The purpose of this project is to leverage existing infrastructure and strong partnerships to sustain and enhance processes of the multi-disciplinary Kansas Maternal Mortality Review Committee (KMMRC). Clinical and non-clinical data abstracted and entered into the Maternal Mortality Review Information Application (MMRIA) related to the deaths of women while pregnant, at delivery, and up to one year after delivery will be reviewed and discussed with the KMMRC on at least a quarterly basis to understand the circumstances surrounding each death, form recommendations to prevent deaths, and implement initiatives to improve outcomes. Leadership will monitor trends and facilitate implementation of data-driven recommendations in partnership with the Kansas Perinatal Quality Collaborative. Quality improvement activities will involve screening, patient education, adoption of patient safety bundles, and/or development of policies reflecting high standards of quality care.
The death of a woman while pregnant or soon after delivery is a tragedy for her family and the community. Based on death certificate data, a total of 66 maternal deaths were identified in Kansas from 2008-2017. During that same time period, 186 pregnancy-associated deaths were identified. Upon closer review of Kansas maternal mortality rates, it was noted that disparities exist, and the Kansas team is monitoring this closely with the Committee. The rate for non-Hispanic black women was nearly two times the rate for non-Hispanic white women. Women who live in rural counties had a higher rate of maternal mortality compared to women residing in the urban areas of the state. Non-Hispanic black women have a rate one and a half times higher than the rate of pregnancy-associated mortality for non-Hispanic white women. Findings from established Maternal Mortality Review Committees have demonstrated that more than half of the deaths can be prevented; it is imperative that Kansas utilizes our review committee to identify and characterize maternal deaths with the goal of identifying prevention opportunities.
The KMMRC was officially established and convened in June 2018 as part of an in-state visit and training with the Review to Action national team. The KMMRC completed the first review of cases on November 30, 2018, and has completed additional reviews since that time; use of MMRIA is fully integrated into the process. The initial review was the result of more than a year of strategic, intentional planning; change in policy; and collaboration with key partners. Leadership and support has been provided by the Kansas Department of Health and Environment, Bureau of Family Health, Title V Director and staff. Implementation has been directly in line with the Review to Action recommendations. Though the Committee is new, makeup reflects every region of the state and a diverse group of experts. Every member is dedicated and engaged, partnerships and collaborations are stronger than ever, and Kansas is positioned—readiness and essential infrastructure/capacity—to successfully implement the goals and objectives of this project. The following outcomes will serve as the foundation of our work.
• Timely, accurate, and standardized information available about deaths to women during pregnancy and the year after the end of pregnancy, including documented opportunities for prevention (short-term)
• Increased awareness of the existence and recommendations of the MMRC among the public, clinicians, and policy makers. (short-term)
• Implementation of data-driven recommendations. (short-term)
• Widespread adoption of patient safety bundles and/or policies that reflect the highest standards of care (intermediate)
• Reduction in maternal complication of pregnancy(long-term)