Maternal Mortality to Action: From Data to Prevention

By Michelle Spanier, RHIT, CCS

Maternal mortality remains a critical public health challenge in Kansas and across the nation. A structured, multidisciplinary review of maternal deaths provides insight into what happened, why it happened and how communities can prevent future loss. The Kansas Maternal Mortality Review Committee, convened by the Kansas Department of Health and Environment, demonstrates how a data-to-action model can transform clinical and community information into prevention strategies.

This paper outlines the maternal mortality abstraction process, the community risk factors that influence outcomes and the role of collaboratives in creating meaningful change.

Evolution of Maternal Mortality Review

Maternal Mortality Review Committees bring together clinicians, public health professionals and community representatives to examine deaths that occur during pregnancy and up to one year postpartum. These committees look beyond death certificates to review medical records, social factors and system issues that may have contributed to the outcome.

The Kansas committee was established to ensure that every maternal death receives a comprehensive and objective review. The purpose is not to assign blame. The purpose is to understand preventable factors and identify opportunities for improvement across clinical care, public health and community support.

The Abstraction Process

The review process begins with identification of all pregnancy-associated deaths in the state. Trained abstractors collect information from multiple sources, including hospital records, prenatal documentation, emergency services reports and, when available, social service and behavioral health information.

Each case is reviewed using standardized questions:

• Was the death related to pregnancy?
• What clinical and social factors were present?
• Was the death preventable?
• What actions might have changed the outcome?
• Which systems or policies could reduce future risk?

This structured approach ensures consistency and allows the committee to translate individual tragedies into actionable recommendations.

Community Risk Factors

Maternal outcomes are shaped by more than medical care alone. Reviews consistently show that social and community conditions play a major role in risk. Common contributing factors include:

• Behavioral health conditions and substance use disorders
• Intimate partner violence
• Limited access to prenatal and postpartum services
• Transportation and geographic barriers
• Economic instability and housing insecurity

Disparities are also evident. National and state data show that some racial and ethnic groups experience maternal mortality at significantly higher rates, reflecting long-standing inequities in access and support. Understanding these factors is essential to prevention.

From Review to Action

The value of a Maternal Mortality Review Committee is realized when findings lead to change. After each review cycle, the committee develops recommendations at several levels:

• Clinical practice, such as improved screening for hypertension and behavioral health conditions
• Health system processes, including referral pathways and postpartum follow-up
• Community supports, such as transportation and home visiting
• Policy initiatives that expand access to care

Collaboratives play a central role in this work. Hospitals, community organizations, behavioral health providers and public health agencies translate recommendations into training, protocols and resources that reach families across Kansas.

Measuring Impact

Success is measured not only by reductions in mortality but by improvements in the systems that surround pregnant and postpartum women. Indicators include:

• Increased use of evidence-based screening
• Stronger coordination between hospitals and community services
• Timelier postpartum visits
• Expanded access to behavioral health care

Each improvement reflects a commitment to learning from the past to protect the next mother and child.

Maternal mortality review demonstrates the power of partnership. Through careful abstraction, honest discussion and collaborative action, data become a roadmap for prevention. Public health leaders have an opportunity to use this model to strengthen communities, reduce disparities and ensure that every family has the chance to thrive.

Resources
Kansas Maternal Mortality Review Committee: https://kmmrc.kdhe.ks.gov
Kansas Department of Health and Environment: https://kdhe.ks.gov
CDC Maternal Mortality Review Information: https://www.cdc.gov