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Implementing Statewide Severe Maternal Morbidity Review

The Illinois Experience

Koch, Abigail R., MA; Roesch, Pamela T., MPH; Garland, Caitlin E., MPH; Geller, Stacie E., PhD

Journal of Public Health Management and Practice: September/October 2018 - Volume 24 - Issue 5 - p 458–464
doi: 10.1097/PHH.0000000000000752
Research Reports: Practice Full Report

Context: Severe maternal morbidity (SMM) rates in the United States more than doubled between 1998 and 2010. Advanced maternal age and chronic comorbidities do not completely explain the increase in SMM or how to effectively address it. The Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists have called for facility-level multidisciplinary review of SMM for potential preventability and have issued implementation guidelines.

Implementation: Within Illinois, SMM was identified as any intensive or critical care unit admission and/or 4 or more units of packed red blood cells transfused at any time from conception through 42 days postpartum. All cases meeting this definition were counted during statewide surveillance. Cases were selected for review on the basis of their potential to yield insights into factors contributing to preventable SMM or best practices preventing further morbidity or death. If the SMM review committee deemed a case potentially preventable, it identified specific factors associated with missed opportunities and made actionable recommendations for quality improvement.

Evaluation: Approximately 1100 cases of SMM were identified from July 1, 2016, to June 30, 2017, yielding a rate of 76 SMM cases per 10 000 pregnancies. Reviews were conducted on 142 SMM cases. Most SMM cases occurred during delivery hospitalization and more than half were delivered by cesarean section. Hemorrhage was the primary cause of SMM (>50% of the cases).

Discussion: Facility-level SMM review was feasible and acceptable in statewide implementation. States that are planning SMM reviews across obstetric facilities should permit ample time for translation of recommendations to practice. Although continued maternal mortality reviews are valuable, they are not sufficient to address the increasing rates of SMM and maternal death. In-depth multidisciplinary review offers the potential to identify factors associated with SMM and interventions to prevent women from moving along the continuum of severity.

Center for Research on Women and Gender, University of Illinois at Chicago, Chicago, Illinois (Mss Koch, Roesch, and Garland); and Department of Obstetrics & Gynecology and Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois (Dr Geller).

Correspondence: Abigail R. Koch, MA, Center for Research on Women and Gender, University of Illinois at Chicago, 1640 West Roosevelt Rd, Ste 503, Chicago, IL 60608 (

The authors thank the Illinois Severe Maternal Morbidity Surveillance and Review Stakeholder Planning Group comprising individuals from the Illinois Department of Public Health's Office of Women's Health and Family Services (OWHFS) as well as Illinois' 10 perinatal center administrators. In addition, the authors thank all Illinois Regionalized Perinatal Network and obstetric hospital staff who assisted in the completion of pilot testing and provided feedback throughout the SMM surveillance and review implementation planning process.

This research was supported by the Association of Maternal and Child Health Programs.

The authors declare no conflicts of interest.

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