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Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois

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Abstract

Objectives

To compare the results of two maternal death review processes conducted from 2002 to 2012 by Illinois regionalized perinatal centers with those conducted by the Illinois Department of Public Health’s (IDPH’s) statewide multidisciplinary external Maternal Mortality Review Committee (MMRC).

Methods

This is a retrospective record review linking MMRC case assessment forms to the IDPH’s Maternal Mortality Review Form database to compare causes of death and potential preventability as determined by both review processes.

Results

MMRC records for 76 maternal death reviews were linked to the IDPH maternal mortality review form database. Most deaths reviewed by the statewide MMRC were due to pregnancy-related causes. The statewide MMRC differed from the regional perinatal centers on cause of death in 55.3 % (n = 42) of cases and on the disposition of potential preventability in 48.7 % (n = 37) of cases. The statewide MMRC judged 69.7 % (n = 53) of cases potentially preventable, compared with 40.8 % (n = 31) for the regional perinatal centers. The MMRC identified more preventable provider and systems factors for potentially preventable deaths compared with regional perinatal centers which identified more preventable patient factors.

Conclusions for practice

The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews.

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Acknowledgments

We acknowledge the 2014 members of the Illinois Maternal Mortality Review Committee: Robert Abrams, M.D. (Southern Illinois University), Harold R. Bigger, M.D. (Rush University), Deborah A. Boyle, M.D. (University of Chicago), Joan Briller, M.D. (University of Illinois at Chicago), Brenda L. Jones, DHSc., MSN, WHNP-BC (Illinois Department of Public Health), Robin L. Jones, M.D. (Aetna Better Health of Illinois), Jerome Loew, M.D. (Rush University), Gary Loy, M.D. (Rush University), Kevin Madsen, M.D. (Advocate Good Samaritan Hospital), Paula Melone, D.O. (Loyala University Medical Center), Frank W. Nagorka, J.D., Trish O’Malley, R.N.C., M.S., APN (Loyola University), J. Roger Powell, M.D. (University of Illinois Urbana-Champaign), Pat Schneider, R.N., M.S., C.N.M. (Hinsdale Hospital), Shirley Scott, M.S., R.N.C. (University of Illinois at Chicago), Michael L. Socol, M.D. (Northwestern University), Charlene Wells, R.N. (Illinois Department of Public Health), Barbara Prochnicki, R.N., M.S. (Rockford Memorial Hospital), Cynthia Wong, M.D. (Northwestern University). None of the acknowledged persons received any compensation for their contribution to this manuscript.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Center for Research on Women and Gender, College of Medicine, University of Illinois at Chicago, 820 S. Wood St., Chicago, IL, 60612, USA

    Stacie E. Geller

  2. Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, IL, USA

    Abigail R. Koch

  3. Perinatal Health Data Section, Center for Health Statistics, Illinois Department of Public Health, Chicago, IL, USA

    Nancy J. Martin

  4. Rush University, Chicago, IL, USA

    Patricia Prentice

  5. Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA

    Deborah Rosenberg

Authors
  1. Stacie E. Geller
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  2. Abigail R. Koch
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  3. Nancy J. Martin
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  4. Patricia Prentice
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  5. Deborah Rosenberg
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Illinois Department of Public Health Maternal Mortality Review Committee Working Group

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Correspondence to Stacie E. Geller.

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Geller, S.E., Koch, A.R., Martin, N.J. et al. Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois. Matern Child Health J 19, 2621–2626 (2015). https://doi.org/10.1007/s10995-015-1782-2

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  • DOI: https://doi.org/10.1007/s10995-015-1782-2

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