Missouri's 2017-2021 Pregnancy-Associated Mortality Review

The Missouri Department of Health and Senior Services has published their annual maternal mortality report for 2017-2021. Missouri's Pregnancy-Associated Mortality Review Board is a multidisciplinary board of experts from across the state who are tasked with examining the causes and contributing factors associated with maternal mortality and ultimately forming recommendations that could prevent these deaths from occurring in the future.

This multi-year report describes maternal mortality and demographic characteristics of women in Missouri. It highlights the factors that may contribute to or cause maternal deaths and prevent future occurrences through their recommendations. The report is published annually.

Maternal mortality is defined by the CDC as deaths in pregnancy or within one year of postpartum. Analysis of data and related patient records indicates that the top causes of pregnancy-related death are mental health (including substance use disorders), cardiovascular issues, and homicide. There are evident disparities in the risk of maternal mortality by ethnicity and race, maternal age, access to care, and socioeconomic status.

Key Findings:

• The pregnancy-related mortality ratio was 32.2 deaths per 100,00 live births

• The pregnancy-related mortality ratio for Black women was 2.5 times the ratio of white women

• 77% of pregnancy-related deaths were determined to be preventable

• All pregnancy-related deaths due to mental health conditions were determine to be preventable

• 44% of all pregnancy-related suicides occurred in 2020

• COVID-19 was the cause of death for 75% of pregnancy-related deaths due to infection in 2021

• Women living in micropolitan counties had the highest ratio of pregnancy-related deaths (38 per 100,000)

• Women residing in rural counties had the highest ratio of pregnancy-associated (not related) deaths (67 per 100,000)

• The ratio of pregnancy-associated (not related) deaths for women who were covered by MO HealthNet was more than 7 times greater than the ratio for those with private insurance

The importance of good health before, during, and after pregnancy is key to improving maternal health outcomes. The recommendations from this report advocate for the implementation of standardized practices and procedures across the health care continuum through evidence-based practices and developing collaborative community referral networks.

Key Recommendations

• Missouri legislature should:

  • Provide funding for a statewide Perinatal Quality Collaborative

  • Establish and fund a statewide Perinatal Psychiatry Access Program to aid health care providers in providing evidence-based mental health care

  • Extend Medicaid coverage to one year postpartum for all conditions

  • Fund Medicaid expansion

  • Increase the seat belt violation fine

  • Pass a state primary enforcement seat belt law that covers all occupants, regardless of where they sit in the vehicle

• Health care providers should:

  • Perform a full assessment for depression and anxiety utilizing a standardized, validated tool at least at the initial visit, later in pregnancy, and at postpartum visits, adding additional screenings as indicated

  • Perform universal screening for substance use disorder utilizing a standard, validated tool on every patient at least one prenatally and at least once during the comprehensive postpartum visit, adding additional screenings a indicated

  • Refer pregnant women to mental health professionals, social workers, community health workers, and substance abuse treatment programs as appropriate

  • Obtain further education regarding screening, referral, and treatment of mental health conditions and cardiovascular disorders associated with pregnancy

  • Obtain further education on the cardiorespiratory physiologic changes in pregnancy and the implications for clinical management in the setting of acute infectious etiologies

• Health care facilities should:

  • Utilize social workers, community health workers, and doulas during pregnancy and postpartum, to increase continuity of care for referrals, care coordination, communication, and addressing social determinants of health

  • Standardize practices and procedures across the health care system by utilizing quality improvement tools

  • Establish protocols for pregnant women who come in for treatment with COVID-19

• Health care staff should:

  • Undergo training on trauma-informed care and implicit bias at least annually

• Community-based organizations should:

  • Collaborate with health care facilities and providers to reduce stigma surrounding maternal mental health and substance use disorder and provide assistance with resources for these conditions

  • Collaborate with health care facilities and providers to educate their community on intimate partner violence and provide resources and assistance for those affected by it

  • Empower pregnant and postpartum women to utilize doula services, home vising, and/or community health workers to facilitate care coordination and increase health care utilization

  • Provide educational outreach on preconception health and early and consistent prenatal care initiation to optimize prenatal, peripartum, and postpartum health

  • Collaborate with providers to educate their community on signs and symptoms of cardiovascular disease in obstetric patients

The full report can be found here.