine. Susceptible non-pregnant women of childbearing age should be offered 

varicella vaccine (two doses administered four weeks apart). Pregnancy should be avoided for 

one month following each dose of vaccine. In lieu of VZIG, varicella vaccine can also be given 

to susceptible non-pregnant women, including postpartum women, within 72 hours after 

exposure to varicella infection. 

• Report varicella vaccine use in pregnancy. If varicella vaccine is inadvertently given within 

one month of pregnancy, the likelihood of untoward effect is considered to be extremely small. 

All such cases should be reported to the VARIVAX Pregnancy Registry (see Appendix C). 

6€
Influenza€

Scenario: A 35 ylo woman, G2P1, delivered an infant without complications. Several days after her

delivery she developed a flu-like syndrome. Approximately one week later the patient developed adult

respiratory distress syndrome secondary to multilobar pneumoccocal pneumonia. Her condition

worsened rapidly and she never recovered. Final cause of death was pneumococcal pneumonia

superimposed on viral infection. Influenza A infection was confirmed.

Influenza vaccine. Recent evaluation of published data suggests that an average of 1-2 

hospitalizations per 1,000 pregnant women could be prevented in each average influenza season by 

immunizing pregnant women." The Advisory Committee on Immunization Practices (ACIP) of the 

Centers for Disease Control and Prevention (CDC) recommends routine influenza immunization of 

women who will be in the second or third trimester of pregnancy during influenza season. Pregnant 

women with medical conditions that increase their risk of complications from influenza should be 

vaccinated regardless of stage of pregnancy. Immunization during pregnancy with the inactivated 

vaccine is considered safe by many experts, however some providers prefer not to administer the 

vaccine during the first trimester to avoid association with spontaneous abortion that might occur 

coincidentally (see Appendix C). 

Pneumococcal vaccine. Current American College of Obstetricians and Gynecologists and 

ACIP/CDC recommendations state that women with high risk conditions for pneumococcal disease 

(e.g., lung disease, asthma, asplenia) be vaccinated, preferably before pregnancy. If an 

unvaccinated, high-risk woman becomes pregnant, some authorities in the field advise deferring 

immunization until after the first trimester (see Appendix C). 

HIV Infection€

Scenario: A 25 ylo pregnant woman with HIV infection presented with dyspnea and a CD4 count of

14 in her last trimester. She was diagnosed with Pneumocystis carinii pneumonia and started on

treatment. She went into labor and delivered a viable preterm infant. Her respiratory condition never

improved and she eventually died of complications. Although this patient had been receiving HIV care

of unknown frequency from an infectious disease specialist, her obstetrical provider was unaware of

the HIV status or any HIV-related treatment she was receiving.

Counseling and testing. After counseling about HIV infection, providers should recommend and 

offer HIV antibody testing to all pregnant women and all women considering pregnancy. 

Treatment. The medical treatment goal for HIV-infected women, pregnant or not, is to maintain 

optimal health of the woman. All HIV-infected pregnant women who are in care should be offered 

antiretroviral therapy. Treatment decisions should consider both the pregnant woman's well being 

and the prevention of vertical transmission to her infant. 

Coordination of care between obstetrical and HIV provider. HIV treatment is more successful 

but far more complex given the variety of pharmacologic regimes available. It is important that a 

provider with experience in the management of HIV be directly involved in the woman's care. This 

means that an HIV-infected woman should be receiving care from both an obstetrical provider and 

an HIV specialist during pregnancy and the postpartum period. Care should be provided in a 

collaborative manner to maximize the health of the mother and minimize risks to the fetus and baby. 

Case Management. Patients with HIV infection who may have difficulty adhering to a treatment 

regimen or have other complex issues should be referred for case management services. 

7€
Septicemia€

Scenario: A 22 y/o G2P1 in her second trimester developed a fever over 1030F without focal signs or

symptoms. Cultures were taken and the patient was sent home. Her condition worsened and she

presented at the emergency department where fetal demise was diagnosed. She deteriorated rapidly

with onset of septic shock. Her underlying cause of death was determined to be beta-hemolytic

Group A streptococcal sepsis.

Treatment. A woman in the peripartum who shows signs of septicemia should be treated with 

broad-spectrum antibiotics and screened for disseminated intravascular coagulopathy (DIC). 

Empiric antibiotic treatment should begin before the final determination of a pathogen. Group A 

betahemolytic Streptococcus pyogenes is a very rare cause of puerperal infection in the present era, 

however it can still cause maternal death. Strep. pyogenes can produce an exotoxin that can cause 

a toxic shock-like syndrome and/or DIC. This pathogen can also present as bacteria with or without 

symptoms and as an upper respiratory tract infection. 

Septic Shock. In cases of fetal demise, prompt diagnosis and treatment of septic shock and DIC are 

required. 

Pregnancy Induced Hypertension (PIH)€

Scenario: A 36 ylo G1PO was admitted at 34 weeks in early labor with a diagnosis of PIH

(B/P144/94, +4 protenuria and +4 reflexes). She was induced and delivered without complications.

After delivery the patient’s blood pressure continued to be elevated and she complained of epigastric

pain and nausea. Her lab values were consistent with HELLP. Treatment included magnesium sulfate

and monitoring on a regular postpartum floor. Approximately 40 hours after delivery she had multiple

grand mal seizures. Her condition deteriorated and she never recovered. Postmortem findings were

consistent with eclampsia with DIC.

Management. HELLP, including immediate postpartum cases, should be managed aggressively. If 

the patient's condition worsens she should be transferred to a unit with a high staff to patient ratio. 

The ACOG Technical Bulletin of Hypertension in Pregnancy reviews methods and techniques of 

practice for obstetrical providers (see Appendix C). 

Chronic Conditions€

Scenario: A 35 y/o G1PO had a documented history of cardiac arrhythmia which was controlled by

medication. When she became pregnant, she discontinued her medication without consulting a

cardiologist. Two months postpartum the patient had palpitations, collapsed suddenly and could not

be resuscitated by the EMTs.

Co-management of chronic illness. If a patient gives a history of a chronic or life threatening 

illness, confirm that she is receiving the appropriate primary and consultant care during pregnancy 

and postpartum. 

Non-adherence to medication regimen. Obstetrical providers should monitor patients' adherence 

to chronic medication regimes. Appropriate medical consultation should be obtained if a patient has 

independently discontinued taking a medication for a potentially life threatening condition. 

8€
Eating Disorders€

Scenario: A 34 y/o G4P2 with a past history of bulimia had a pregnancy and birth without

complications. Five weeks postpartum she collapsed and was admitted in a coma. She never

regained consciousness. Apparently she had been purging daily to reduce her weight.

Screening and Referral. Women with histories of eating disorders are at risk for an exacerbation of 

this problem during the prenatal and postpartum periods. All pregnant and postpartum women 

should be screened for eating disorders and referred as appropriate. 

Strategies for Hospital and Ambulatory Care Facilities 

Anesthesia and Analgesics€

Scenario: A 35 y/o G4P2 had a difficult labor and delivered by cesarean section. She received

various analgesics through epidural, IV and IM routes during labor and delivery, in the recovery room,

and on the postpartum floor. Her care was managed by several providers and through different shifts

of nursing staff. No system was in place to track the cumulative amount of narcotics administered.

Monitoring. The administration of analgesics should be monitored closely for cumulative amount, 

particularly for women whose care is managed by multiple providers (e.g. anesthesia, obstetrics). 

Care of Critically Ill Patients€

Scenario: A 33 y/o G3P2 with a postpartum wound infection, developed shortness of breath, chest pain

and respiratory arrest. She was resuscitated but needed mechanical ventilation. The patient was

transferred to an intensive care unit, but needed isolation because of her wound infection. When her

respirator malfunctioned, no staff were available to assist her.

Policies and Procedures 

• Existing policies requiring minimum staffing levels for critically ill patients and protocols for 

monitoring life-support equipment should be followed. 

• Emergency equipment and procedures should be reviewed on a regular, established schedule. 

• Guidelines should be established for oversight of the care of critically ill obstetrical patients by 

senior medical staff. 

• If the need for more intensive obstetrical and neonatal care is anticipated, the patient should be 

transferred to a hospital with an appropriate level of care. 

Documentation€

Scenario: A 43 y/o Spanish-speaking G8PO with a history of infertility had a cerclage placed early in

pregnancy. At 27 weeks she began bleeding and had signs of infection. She refused removal of the

cerclage to preserve her pregnancy and subsequently developed septicemia and died. Medical

records did not indicate that an interpreter was provided or that she understood the risks she was

taking in refusing treatment.

9€
When applicable the following information should be recorded in each patient's record: 

• Written informed patient consent or non-consent for services or treatment, particularly when 

patient decisions may negatively effect patient's life and outcome of pregnancy. 

• Offer and receipt of social services. 

• Explicit chronology during emergencies or during the care of critically ill patients. 

• Use of translation and interpreter services. 

• Prenatal care record in obstetrical inpatient record after the third trimester. 

Strategies for the Public Health Community 

Access€

Scenario: A 38 y/o G3P2 non-English speaking Hispanic woman was enrolled in Healthy Start

during her pregnancy. Several months postpartum she developed nausea and vomiting and

eventually became non-responsive. When she arrived at the emergency department she was

comatose with severe diabetic ketoacidosis and never recovered. Staff had difficulty communicating

with family members and could not determine if she had seen a primary care provider since she had

given birth

Translation Services 

• Hospital and other health care facilities should provide medical interpreter services for nonEnglish speaking patients. 

• According to MDPH regulation 105 CMR:130 615(c), health education materials and activities 

shall be available in the languages of any non-English speaking group which comprises at 

least 10% of the population served by the maternal-newborn services. 

Transition from Obstetrical to Primary Care: 

• All patients, including those patients enrolled in Healthy Start or the uncompensated care pool, 

should be referred to a primary care provider after obstetrical care is completed. 

• Outreach services for the Healthy Start program should expand to the postpartum period to 

assist women in accessing ongoing primary care. 

Preconception care 

• Public health professionals and clinicians working with women of child-bearing age should 

offer information about family planning services, early signs of pregnancy, warning signs of 

miscarriage and associated sepsis, and the importance of seeking early prenatal care. 

• Public health professionals and clinicians working with women of child-bearing age with 

chronic or life threatening conditions should provide pre-conception counseling about the 

impact of pregnancy on her health, the impact of her condition on pregnancy, and options 

available for family planning. 

Skin Cancer€

Scenario: A 25y/o G2P1 delivered a healthy infant without complications. Two months postpartum

she was diagnosed with metastatic malignant melanoma. She had neglected to tell her prenatal

provider that she had had a bleeding lesion on her scalp for at least 6 months.

10€
Periodic Screening. All women should be encouraged to have a complete skin exam, including the 

scalp, by a specially trained health care provider, beginning as early as age 20. In families with a 

history of melanoma, screening should begin between ages 12 and 14. The American Cancer 

Society recommends a cancer-related checkup, including skin examination, every three years for 

people between 20 and 40 years of age, and every year for anyone age 40 and older. 

Cardiovascular Disease€

Scenario: After successfully quitting during her pregnancy, a 42 y/o G3P3 resumed smoking a pack

of cigarettes per day after delivery. She had been complaining of “bad indigestion” for a couple of

days when she suffered a fatal heart attack at her workplace.

Screening and Education 

• Screen all patients with a history of smoking for relapse or continued smoking postpartum. 

Counsel and refer for cessation as needed. 

• Health education programs in schools and anticipatory guidance in all patient age groups by 

primary care clinicians should include prevention strategies for cancer and cardiovascular 

disease. 

Conclusions 

Maternal death, while rare, is a critical health indicator for women giving birth in the Commonwealth. 

Improved and expanded case-finding methods used in this study facilitated the identification of more 

deaths than previously noted and demonstrate the importance of expert case review in conjunction 

with an active maternal mortality surveillance system. The review of medical causes of maternal 

death suggests that some of these deaths may have been prevented. Lessons learned from these 

deaths can enhance the development of a comprehensive strategy to improve women's health at 

clinical, institutional and community levels. 

11€
Notes and References 

1. Sachs B, Brown D, Driscoll S, et al. Maternal Mortality in Massachusetts - Trends and Prevention. 

The New England Journal of Medicine 1987; 316:667-672. 

2. Sachs BP, Brown DA, Driscoll SG, et al. Hemorrhage, infection, toxemia, and cardiac disease, 

1954-85: causes for their declining role in maternal mortality. Am J Public Health 1988; 78:671-5. 

3. NCCDPHP, CDC. State-specific maternal mortality among black and white women - United 

States, 1987-1996. MMWR 1999; 48:492-496. 

4. All appointed members of the committee and assigned DPH staff also signed a confidentiality 

pledge as a prerequisite to their participation in this effort. 

5. Jewett JF. Changing maternal mortality in Massachusetts. The New England Journal of Medicine 

1957; 256:395-400. 

6. Atrash HK, Lawson HW, Ellerbrock TV, Rowley DL, Koonin LM. Pregnancy-Related Mortality. In: 

Wilcox LS, Marks JS, eds. From Data to Action: CDC's Public Health Surveillance for Women, 

Infants, and Children. Washington, DC: U.S. Department of Health and Human Services/CDC, 

1995:141-154. 

7. Atrash H, Rowley D, Hogue C. Maternal and perinatal mortality. Curr Opin Obstet Gynecol 1992; 

4:61-71. 

8. This definition differs from ICD-10 which uses the term "pregnancy related" to refer to a death 

from any cause during or within 42 days of the end of pregnancy (see Appendix B). 

9. Massachusetts rates are not comparable to those of other states due to variations in definitions 

and case finding methodology. 

10. Two deaths were caused by postpartum cardiomyopathy and occurred two and a half and seven 

years postpartum. The third death occurred 365 days post partum from a cause unrelated to 

pregnancy. 

11. Deaths per 100,000 live births that occurred in Massachusetts. 

12. "G" is for Gravida or total number of pregnancies, and "P" is for Para or total number of live births. 

13. Neuzil K, Reed G, Mitchell E, Griffin M. Influenza-associated morbidity and mortality in young and 

middle-aged women. JAMA 1999; 281:901-907. 

14. Healthy Start is a state sponsored prenatal care program for uninsured low income women not 

eligible for Medicaid. 

15. World Health Organization. Manual of the International Statistical Classification of Diseases, 

Injuries, and Causes of Death. 9th Revision, WHO, Geneva, (1977), and World Health 

Organization. International Classification of Diseases and Related Health Problems, 10th 

Revision, WHO, Geneva, (1992) 

Acknowledgements 

The Committee would like to thank the following experts for their assistance with case reviews in their 

specialty areas. Oncology: Howard Koh, MD, Commissioner, MDPH. Infectious diseases: Alfred 

DeMaria, Jr, MD, Assistant Commissioner. MDPH. Neurology: Karla Kanis, MD. Beth Israel Deaconess 

Medical Center. 

This bulletin was co-authored by Angela Nannini and Judith Weiss of the Bureau of Family and 

Community Health, with technical assistance from Lauren Khalil and Jane Kim. Special thanks go to 

MMMRC members and staff for their invaluable participation in the case review process and preparation 

of this bulletin. Thanks also go to the following people for their review: Marlene Anderka, Dan Friedman, 

Bruce Cohen, Kathleen Atkinson, Alfred DeMaria, Jr, Susan Lett, Joanne Malchow, and Deborah Klein 

Walker, Massachusetts Department of Public Health; and Jerry O'Keefe and Judy Parlato, Division of 

Health Care Finance and Policy. This bulletin was designed by Scott LeBrun of the Graphics 

Department, MDPH. 

12€
Appendix A: Committee Members & Staff€

MMMRC Committee Members: 

Susan DeJoy, CNM, MSN€

Assistant Professor of Obstetrics and€

Gynecology€

Tufts University School of Medicine;€

Director, Division of Midwifery and€

Community Health€

Baystate Medical Center€

Fred Frigoletto, Jr., MD€

Charles Montraville Green and Robert Montraville€

Green Professor of Obstetrics and Gynecology€

Harvard Medical School;€

Chief of Obstetrics€

Massachusetts General Hospital€

Gary Kraus, MD€

Medical Director€

Anna Jaques Hospital€

J.R O'Grady, MD€

Professor of Obstetrics and Gynecology€

Tufts University School of Medicine;€

Director, Obstetrical Services€

Baystate Medical Center€

Steven Ringer, MD€

Assistant Professor of Pediatrics€

Harvard Medical School;€

Director, Newborn Services€

Brigham and Women's Hospital€

Drucilla Roberts, MD€

Assistant Professor of Pathology€

Harvard Medical School;€

Assistant Pathologist€

Massachusetts General Hospital€

Benjamin Sachs, MB, BS, DPH Committee Chair€

Harold H. Rosenfield Professor of Obstetrics and€

Gynecology and Reproductive Biology Harvard€

Medical School;€

Professor of Obstetrics and Gynecology€

Harvard School of Public Health;€

Chief, Dept. of Obstetrics & Gynecology€

Beth Israel Deaconess Medical Center€

Judith Weber, BSN, MPH, CNM, FAACE€

Adjunct Faculty€

Boston University School of Public Health and€

Rivier College;€

Midwives of the Merrimack Valley€

MDPH Committee Staff: 

Judith Weiss, ScD€

Co-Director, MMMRC€

Bureau of Family and Community Health€

Angela Nannini, FNP, PhD€

Co-Director, MMMRC€

Bureau of Family and Community Health€

Sally Fogerty, MEd€

Assistant Commissioner€

Bureau of Family and Community Health€

Lauren Khalil€

Bureau of Family and Community Health€

Elaine Trudeau€

Registrar, Registry of Vital Records€

Jane Kim€

Registry of Vital Records€

Paul Dreyer, PhD€

Director€

Division of Health Care Quality€

Chris Duerr, MSN, RN, CPNP€

Division of Health Care Quality€

Marie Eileen Onieal, MMHS, RN, CPNP€

Bureau of Health Quality Management€

13€
Appendix B: Other Definitions of Maternal Death 

1. World Health Organization (WHO), International Classification of Diseases, Ninth Revision 

(ICD-9) and Tenth Revision (ICD-10):15 

Maternal death: 

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of 

the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy 

or its management but not from accidental or incidental causes. 

Two additional definitions have been added to ICD-10: 

Late maternal death: 

The death of a woman from direct or indirect obstetric causes more than 42 days but less than 1 year 

after the termination of pregnancy. 

Pregnancy-related death: 

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of 

the cause of the death. 

2. National Center for Health Statistics (NCHS): 

Deaths that occur during pregnancy or within 42 days after pregnancy termination, regardless of 

pregnancy duration and site, from any cause related to or aggravated by the pregnancy, but not from 

accidental or incidental causes. 

3. Other state maternal mortality review efforts: 

A number of other states have conducted maternal mortality reviews. Definitions of maternal death 

vary by time interval from the end of pregnancy until death, and causes of death. All state 

definitions include deaths that occur during pregnancy. However, the interval of time between the 

end of pregnancy and death varies from a minimum of 42 days to a maximum of 18 months. Some 

states, similar to Massachusetts, consider all causes of maternal deaths occurring within a specified 

time period, while other states restrict their definitions to pregnancy-related deaths only. Deaths 

from injuries and cancer often are omitted from review because they are considered to be nonpregnancy-related. Variation in definitions, case inclusion and exclusion criteria, and case finding 

methods, results in mortality ratios that are not comparable across states. 

14€
Appendix C: List of Resources 

Infectious Disease: 

Telephone numbers 

• Varicella zoster immune globulin (VZIG): For information about obtaining free VZIG call 617-522-

3700 

• VARIVAX Pregnancy Registry (1-800-986-8999). All cases of varicella vaccine given while pregnant 

or within four weeks before pregnancy should be reported to the registry. 

• HIV testing number 1-800-750-2016 (consumer) 

• HIV information and counseling number 1-800-235-2331 (consumer) 

Recommendations 

• U.S. Public Health Service Task Force. "Recommendations for the Use of Antiretroviral Drugs in 

Pregnant Women Infected with HIV-1 for Maternal Health and for Reducing Perinatal HIV-1 

Transmission in the United States". MMWR 1998, Jan 30; 47(RR-2): 1-30. Guidelines updated in 

2000 are available in PDF and HTML format at http://www.hivatis.org/trtgdlns.html#Perinatal 

• General recommendations on immunization: recommendations of the Advisory Committee on 

Immunization Practices (ACIP). MMWR 1994; 43 (RR-1). 

• Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices 

(ACIP). MMWR 1996; 45 (RR-11). 

• Prevention of varicella updated: recommendations of the Advisory Committee on Immunization 

Practices (ACIP). MMWR 1999; 48(RR-06). 

• Prevention and control of influenza: recommendations of the Advisory Committee on Immunization 

Practices (ACIP). MMWR 1999; 48(RR-04). 

All immunization recommendations are available at http://www2.cdc.gov/mmwr/ 

Management of PIH: 

ACOG Technical Bulletin of Hypertension in Pregnancy, Number 219, January 1996 

Translation and Interpreter Services: 

A listing of qualified vendors of translation and interpreter services that contract with various state 

entities may be found on the Commonwealth of Massachusetts website: http://www.comm-PASS.com 

Search the site using the following criteria: 

Document Type: closed 

Purchasing Entity: Operational Services Division 

Product Category: Professional Services 

Keyword: translation 

Select Foreign Language Written Translation & Oral Interpretation Services, Reference No: 

ST8J51 1; Contractor Contact Listing with Language, Rate and Zone Information. 

15€