Pregnancy-Associated Mortality Review (PAMR)

In 2010, the Louisiana Pregnancy-Associated Mortality Review (PAMR) program was established by the Louisiana Department of Health, Office of Public Health, Bureau of Family Health to understand and address maternal mortality in our state.

In 2018, the Louisiana Pregnancy-Associated Mortality Review implemented an enhanced multidisciplinary review process to be in full alignment with national best practices promoted by the U.S. Centers for Disease Control and Prevention (CDC). This work is funded by the CDC’s Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE-MM) program and is authorized by the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality (Louisiana Perinatal Commission). Through epidemiological surveillance and multidisciplinary case review, the Louisiana Pregnancy-Associated Mortality Review works to quantify and understand pregnancy-associated deaths in order to create actionable, comprehensive recommendations to prevent future deaths.

The case review process was further enhanced by expanding the Louisiana Pregnancy-Associated Mortality Review Committee to ensure representation from a variety of geographic regions and fields of expertise, including substance use and mental health. Today, the Committee consists of both clinical and non-clinical experts and prides itself in the varied perspectives of its members. To ensure that the Committee’s work is informed by individuals who know and understand the context of Louisiana, the Bureau of Family Health team continues statewide recruitment efforts. In 2023, we enhanced our recruitment process, seeking member with varied perspectives on maternal health, by developing a statewide application open to healthcare professionals, community health/public health workers, community-based organizations, social services, community advocates and individuals with lived experience as members of communities disproportionately impacted by maternal mortality. If you are interested in becoming a member of the Louisiana Pregnancy-Associated Mortality Review Committee, please complete the online application.

Louisiana Pregnancy-Associated Mortality Review’s mission is to protect and promote the health of women and families in Louisiana through surveillance, multidisciplinary case review, timely reports, and provision of actionable recommendations. This helps to understand and prevent pregnancy-associated deaths and support transformation and innovation in individuals, families, providers, birthing facilities, health systems, and communities.

Louisiana Pregnancy-Associated Mortality Review’s goals are to:

• Perform a multidisciplinary review of cases to gain a holistic understanding of the issues
• Determine the annual number of pregnancy-associated deaths to identify trends and risk factors among pregnancy-associated deaths in Louisiana
• Recommend actionable strategies and interventions at the individual, provider, and system levels to prevent future deaths
• Disseminate the findings and recommendations to a broad array of individuals and organizations

Case Identification, Confirmation, and Selection

In Louisiana, maternal deaths are identified through a combination of data linkages between death and birth certificates, the pregnancy checkbox on death certificates, and obstetric code (O-code) causes of death. Due to data limitations, the use of vital records death data and data linkages alone is not enough to identify true pregnancy-associated deaths. Potential pregnancy-associated deaths identified using these methods require validation by the Bureau of Family Health’s maternal and child health coordinators using medical records and/or coroner reports. This validation process reduces or eliminates “false positive” identifications of pregnancy-associated deaths that could result from the pregnancy box being checked in error, errors in ICD-10 codes, or when a birth and death record are incorrectly identified as a match. A death is considered “confirmed,” and is selected for review, if the maternal and child health coordinator confirms a pregnancy within one year of death based on the available records.

Case Abstraction, Informant Interviews, and Case Narrative Development
Once a case is confirmed as a pregnancy-associated death, the regional maternal and child health coordinators abstract data from various sources including, but not limited to, records from prenatal/postpartum care, hospital, behavioral health providers, coroners, emergency medical services, and law enforcement agencies. Additionally, the informant interviewer contacts potential participants, including loved ones and close friends of the decedent, to arrange a conversation aimed at collecting valuable insights into the decedent’s life that may not be fully captured from medical records alone. Using information obtained during the abstraction process and informant interviews, the maternal and child health coordinators develop a de-identified case narrative that details the decedent’s life from preconception through death, including both medical and social information.

Committee Review
During case review meetings, the Louisiana Pregnancy-Associated Mortality Review Committee conducts an in-depth review of each case to answer the following questions:

1. Was the death pregnancy-related?
2. What was the underlying cause of death?
3. Was the death preventable?
4. What factors contributed to the death?
5. If there was at least some chance that the death could have been prevented, what were the specific and feasible actions that, if implemented or altered, might have changed the course of events?

The Louisiana Pregnancy-Associated Mortality Review Committee uses the answers to these questions to create specific, feasible recommendations for prevention. Recommendations are made for each level of care, including but not limited to, healthcare providers, healthcare systems, hospitals and birthing facilities, insurance payors, government and public health agencies, policy makers, and local social and community organizations.

Throughout case discussions, objectivity is maintained by asking any committee member with personal knowledge about a particular case to recuse himself or herself. This is to ensure no specific details or anecdotal information about the case is shared beyond what is presented in the case narrative.

Research shows that lived experience adds critical value to the mortality review process, and informant interviews serve as a form of qualitative data collection that captures the voices of family members and loved ones – those who knew the decedent best. By serving as a proxy for the decedent’s voice, interviews with loved ones aim to deepen understanding of the case and “complete the picture” by shedding light on the emotional, interpersonal, and structural realities the decedent faced in the time leading to their death – realities that are often missing from clinical records.

In 2024, the Louisiana Pregnancy-Associated Mortality Review initiated the use of informant interviews as part of its case review process. Current guidance for the implementation of the informant interviews in this context suggests that cases be prioritized to reflect the nuances of the setting.

Using records available for eligible cases, the informant interviewer identifies potential participants, including the decedent’s family members or loved ones, to schedule a discussion focused on gathering important perspectives on the decedent’s life beyond what medical records reveal. If a family member or loved one agrees to participate, the interviewer has a detailed conversation with them, exploring the decedent’s social and behavioral health history and discussing social determinants that may have impacted their most recent pregnancy. These conversations offer valuable context about the circumstances leading to the decedent’s death, providing a more complete picture of their lived experience. Incorporating informant interviews has enriched committee deliberations, deepened the understanding of the lived experience behind the data, and enhanced the quality of recommendations, particularly those tied to provider communication and bereavement support.

Across the country, maternal mortality review committees (MMRCs) have found it difficult to categorize accidental overdoses and suicides as pregnancy-related or pregnancy-associated, but not related when posed with the questions “Was the death pregnancy-related? If this person was not pregnant, would they have died?”

The Utah Tool, developed by the Utah Maternal Mortality Review Committee, is a structured decision-making aid designed to assist maternal mortality review committees in determining whether or not suicide or overdose deaths are pregnancy-related. The tool incorporates a series of guiding questions and evidence-based considerations – such as the timing of pregnancy, documented perinatal mental health conditions, changes in substance use, and relevant psychosocial stressors – to support a more consistent and clear classification process. Because of this, there has been a decrease in the number of cases that were classified as pregnancy-associated, but unable to determine relatedness.

There is a growing recognition that discrimination contributes to adverse maternal health outcomes. To acknowledge these disparities and the importance of this issue, the U.S. Centers for Disease Control and Prevention added a discrimination checkbox, which includes discrimination and interpersonal and structural racism, to the Maternal Mortality Review Committee Decisions Form in 2020.

The disparity in maternal mortality is a complex issue due to many factors including, but not limited to, implicit bias and structural racism impacting social determinants of health. For the Louisiana Pregnancy-Associated Mortality Review Committee, it can be difficult to determine racism, bias, or discrimination as a contributing factor in a pregnancy-associated death with the information available in medical records. To review each death holistically and determine all contributing factors, the leadership of the Louisiana Pregnancy-Associated Mortality Review Committee developed a tool.

The Louisiana Bias or Racism and Social Determinants of Health (LABoRS) tool was developed to help the Louisiana Pregnancy-Associated Mortality Review Committee answer the question, “Did discrimination contribute to the death?” The tool provides a standardized process to guide targeted discussions to evaluate each case and build consensus around whether bias, discrimination, racism, and/or social determinants of health contributed to the death. The goal of the tool is to support the broader identification of contributing factors and to develop actionable recommendations that address factors related to social determinants of health, including those related to bias, discrimination, and/or racism.