Maternal Mortality Review Panel

The Department of Health has submitted its 2023 Maternal Mortality Review Panel report to the Washington State Legislature, summarizing findings from perinatal deaths from 2014 through 2020 and recommendations based on perinatal deaths from 2017 through 2020. 

Washington State Maternal Mortality Review Panel: Maternal Deaths 2017–2020  February 2023 Report (PDF)

The report includes an addendum from the American Indian Health Commission, entitled Tribal and Urban Indian Leadership Recommendations.

The Washington State Maternal Mortality Review Panel (MMRP) successfully reviewed maternal deaths from 2017–2020 and the Department of Health published this legislative report of findings and recommendations from the Panel. The Panel developed six recommendations and activities for implementation to help reduce preventable maternal deaths and improve perinatal care for all people in the state. These recommendations are included in the report. The report and recommendations were submitted to the health care committees in the Legislature in February 2023.

The findings of the report include:

• Rates of maternal mortality in Washington are stable. Historical data collected on maternal deaths that occurred between 2000 and 2020 show maternal mortality rates in the state varied over time, but they’re relatively stable and are not increasing like they are nationally.
• Maternal mortality rates in Washington have historically been lower than national rates.
• However, critical disparities persist by race and ethnicity, socioeconomic status, and urban/rural status.
• The latest report contains policy, funding, clinical, and institutional recommendations from reviews of maternal deaths during the period from 2017–2020 and findings based on cumulative data from 2014–2020 deaths.
• The Panel identified 224 pregnancy-associated deaths from 2014–2020. These are defined as deaths from any cause during pregnancy or within one year of the end of pregnancy.
• Of these 224 deaths, the Panel identified 97 pregnancy-related deaths (defined as deaths due to a pregnancy complication, a chain of events initiated by pregnancy, or aggravation of unrelated condition(s) by the physiological effects of pregnancy).
• There were 15.9 pregnancy-related deaths per 100,000 live births from 2014–2020 in Washington, lower than the U.S. rate of 18.6 pregnancy-related deaths per 100,000 live births in this timeframe.
• Leading underlying causes of pregnancy-related deaths in Washington were behavioral health conditions (32 percent), predominantly by suicide and overdose. Other common causes were hemorrhage (12 percent) and infection (9 percent).
• The Panel found 80 percent of pregnancy-related deaths were preventable, meaning there was at least some chance of the death being averted if a factor that contributed to the death had been different.
• In Washington, the rate of all pregnancy-associated deaths for non-Hispanic Black people and non-Hispanic Native Hawaiian and Pacific Islander people was more than 2.5 times the corresponding rate for non-Hispanic white people.
• In Washington, the rate of pregnancy-associated death in non-Hispanic American Indian and Alaska Native people was 8.5 times greater than the corresponding rate for non-Hispanic white people.

Based on findings from its review of 2017–2020 deaths, the MMRP developed recommendations to help reduce preventable maternal deaths and improve health care for people before, during, and after pregnancy. The recommendations are to:

1. UNDO RACISM & BIAS 
   Address racism, discrimination, bias, and stigma in perinatal care.
2. ADDRESS MENTAL HEALTH & SUBSTANCE USE DISORDER
   Increase access to mental health and substance use disorder prevention, screening, and treatment for pregnant and parenting people.
3. ENHANCE HEALTH CARE QUALITY AND ACCESS
   Expand equitable and high-quality health care by improving care integration, expanding telehealth services, and increasing reimbursement
4. STRENGTHEN CLINICAL CARE
   Strengthen the quality and availability of perinatal clinical and emergency care that is comprehensive, coordinated, culturally appropriate, and adequately staffed.
5. MEET BASIC HUMAN NEEDS
   Meet basic needs of pregnant and parenting people by prioritizing access to housing, nutrition, income, transportation, child care, care navigation, and culturally relevant support services.
6. ADDRESS & PREVENT VIOLENCE
   Prevent violence in the perinatal period through survivor-centered and culturally appropriate coordinated services.

Now that the 2023 Maternal Mortality Review Report has been published, DOH will offer learning opportunities that are open to the public, at which we will discuss report findings, recommendations, and future implementation activities. We encourage any individual or organization to share with us how you apply the Panel’s recommendations, plan to apply them, or are considering applying them. If you have questions or comments or would like DOH to present the report with your team or organization, contact us at maternalmortalityreview@doh.wa.gov.

Since publication of the previous report, in 2019, DOH and its partners have been working on implementing recommendations from that report. Here are some examples.

Centers of Excellence for Perinatal Substance Use

According to the CDC, the number of women with opioid-related diagnoses documented at delivery increased by 131% from 2010 to 2017. The Healthcare Cost and Utilization Project (HCUP), which is managed by the U.S. Agency for Healthcare Research and Quality, published data from 2017 showing that approximately one baby is diagnosed with neonatal abstinence syndrome (NAS) every 19 minutes in the U.S, or nearly 80 newborns diagnosed every day. The number of babies born with NAS increased by 82% nationally from 2010 to 2017. Increases were seen for nearly all states and demographic groups. According to 2018 HCUP data, Washington State has a rate of 9.8 per 1,000 of NAS among newborn hospitalizations.

The Maternal Mortality Review Panel (MMRP) found that opioids were involved in the majority of pregnancy-associated accidental overdose deaths from 2014-2016. The Panel subsequently recommended implementing evidence-based protocols and patient safety tools and guidelines that address this and other leading causes of death among pregnant and postpartum Washingtonians. In response to the Panel’s findings and recommendations, the Washington State Department of Health (DOH), Health Care Authority (HCA), and Washington State Hospital Association (WSHA) collaborated to create the Centers of Excellence for Perinatal Substance Use (COE).

The COE is a voluntary certification program open to birthing hospitals in Washington state. The purpose of this program is to recognize the vitally important role birthing hospitals and care providers play in supporting people who are pregnant and have a substance use disorder and to promote systemic improvements to our perinatal practices.

To become a Center of Excellence, birthing hospitals must meet eight criteria. The criteria, along with instructions on how to apply, are found on the Centers of Excellence webpage. 

A pilot program launched in October, 2021, with 13 hospitals enrolled in the AIM Bundle: Care for Pregnant and Postpartum People with Substance Use Disorder. DOH, in partnership with the Washington State Hospital Association (WSHA) launched the SUD Learning Collaborative in April 2022. This program supports hospitals’ efforts in becoming a Center of Excellence. The COE program is funded through the ERASE MM grant awarded from the Center for Disease Control and Prevention (CDC).

For more information, contact Tibbs Christensen, Maternal Health Coordinator, tiffany.tibbschristensen@doh.wa.gov.

Maternal Behavioral Health Mini Grants

Findings from the 2019 report show one of the leading underlying cause of death among pregnancy-related deaths were behavioral health conditions, including suicide and overdose. Some contributing factors to these deaths include lack of knowledge about behavioral health conditions, treatments, and resources, as well as stigma and bias related to behavioral health conditions.

The Maternal Behavioral Health Mini Community Grant opportunity focused on the Maternal Mortality Review Panel’s recommendation to “Increase knowledge and skill of providers, patients, and families about behavioral health conditions during and after pregnancy, and the treatment and resources that are available for support.”

Funds for these community grants were made available through the ERASE MM project, awarded to DOH by the Centers for Disease Control and Prevention; the Preventative Health Services Block Grant; the Maternal and Child Health Block Grant; and the Maternal Infant Health Opioid Legislative Funding.

Maternal and Behavioral Health Funding Grantees 2021–2023

Community Birth Center

Overview: To decrease disparities and address the role of behavioral health in the maternal and infant mortality crisis, they will conduct (1) bi-weekly gathering spaces for antepartum and postpartum families fostering a community model of maternal and newborn wellness check-ins and support for perinatal mental health, and (2) racial bias training and accountability network for perinatal providers to establish and shift foundational cultural understandings necessary to provide unbiased, culturally competent care.

University of Washington

Overview: Address perinatal mood and anxiety disorders (PMADs) among parents of infants needing care in the NICU through (1) increasing PMAD knowledge and skill among NICU providers through virtual education modules, (2) educating NICU families about PMADs and available resources, and (3) improving PMAD screening during infants NICU course.

Western Washington University

Overview: Implement a Perinatal Support Pathway (PSP), a first-line support for perinatal people with mild-to-moderate behavioral health concerns, through (1) educating perinatal care providers in Whatcom County about perinatal behavioral health, effective screening, and referral to PSP, and (2) implementing PSP by training peer providers in an empirically supported intervention called Listening Visits.

First Five Fundamentals

Overview: Conduct three activities that build upon their existing work and increase perinatal support services for Spanish-speaking and Black and African American families by (1) increasing availability of Group Peer Support groups; (2) increasing health provider awareness of and capacity to address PMADs; and (3) increasing community partner and family awareness of PMADs and the community resources available to support families via social media marketing.

Providence Health Care Foundation

Overview: Support the Maternal Medication-Assisted Treatment (MMAT) program by (1) providing outreach and education to physicians about the MMAT program; (2) strengthening eat-sleep-console community referral program; and (3) implementing TeamBirth, which places emphasis on shared decision making throughout the labor process.

For more information, contact: Tiffany Tibbs Christensen, Maternal Health Coordinator, tiffany.tibbschristensen@doh.wa.gov 

The application deadline has now passed to apply to join the Washington State Maternal Mortality Review Panel (MMRP) for a three-year term (2023–2025). We will be recruiting again in 2025 for the next three-year term. 

In recruitment periods, the MMRP seeks experts such as:

• Tribal health or urban Indian health leaders and providers
• Medical, nursing, and service providers specializing in perinatal, obstetric, newborn, or pediatric care, such as clinicians, midwives, doulas, community health workers, nurses, social workers, other providers. This may also include experts in obstetric care with other relevant clinical expertise areas, such as cardiology, oncology, or autoimmune disorders.
• Birthing hospital or licensed birthing center representatives
• Coroners, medical examiners, or pathologists
• Behavioral health and service providers
• State agency representatives
• Experts in health equity and social determinants of health issues (e.g., racism, housing access) as they impact maternal mortality, perinatal care, and pregnancy outcomes.
• Individuals with other expertise areas at the Department of Health’s discretion (e.g., injury and violence prevention, WIC, researchers, CPS, EMS, etc.)
• Individuals or organizations that represent the populations most affected by pregnancy-related deaths or pregnancy-associated deaths and lack of access to maternal health care services.
  • In Washington, this includes people who have been pregnant and/or experienced childbirth AND who are Black, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Medicaid (Apple Health) recipients, from low-income backgrounds, or have experienced mental and behavioral health conditions such as opioid use disorder or postpartum depression.
  • It also includes people are closely related to people who meet these criteria.

Read more about our process here

If you have any questions, please contact the Maternal Mortality Review Coordinator at maternalmortalityreview@doh.wa.gov

Washington state’s maternal mortality law gives the Department of Health the authority to obtain pertinent vital records, medical records, and autopsy reports related to maternal deaths. The law also provides protections for those records and for the panel members who participate in the review. This authority and protection allowed the Department and the Panel to determine which deaths were preventable and identify the issues that lead to preventable deaths.

In 2019, Washington state expanded the law to support and strengthen the maternal mortality reviews conducted by the Maternal Mortality Review Panel. The law was amended to permanently establish the Panel and the maternal mortality review process in Washington. Other changes included:

• Requiring tribal representation.
• Expanding representation to include all types of obstetric, perinatal, and women’s health medical, nursing, and service providers, as well as individuals or organizations that represent populations most affected by maternal mortality and lack of access to maternal care.
• Data related to the maternal mortality review can be shared with the Centers for Disease Control and Prevention, local health jurisdictions, regional maternal mortality review efforts such as American College of Obstetrics and Gynecology District VIII, and tribal entities.
• Access to records from the Department of Children, Youth and Families.
• Requiring hospitals and birthing centers to make good faith efforts to report deaths that occur during pregnancy or within 42 days of pregnancy to the local coroner or medical examiner, who will then conduct a death investigation with autopsy strongly advised. Counties will be reimbursed 100 percent for autopsies. (For more information on reporting and death investigation requirements, see Resources below.)

• Maternal Deaths 2014–2020 Legislative Factsheet 2023 (PDF)
• Prevention Recommendations and Activities for Policymakers 2023 (PDF)
• Prevention Recommendations and Activities for Providers and Facilities 2023 (PDF)
• Prevention Recommendations and Activities for Agencies, Organizations, and Institutions 2023 (PDF)
• Maternal Death Reporting and Death Investigation Requirements (PDF)
• Review to Action website – promoting the maternal mortality review process
• Urgent Maternal Warning Signs Educational Materials (CDC)
• Maternal Obesity Anesthesia Checklists (PDF)
• Safer Care of Obese Pregnant Patients (PDF)
• Black Mamas Matter report on Maternal Mortality Review Committees
• Maternal Mortality Autopsy Guidelines (PDF)
• Maternal Mortality Frequently Asked Questions (PDF)
• Webinar: Investigating Maternal Mortality in Washington State
• Postpartum Follow-up Care Schedule Recommendations for Women Diagnosed with Hypertensive Disorders during Pregnancy (PDF)
• Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) Strategic Plan: 2021-2024

Past maternal mortality reports

• Maternal Mortality Review – A Report on Maternal Deaths in Washington 2014-2016 (PDF) (2019 Report)
• Maternal Mortality Review – A Report on Maternal Deaths in Washington 2014-2015 (PDF)

Fact Sheets and Resources Archive

• Maternal Deaths 2014-2016 Legislative Factsheet 2019 (PDF)
• Maternal Mortality Review Panel: An early look at 2017 Maternal Deaths (PDF)
• Prevention Recommendations and Activities for Policy Makers and State Agencies (PDF)
• Prevention Recommendations and Activities for Perinatal Clinical and Service Providers (PDF)

The Department of Health welcomes your input on how the Maternal Mortality Review Panel can best meet the goals established by the legislature. There will not be a formal public hearing process (unless necessary to update the Washington Administrative Code). However, we encourage interested parties to share their ideas with Department of Health staff.

To ask questions, share ideas, or receive notification when the MMRP report is released, please contact us at maternalmortalityreview@doh.wa.gov.