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Why was the Pregnancy-Associated Mortality Review Program created and what are its goals?
Ohio’s Pregnancy-Associated Mortality Review (PAMR) Program was born out of the need to improve how we track and understand maternal deaths. The usual data systems that were used to track deaths involving pregnancy did not give a clear picture. Too often, vital details about a pregnant person’s death during or after pregnancy were overlooked or misclassified. PAMR came in to fill these gaps by taking a closer, more detailed look at every death related to pregnancy. The idea was simple: if we can understand where things went wrong, we can do something about it. The main goal is to find the underlying cause of each case, not just by looking at the immediate cause but also by understanding the broader circumstances. This means examining everything from clinical care to systemic issues, like delays in treatment or gaps in follow-up care. By doing this, PAMR hopes to:
- Collect and review all relevant cases in a way that leaves no stone unturned.
- Clearly sort out deaths that are directly caused by pregnancy complications from those that happen alongside pregnancy (even if the cause isn’t the pregnancy itself).
- Pinpoint what could have been done differently to potentially save lives.
- Use these insights to recommend changes in policies and healthcare practices.
Differentiating Pregnancy-Related Versus Pregnancy-Associated Deaths
A big part of PAMR’s work is making sure we are we are speaking the same language when we talk about these deaths.
Pregnancy-Related Deaths
These are the deaths that happen because something went wrong directly during pregnancy or shortly after childbirth. In these cases, the complications of being pregnant are directly to blame.
Pregnancy-Associated Deaths
This is a broader bucket. It includes any death that happens during pregnancy or within one-year postpartum, even if it was not caused by pregnancy complications. For example, if a pregnant woman dies from a condition that she had before pregnancy or from something accidental, it still falls under this category if it occurs during the risk period.
Breaking these down helps health professionals and policymakers determine the best ways to step in. By understanding whether a death was directly tied to pregnancy issues or just happened to occur during pregnancy, more tailored solutions can be developed to prevent future tragedies.
How the PAMR process works
- Health departments gather data from multiple sources like hospitals, death certificates and other records. The goal is to make sure they find every single case that might be related to pregnancy. The goal is not to miss anyone.
- Once the cases are gathered, a team of experts from different areas reviews each case in-depth. This could include obstetrics, pathology, and public health. They piece together the medical history, the care provided, and any other relevant details.
- With all the information on hand, the team then classifies each death. Is it a pregnancy-related death, where the pregnancy itself or its complications are the culprit? Or is it a pregnancy-associated death, where the death happened during the pregnancy or postpartum period without being directly caused by it? This step is essential for understanding what factors were at play.
- The team looks for any red flags or missed opportunities. Was there a delay in getting help, or was there a breakdown in communication? By identifying these contributing factors, they can figure out where changes might save lives in the future.
- The last step is using all those insights to make practical recommendations. These might involve changing clinical practices, improving training, or even altering public health policies to better protect maternal health.
PAMR trends and five categories of pregnancy-related death
As a follow up to their last report consisting of data from 2017-2018, this report highlights maternal mortality trends in Ohio in 2020. Specifically, PAMR identified statistics based on pregnancy-associated deaths, pregnancy-related deaths, the causes of death, racial disparities, and timing of death. The Ohio Department of Health and the Ohio Department of Children and Youth decided to not include 2019 data due to the COVID-19 pandemic and staffing challenges.
This PAMR report includes 88 contributing factors to pregnancy-related deaths. These factors fall into five key categories, each highlighting specific areas where interventions could potentially improve maternal outcomes.
- Inadequate Assessment of Risk. This category reflects instances where there was a failure to fully recognize the seriousness or complexity of a patient’s condition. In many cases, early warning signs were either overlooked or misinterpreted, resulting in missed opportunities for timely intervention. Enhancing risk assessment protocols and training can help in identifying high-risk pregnancies more accurately.
- Lack of Care Coordination/Continuity of Care. Effective maternal care relies heavily on seamless communication and coordination among healthcare providers. Gaps in care continuity, whether due to fragmented services or inadequate information-sharing systems, can lead to suboptimal management of complications. Addressing these systemic issues by establishing robust care networks and improving referral processes is critical for ensuring consistent, quality care throughout the perinatal period.
- Lack of Knowledge. This factor highlights the impact of knowledge deficits among both patients and providers. Instances where up-to-date clinical practices and protocols were not applied can result from insufficient education or training. Strengthening continuing education programs for healthcare professionals and enhancing health literacy among patients may help bridge these knowledge gaps, thereby improving health outcomes.
- Lack of Access/Financial Resources. Socioeconomic factors play a crucial role in health disparities. Limited access to healthcare services, often compounded by financial constraints, can delay the receipt of necessary medical care and treatment. Strategies to expand access and mitigate financial barriers are essential for ensuring that all women receive comprehensive prenatal and postpartum care, regardless of their economic status.
- Clinical Skill/Quality of Care. Even when care is accessed, the quality of that care remains a pivotal factor. Variations in clinical skills, whether due to diagnostic errors, delayed interventions, or substandard treatment protocols, have a significant impact on patient outcomes. Ongoing quality improvement initiatives and rigorous adherence to evidence-based practices are vital in reducing preventable maternal mortality.
Key statistics on pregnancy-related deaths and causes
The report pointed out some key findings concerning maternal mortality in Ohio in 2020. PAMR identified 130 pregnancy-associated deaths. Out of the 127 pregnancy-associated deaths (three cases were not reviewed because they had ongoing investigations), 28 percent (n=35) were classified as pregnancy-related. The leading causes of death were:
- Infection—31 percent. Infections include postpartum genital tract infections, urinary tract infections, and sepsis/septic shock. COVID-19 falls within this category at 14 percent
- Other—31 percent. Including but not limited to cardiovascular conditions, injury, cardiomyopathy, hemorrhage, and hypertensive disorders of pregnancy
- Mental health conditions—20 percent. Includes overdoses related to depressive disorders and substance use disorder
- Thrombotic embolisms—17 percent
Alarmingly, 66 percent of pregnancy-related deaths (n=23) were determined as preventable. From the leading causes of death:
- 45 percent of deaths from infection were deemed as preventable
- 100 percent of deaths due to mental health conditions were determined as preventable
- 50 percent of deaths from cardiovascular conditions were identified as preventable
- 50 percent of deaths due to thrombotic embolism were preventable
- 100 percent of deaths due to injury were preventable
Alarmingly, 66 percent of pregnancy-related deaths were determined as preventable.
Racial disparities persist in Ohio among birthing parents
When categorizing pregnancy-related deaths by race and ethnicity, 68 percent (n=24) were non-Hispanic white women, whereas 26 percent (n=9) were non-Hispanic Black women. Six percent (n=2) were Hispanic women or non-Hispanic women of a race other than white or Black. More white women experienced pregnancy-related deaths due to overdose deaths.
PAMR adopted new criteria from the Utah Department of Health Perinatal Mortality Review Committee, which identified that pregnancy itself is the event that leads to accidental drug-related deaths or suicide among pregnant and postpartum individuals. In other words, unintentional overdose deaths were pregnancy-related.
Leading causes of death by race/ethnicity
Even though the methodology changed, Non-Hispanic Black women are still overrepresented among pregnancy-related deaths in the state in 2020. In fact, non-Hispanic Black women were 1.5 times more likely to die from pregnancy-related causes compared to non-Hispanic White women. The following table lists the leading causes of death by race and ethnicity.
When pregnancy-related deaths occurred
The first several weeks post pregnancy or birth prove the most dangerous time for pregnancy-related deaths, according to this data.
Out of the 35 pregnancy-related deaths, 29 percent happened during pregnancy, 46 percent occurred within 42 days (about 1 and a half months) after the end of pregnancy, and 26 percent happened within 43 days to one year after the end of pregnancy.
Most non-Hispanic Black women (89 percent) and non-Hispanic white women (83 percent) experienced a death 1-365 days after the end of pregnancy. In addition, the timing of death based on the leading causes mostly occurred after pregnancy (except for cardiovascular conditions and injury, with each had 50 percent during and after pregnancy). Overall, most maternal deaths happened during the postpartum period, which is a crucial time called the fourth trimester.
PAMR recommendations according to contributing factors
PAMR suggested solutions to prevent future maternal deaths based on contributing factors to pregnancy-related deaths in 2020. Recommended solutions are based on communities, systems of care, facilities, and providers. The following table presents some solutions, but it is not an exhaustive list of suggestions. It is important to take their recommendations into consideration to prevent future maternal deaths.
Conclusion
The PAMR process is a thoughtful effort to really understand the full picture of maternal deaths. By taking the time to carefully review each case, separating out deaths that are directly caused by pregnancy complications from those that occur during the high-risk period, PAMR shines a light on where our healthcare system can improve. The process brings together experts from different fields, making sure that every detail is considered and that we learn not only about what went wrong but also about what we can do better in the future.
Ultimately, PAMR is about saving lives by turning insights into practical actions that make a real difference in maternal care.
