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Rural Focus and Representation in State Maternal Mortality Review Committees: Review of Policy and Legislation

Published:August 05, 2019DOI:https://doi.org/10.1016/j.whi.2019.07.001

      Abstract

      Objectives

      Between 1990 and 2013, maternal mortality nearly doubled in the United States and rural residents experienced decreasing access to obstetric care. To improve maternal health, many states have established maternal mortality and morbidity review committees (MMRCs). We assessed the extent of rural representation in state policy efforts related to MMRCs.

      Methods

      We reviewed publicly available information on MMRCs (websites, statutes, bills, media) in all 50 states and the District of Columbia, separately identifying highly rural states (with >30% of the population being rural residents). We assessed whether each state 1) had established an MMRC, 2) had passed legislation requiring an MMRC, 3) had considered, but not passed, legislation requiring an MMRC, 4) mentioned rural populations in MMRC legislation, 5) required representation on the MMRC from any particular groups, and 6) required rural representation on the MMRC.

      Results

      As of December 2018, MMRCs were established in 45 states and the District of Columbia, an increase from 23 in 2010. Legislation was in place in 27 states, up from 6 in 2010. Only three states specifically mentioned rurality in legislation (including one highly rural state), and only two states required rural representation among their MMRC members (neither of which were highly rural states).

      Conclusions

      Recent growth in MMRCs has had a limited focus on rural residents, despite their worse health outcomes and more limited access to health care, including obstetric services. Lack of rural representation may hamper geographically tailored efforts to reverse rising rates of maternal morbidity and mortality nationally.
      Maternal mortality is defined as a death attributable to “a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy” occurring during pregnancy and up to one year postpartum (
      • Centers for Disease Control and Prevention
      Pregnancy mortality surveillance system.
      ). Maternal morbidities are “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health” (
      • Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      ). Maternal mortality is a growing challenge in the United States, claiming the lives of 700–900 individuals every year; more than one-half of these deaths are likely preventable (
      • Centers for Disease Control and Prevention
      Report from maternal mortality review committees: A view into their critical role.
      ). Between 1990 and 2013, maternal mortality increased dramatically, nearly doubling in the United States, while declining in all other developed nations (
      • Kassebaum N.J.
      • Barber R.M.
      • Dandona L.
      • Hay S.I.
      • Larson H.J.
      • Lim S.S.
      Global, regional, and national levels of maternal mortality, 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015.
      ).

      Maternal Morbidity and Mortality Risk

      Risk for maternal morbidity and mortality is unevenly distributed, with some populations bearing substantially greater risk. Among the groups at highest risk are Black women, low-income individuals, and rural residents (
      • Building U.S. Capacity to Review and Prevent Maternal Deaths
      Report from nine maternal mortality review committees.
      ,
      • Centers for Disease Control and Prevention
      Pregnancy mortality surveillance system.
      ,
      • Ely D.M.
      • Driscoll A.K.
      • Mathews T.J.
      Infant mortality rates in rural and urban areas in the United States, 2014 key findings data from the National Vital Statistics System.
      ). Those with more than one of these characteristics may be at highest risk (
      • Lu M.C.
      Reducing Maternal Mortality in the United States.
      ). Clinical efforts are underway to address the issue of rising maternal morbidity and mortality, but policy efforts to align systems and structures with evidence are also required to ensure improvement in maternal health (
      • Clark S.L.
      • Belfort M.A.
      The case for a national maternal mortality review committee.
      ,
      • Lu M.C.
      Reducing Maternal Mortality in the United States.
      ,
      • Mann S.
      • Hollier L.M.
      • McKay K.
      • Brown H.
      What We Can Do about Maternal Mortality — And How to Do It Quickly.
      ).
      Geography is an important determinant of access to, and outcomes associated with, care, including maternity care. Rural residents tend to have lower incomes and more health-related complications than people living in urban areas, and their access to care is limited by greater distances to care, clinician workforce shortages, and hospital and unit closures (
      • Health Resources and Services Administration
      Designated Health Professional Shortage Areas Statistics First Quarter of Fiscal Year 2019 Designated HPSA Quarterly Summary As of December 31, 2018.
      ,
      • Health Resources and Services Administration
      Shortage Areas.
      ,
      • Probst J.C.
      • Laditka S.B.
      • Wang J.-Y.
      • Johnson A.O.
      Mode of travel and actual distance traveled for medical or dental care by rural and urban residents.
      ,
      • Rural Health Research Gateway
      Rural hospital closures.
      ,
      • Rural Health Research Gateway
      Rural Health Research RECAP: Rural Communities: Age, Income, and Health Status.
      ). These challenges affect care for rural residents during all stages of life, including pregnancy and childbirth. On average, rural residents have worse health (e.g., self-reported health, injury, smoking, obesity, pregnancy complications, preterm birth, low birth weight) before pregnancy, during pregnancy, and in the year after childbirth, compared with urban residents (
      • American College of Obstetricians and Gynecologists
      Health disparities in rural women. Committee Opinion No. 586.
      ). Moreover, maternal mortality rates are significantly higher in rural areas than in urban areas; in 2015, the maternal mortality rate in the most rural areas of the United States was 29.4 per 100,000 live births, whereas in large metropolitan areas it was 18.2 (
      • Fine Maron D.
      Maternal health care is disappearing in rural America.
      ).
      Although a variety of clinicians provide maternity care for rural residents, including family physicians, obstetricians, and midwives (
      • Kozhimannil K.B.
      • Casey M.M.
      • Hung P.
      • Han X.
      • Prasad S.
      • Moscovice I.S.
      The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities.
      ), shortages in the availability of clinicians in each of these specialties affect access to care in rural communities (
      • Ollove M.
      A shortage in the nation’s maternal health care.
      ). For example, fewer than 10% of obstetricians are located in rural areas. This translates to nearly one-half of U.S. counties—most of them rural—not having an obstetrician (
      • Rayburn W.F.
      The obstetrician – gynecologist workforce in the United States: Facts, figures and implications.
      ). Workforce issues are closely related to the supply of hospital-based obstetric services.
      Fewer than one-half of rural residents live within a 30-minute drive of the nearest hospital offering obstetric services (
      • Rayburn W.F.
      The obstetrician – gynecologist workforce in the United States: Facts, figures and implications.
      ). Approximately 12% of those residing in rural towns (2,500–9,999 people) live more than an hour from a hospital with obstetric services, and 21% of residents of the most sparsely populated rural areas (<2,500 people) live more than 1 hour from a hospital with obstetric services (
      • American College of Obstetricians and Gynecologists
      Health disparities in rural women. Committee Opinion No. 586.
      ,
      • Rayburn W.F.
      The obstetrician – gynecologist workforce in the United States: Facts, figures and implications.
      ). From 2004 to 2014, 9% of rural counties lost hospital-based obstetric services (
      • Hung P.
      • Henning-Smith C.E.
      • Casey M.M.
      • Kozhimannil K.B.
      Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.
      ), and these rural communities saw an increase in out-of-hospital births, births in hospitals without obstetric units, and—in rural counties not adjacent to urban areas—an increase in preterm birth rates (
      • Kozhimannil K.B.
      • Hung P.
      • Henning-Smith C.
      • Casey M.M.
      • Prasad S.
      Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States.
      ). From 2011 to 2018, hospital obstetric unit closures in 152 rural communities resulted in an increased travel distance of at least 30 minutes for pregnant residents in more than one-half of these communities (
      • Chartis Center for Rural Health
      The rural health safety net under pressure; Research update: Decline of access to OB services.
      ).

      Maternal Morbidity and Mortality Response

      Although national estimates for maternal morbidity and mortality can be tabulated through the use of vital statistics and national surveillance systems, simply identifying the occurrence of maternal death does not elucidate contributing factors or clarify strategies for prevention. Both state and federal policies have focused on the establishment of committees to review cases of maternal mortality (and sometimes also morbidity), called maternal mortality review committees (MMRCs). MMRCs collect data on risk markers, including health care and clinical factors, as well as social determinants of health. As such, MMRCs are uniquely positioned to review and document individual causes of death, make recommendations for the prevention of future deaths, and promote and implement prevention activities (
      • Centers for Disease Control and Prevention
      Report from maternal mortality review committees: A view into their critical role.
      ,
      • Review to Action
      What makes maternal mortality review unique?.
      ).
      MMRCs have traditionally been primarily comprised of medical professionals, but many have expanded to include public health professionals, social workers, community members, and other stakeholders (
      • Centers for Disease Control and Prevention
      Report from maternal mortality review committees: A view into their critical role.
      ). Some form of maternal mortality review process or MMRC has intermittently existed in most states for over a century (
      • Review to Action
      What makes maternal mortality review unique?.
      ). Yet legislative protections for MMRCs and regulation requiring reviews and reporting of maternal deaths by MMRCs have only been instituted recently, primarily over the last two decades (
      • Martin N.
      • Fields R.
      Here’s one issue blue and red states agree on: Preventing deaths of expectant and new mothers.
      ,
      • Review to Action
      Authority and protections.
      ). The federal Preventing Maternal Deaths Act was signed into law on December 21, 2018 (
      • Preventing Maternal Deaths Act of 2018
      Congress.
      ), encouraging all states to form MMRCs to investigate maternal deaths and to make recommendations for prevention. This national legislation builds upon efforts by states, which have increasingly—but not universally—established MMRCs in the wake of rising rates of maternal morbidity and mortality (
      • Barfield W.
      Transforming tragedy into effective maternal mortality prevention efforts.
      ).
      As the number of MMRCs has increased over time, it is not clear to what extent rural populations—and their unique needs—are being recognized and explicitly included in policies designed to address the growing crisis of maternal mortality. Ensuring that there is adequate and appropriate rural representation in policy efforts is necessary to inform geographically tailored interventions to reverse the increasing rates of maternal morbidity and mortality nationally, particularly in rural areas. The goal of this analysis was to assess the extent of rural focus and representation in current state policy efforts to develop committees to review maternal morbidity and mortality.

      Methods

      We assessed the existence of state-specific MMRCs in all 50 states and the District of Columbia (51 “states”), including those housed within a state department of health or related agency. In states with currently existing MMRCs, we identified the text of laws using official state legislative documentation. For existing MMRCs and existing and proposed legislation, we extracted information pertaining to MMRC goals and scope, year of MMRC establishment or year first convened, and if legislation was proposed or existing, along with the associated year. If legislation was proposed, but not signed into law, we looked at whether the bill was re-introduced in a later legislative session. Finally, we analyzed the language of the legislation pertaining to each MMRC to assess whether it required representation from any particular group. We designated states as requiring representation if the text of their legislation stated that committee members “must” or “shall” include any particular groups or perspectives (such as specific medical professionals, state departments, academic institutions, community members, etc.). In addition to identifying whether any type of representation was required, we identified whether rural populations were mentioned and whether rural representation was specifically mandated. To ensure consistency, two of the authors individually extracted data, then cross-checked their results and related designations to ensure systematic classification. Few (three) inconsistencies were found between the two researchers, and all coauthors were consulted and final designations were agreed upon.
      We conducted reviews of the following in our assessment process: 1) information available through the Review to Action website, developed by the Association of Maternal and Child Health Programs in partnership with the CDC Foundation and the CDC Division of Reproductive Health (
      • Review to Action
      Review to action: Building U.S. capacity to review and prevent maternal deaths.
      ), 2) online state legislative records, 3) media coverage and journal articles for references to recent or current legislative proposals related to maternal morbidity and mortality, 4) state departments of health and other state-specific health related organization websites, and 5) national bill tracker websites. We used search terms including “maternal mortality,” “maternal morbidity,” and “maternal death” to identify records.
      In addition to assessing whether rural representation was required in states across the nation, we also assessed rural representation among highly rural states, which we defined as those states with 30% or more of the state's population residing in nonmetropolitan communities, based on definitions of rurality from the U.S. Census Bureau (
      • U.S. Census Bureau
      2010 Census urban and rural classification and urban area criteria.
      ). We identified 18 states as highly rural: Alabama, Alaska, Arkansas, Iowa, Kentucky, Maine, Mississippi, Montana, New Hampshire, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Vermont, West Virginia, and Wyoming.
      This study was determined exempt from review by the University of Minnesota Institutional Review Board.

      Results

      As of December 2018, 45 states and the District of Columbia (46 states) had MMRCs; 27 of these were protected by legislation, and 9 of those laws passed in 2018 (Table 1). That is, 59% of all states with MMRCs (27 of 46) had statutory protection for maternal mortality review by the end of 2018. Of the 27 states that had MMRC legislation in 2018, 14 states (52%) required representation from any specific group or population. Only two states (Pennsylvania and Texas) explicitly required representation from rural communities in their legislative language. Figure 1 shows the increase over time in established and legislated MMRCs, as well as any required representation and rural representation specifically. In 2010, 23 states had MMRCs, but only 6 (26% of those with MMRCs) were protected by legislation. By 2018, 27 states (59% of those with MMRCs) had statutory protection for their MMRCs. Requirements for representation from any particular group were present in some states’ MMRC legislation throughout the study period, and increased over time (in 3 states by 2010 and in 14 states by 2018). The first requirement for rural representation on an MMRC occurred in 2013 (Texas).
      Table 1Maternal Mortality Review Committees by State, Percentage of State That Is Rural, Year Established, Year Legislated, Representation Requirements, and Rural Representation Requirement as of December, 2018
      StatePercentage of Population That Is Rural
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      Year EstablishedYear LegislatedRequired Representation of Any Specific Group or PopulationRequired Rural Representation
      Alabama
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      41.020182018NoNo
      Alaska
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      34.01989n/aNoNo
      Arizona10.220112011YesNo
      Arkansas
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      43.8n/an/aNoNo
      California5.02006n/aNoNo
      Colorado13.81993n/aNoNo
      Connecticut12.020152018NoNo
      Delaware16.720112008NoNo
      District of Columbia0.020182018YesNo
      Florida8.81996n/aNoNo
      Georgia24.920122014NoNo
      Hawaii8.120162016NoNo
      Idaho29.420072007YesNo
      Illinois11.52000/2016
      The Illinois Maternal Mortality Review Committee was convened in 2000 and reviews all pregnancy-associated deaths that were potentially related to pregnancy, excluding injury-related deaths. The Illinois Severe Maternal Morbidity committee convened in 2016. This review is done at the hospital level and is an effort to reduce maternal morbidity. Neither are protected with legislation.
      n/aNoNo
      Indiana27.620182018YesNo
      Iowa
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      36.01952n/a
      Although legislation was passed in 2008 requiring reporting of maternal deaths in Iowa, it does not specify that a maternal mortality review committee must exist, simply that an annual review must occur. As of February 2019, the Iowa Medical Society was tasked with the review. A second piece of legislation was passed in 2018 that is designed to ensure Iowa perinatal patients receive appropriate maternal and neonatal care as close to their homes as possible. This legislation mentions rural multiple times in the legislative language, but does not require representation, because it does not involve a maternal mortality review committee.
      NoNo
      Although legislation was passed in 2008 requiring reporting of maternal deaths in Iowa, it does not specify that a maternal mortality review committee must exist, simply that an annual review must occur. As of February 2019, the Iowa Medical Society was tasked with the review. A second piece of legislation was passed in 2018 that is designed to ensure Iowa perinatal patients receive appropriate maternal and neonatal care as close to their homes as possible. This legislation mentions rural multiple times in the legislative language, but does not require representation, because it does not involve a maternal mortality review committee.
      Kansas25.820182018YesNo
      Kentucky
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      41.61995
      In 2018, Kentucky passed legislation that added maternal mortality review to their existing Child Fatality Review Team. Before 2018, a private medical society in Kentucky reviewed maternal deaths and did not issue public reports. However, the medical society did publish some analyses of Kentucky's maternal mortality in their own journal.
      2018NoNo
      Louisiana26.819922018YesNo
      Maine
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      61.320052005NoNo
      Maryland12.820002000NoNo
      Massachusetts8.01997n/aNoNo
      Michigan25.41950n/aNoNo
      Minnesota26.72012n/aNoNo
      Mississippi
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      50.620172017NoNo
      Missouri29.62011n/aNoNo
      Montana
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      44.120132013YesNo
      Nebraska26.920132013YesNo
      Nevada5.8n/an/aNoNo
      New Hampshire
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      39.720132010YesNo
      New Jersey5.31932n/aNoNo
      New Mexico22.61993n/aNoNo
      New York12.12010n/aNoNo
      North Carolina
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      33.920152015NoNo
      North Dakota
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      40.1n/an/aNoNo
      Ohio22.12010n/aNoNo
      Oklahoma
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      33.82009n/aNoNo
      Oregon19.020182018NoNo
      Pennsylvania21.320182018YesYes
      Rhode Island9.31931n/aNoNo
      South Carolina
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      33.720162016NoNo
      South Dakota
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      43.3n/an/aNoNo
      Tennessee
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      33.620172016YesNo
      Texas15.320142013YesYes
      Utah9.41995n/aNoNo
      Vermont
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      61.120112011YesNo
      Virginia24.52002n/aNoNo
      Washington15.920162016NoNo
      West Virginia
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      51.320082008YesNo
      Wisconsin29.81997n/aNoNo
      Wyoming
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (U.S. Census Bureau, 2018).
      35.2n/an/aNoNo
      Abbreviation: n/a, not applicable.
      Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (
      • U.S. Census Bureau
      2010 Census urban and rural classification and urban area criteria.
      ).
      The Illinois Maternal Mortality Review Committee was convened in 2000 and reviews all pregnancy-associated deaths that were potentially related to pregnancy, excluding injury-related deaths. The Illinois Severe Maternal Morbidity committee convened in 2016. This review is done at the hospital level and is an effort to reduce maternal morbidity. Neither are protected with legislation.
      Although legislation was passed in 2008 requiring reporting of maternal deaths in Iowa, it does not specify that a maternal mortality review committee must exist, simply that an annual review must occur. As of February 2019, the Iowa Medical Society was tasked with the review. A second piece of legislation was passed in 2018 that is designed to ensure Iowa perinatal patients receive appropriate maternal and neonatal care as close to their homes as possible. This legislation mentions rural multiple times in the legislative language, but does not require representation, because it does not involve a maternal mortality review committee.
      § In 2018, Kentucky passed legislation that added maternal mortality review to their existing Child Fatality Review Team. Before 2018, a private medical society in Kentucky reviewed maternal deaths and did not issue public reports. However, the medical society did publish some analyses of Kentucky's maternal mortality in their own journal.
      Figure thumbnail gr1
      Figure 1Number of states and the District of Columbia with existing and/or legislated Maternal Mortality Review Committees, representation requirements, and rural representation requirement, by year.
      All 46 MMRCs review cases of maternal death with the goal of reducing rates of maternal mortality. Seventeen of the 46 states also specify reducing maternal morbidity as a goal. Five of those state MMRCs (Illinois, Indiana, Oregon, South Carolina, and Texas) take their analysis further and review cases of maternal morbidity, as well as cases of maternal mortality.
      Figure 2 shows an overview of the status of MMRCs across states, as of December 2018. It includes data on the establishment and legislation of committees, the prevalence of failed legislation (e.g., legislation that was proposed to either establish an MMRC or provide statutory protection and requirements of an existing MMRC but did not pass as of December 2018), as well as whether any representation was required, if rural populations were mentioned, and whether rural representation was specifically required in statute. As of December 2018, 7 states had introduced legislation that failed, 14 states required representation from a particular group, 3 states mentioned rural populations, and 2 states required rural representation.
      Figure thumbnail gr2
      Figure 2Status of state and the District of Columbia Maternal Mortality Review Committees (MMRCs) in the United States, as of December 2018. *Legislation that was proposed to either establish an MMRC or provide statutory protection and requirements of an existing MMRC but did not pass as of December 2018.
      The circumstances of failed attempts to pass MMRC legislation vary by state. Seven states (Arkansas, California, Colorado, Missouri, New Jersey, New Mexico, and New York) had proposed legislation between 2015 and 2018 that did not pass by December 2018. All of these states, except for Arkansas, have existing nonlegislated MMRCs. For example, Missouri, New Jersey, and New York all had proposed or pending legislation at the time of this analysis. Missouri legislators introduced legislative protections and changes to their existing MMRC in 2018 that would have required reviews of maternal deaths as well as cases of severe maternal morbidity. The legislation would have also required representation for certain groups, including patient and community health advocates (rural representatives were not specifically mentioned), but the bill did not make it out of committee. New Jersey's legislature has proposed an MMRC bill that is currently pending; this legislation would provide legal protection, require reporting, require representation of certain groups (although rural representation would not be required), and include the explicit goal of reducing or eliminating racial and other disparities. New York has pending legislation stating their MMRC members should include individuals “who serve and are representative of the diversity of the women and mothers in medically underserved areas of the state or areas…with disproportionately high occurrences of maternal mortality or morbidity,” implying, but not explicitly stating, a requirement that rural communities be represented. Many states continue to engage in legislative action regarding MMRCs.
      We also looked specifically at MMRCs in highly rural states, defined as those with 30% or more of the state's population living in non-metropolitan areas (Figure 3). Of these 18 highly rural states, 6 states had MMRCs in 2010 with 3 legislated, and in 2018, 14 had MMRCs with 11 of these being legislated. Only 5 of the 11 highly rural states with legislated MMRCs required any type of representation, and none of them required rural representation. Four highly rural states did not have MMRCs in place (Arkansas, North Dakota, South Dakota, and Wyoming). In 2017, Arkansas announced the formation of an interim team to review maternal mortality, with the potential to develop an MMRC. As of December 2018, the Arkansas Department of Health was still in the planning stages for this task. Two highly rural states (North Dakota and Wyoming) had no legislative history regarding maternal morbidity and mortality. The fourth highly rural state (South Dakota) had legislation supporting the analysis of maternal mortality, but only as it related to abortion.
      Figure thumbnail gr3
      Figure 3Highly rural states* and the status of state and the District of Columbia Maternal Mortality Review Committees in the United States, as of December 2018. *Highly rural states defined as those with 30% or more of the population residing in rural communities, as of 2010 Decennial Census, U.S. Census Bureau (
      • U.S. Census Bureau
      2010 Census urban and rural classification and urban area criteria.
      ).

      Discussion

      This analysis of state maternal morbidity and mortality review efforts and policies revealed increasing attention to, and statutory support for, MMRCs, which together constitute the primary infrastructure for understanding patterns of maternal deaths in communities across the country (
      • Building U.S. Capacity to Review and Prevent Maternal Deaths
      Report from nine maternal mortality review committees.
      ,
      • Lu M.C.
      Reducing Maternal Mortality in the United States.
      ,
      • Zaharatos J.
      • St. Pierre A.
      • Cornell A.
      • Pasalic E.
      • Goodman D.
      Building U.S. capacity to review and prevent maternal deaths.
      ). In 2010, 23 states had established MMRCs; this number doubled by 2018. However, to date, MMRCs have had a limited focus on rural residents and their unique health care needs and challenges during pregnancy through 1 year postpartum. In 2018, maternal mortality review was near universal across the United States, with MMRCs established in 45 states and the District of Columbia, yet four of the five states without MMRCs are highly rural. Only three state MMRCs (Iowa, Pennsylvania, and Texas) explicitly mention rural residents, with only two of those (Pennsylvania and Texas) requiring rural representation on the states’ MMRCs.
      In other nations, having a robust data collection and analysis infrastructure for maternal morbidity and mortality has supported improvements in health. For example, in the U.K., there has been a maternal death review process since 1954 (the longest running such process anywhere in the world), and it has supported recent efforts to address maternal health, resulting in a decline from 11 maternal deaths per 100,000 live births in 2008 to 9 in 2015 (“
      • Maternal, newborn, child and adolescent health
      Maternal and perinatal death reviews in the UK.
      ,
      • The World Factbook
      Country comparison maternal mortality rate.
      ). This population-level strategy was supported by data from the careful and systematic review of each mortality and near-mortality case and efforts to improve processes in response.
      In total, 90% of all states have MMRCs, but only 78% of highly rural states do so. This may be due, in part, to resource constraints within more rural states. On average, these states have smaller populations, meaning fewer births and incidences of maternal morbidity and mortality to review, as well as more limited resources to support maternal mortality review efforts. Additionally, not all state legislatures operate in the same way, because more rural states generally have part-time, rather than full-time, legislators and may be less likely to have substantial legislative staff support (
      • National Conference of State Legislatures
      Full- and part-time legislatures.
      ). This factor may constrain these states’ ability to quickly respond to emerging issues and needs.
      The lack of attention to rural residents in state MMRCs is troubling, given higher rates of infant mortality in rural areas (
      • Ely D.M.
      • Driscoll A.K.
      • Mathews T.J.
      Infant mortality rates in rural and urban areas in the United States, 2014 key findings data from the National Vital Statistics System.
      ) and more limited access to maternity-related health care services, including recent closures of rural hospitals and rural obstetric units (
      • Hung P.
      • Henning-Smith C.E.
      • Casey M.M.
      • Kozhimannil K.B.
      Access to obstetric services in rural counties still declining, with 9 percent losing services, 2004-14.
      ,
      • The Cecil G. Sheps Center for Health Services Research
      95 Rural hospital closures: January 2010-present.
      ). Rural residents, on the whole, are less likely to obtain recommended preventive care than urban residents (
      • Casey M.M.
      • Thiede Call K.
      • Klingner J.M.
      Are rural residents less likely to obtain recommended preventive healthcare services?.
      ,
      • Loftus J.
      • Allen E.M.
      • Call K.T.
      • Everson-Rose S.A.
      Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans.
      ), largely owing to the higher rates of people being uninsured and greater constraints on access to care. These factors may have a significant impact on outcomes for maternal and infant health, and more research and policy attention is urgently needed to reverse the trend of rising maternal morbidity and mortality in communities across the United States (
      • Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      ,
      • Centers for Disease Control and Prevention
      Pregnancy mortality surveillance system.
      ). Maternal and infant health risks are higher among rural residents, including for hospitalization with complications during pregnancy, preterm birth, low birth weight, and infant mortality (
      • American College of Obstetricians and Gynecologists
      Health disparities in rural women. Committee Opinion No. 586.
      ). Where populations are sparse, it is difficult to detect patterns unless data are routinely collected and analyzed. It is particularly important that data are analyzed separately for rural populations, to identify unique risk factors and opportunities for intervention, especially in states with large urban populations, where risks to rural residents might not be apparent in average statistics.

      Limitations

      In this study, we identified important state-level differences in the prevalence and scope of MMRCs, as it relates to their rural focus and representation. As with any study of this type, we were limited by the information available to us. We reviewed publicly available documents, and it is possible that more detail exists elsewhere on the exact history and composition of state MMRCs that we were unable to access for the purposes of this study. Further, this study examined the prevalence of MMRCs, but not the mechanics of how they operate. Although they may exist in statute, this fact alone does not guarantee that MMRCs are actively meeting or making recommendations that will have an impact (
      • Kozhimannil K.B.
      • Hernandez E.
      • Mendez D.D.
      • Chapple-McGruder T.
      Beyond the Preventing Maternal Deaths Act: Implementation and further policy change.
      ).

      Implications for Practice and/or Policy

      Rural perspectives could strengthen the work of MMRCs. One of the greatest assets of MMRCs is their capacity to make recommendations and identify opportunities for prevention (
      • Review to Action
      What makes maternal mortality review unique?.
      ). Examining maternal mortality through a rural perspective to identify how needs and resources vary from those in urban settings would help to inform prevention planning and activities. Rural inclusion and representation on MMRCs would also help to identify quality issues that have an impact on performance measure results and contribute to quality improvement efforts. MMRCs are an essential structural element at the state level to contribute to efforts to comprehensively address the issue of maternal mortality, but rural representation in the design and implementation of MMRCs is needed to ensure that the unique needs and constraints of rural areas are taken into account. Policymakers at the state and federal levels should consider ways to provide funding and other resources (e.g., travel and meeting support, facility space) to make rural representation possible, especially in resource-constrained rural states and communities.
      In addition to efforts around MMRCs, other work is urgently needed to ensure that rural residents have access to care and that they experience healthy outcomes during pregnancy, childbirth, and the postpartum period. The federal Improving Access to Maternity Care Act, passed in December 2018, is a meaningful step forward in addressing some of the obstetric workforce issues that contribute to poorer access to care among rural residents. The federal Rural MOMs Act, which was introduced in Congress in the fall of 2018, would provide support for data, training, technology, and funding for rural residents and providers to improve pregnancy and childbirth outcomes. More funding and resources are needed at the federal and state levels to address rural infrastructure, including facilities, transportation, and technology needs, as they relate to maternity care and other aspects of health. Although the Rural MOMS Act did not pass in 2018, it will likely be reintroduced as legislative efforts to support rural maternal health continue.
      The issue of maternal morbidity and mortality is urgent and complex. It requires quick and thoughtful action on multiple fronts, including, but not limited to, MMRCs in every state, as well as required representation from rural stakeholders on each of those MMRCs. The increase in MMRC legislation and the recent passage of federal legislation to support MMRCs is warranted and welcomed, after the alarming increase in maternal mortality in the United States. However, disproportionate risk for poor maternal outcomes, especially among low-income, Black, and rural individuals, must be incorporated into structures and systems designed to address this crisis, to both reverse this trend and to improve equity.
      We recognize that states may be focusing on the needs of rural areas in MMRCs without having written such practices into law. More research is needed to fully understand both the composition of individual state MMRCs and how they operate. Other important aspects of the variability across MMRCs, including attention to racial equity, were beyond the scope of this analysis, but investigation of this topic is strongly recommended.

      Conclusions

      As the U.S. grapples with the development and implementation of policy efforts to decrease maternal morbidity and mortality, particular attention to the inclusion of rural areas is warranted. Ongoing federal and state policy discussions related to maternal health should pay explicit attention to addressing the unique needs and health challenges of rural residents by ensuring rural representation in MMRCs and in other policy-making and decision-making bodies. Our findings showed that few states currently require such representation within MMRCs. Greater focus on the inclusion and integration of rural voices and experiences in current and future policy efforts to improve maternal health outcomes is needed.

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      Biography

      Katy B. Kozhimannil, PhD, MPA, is Associate Professor, University of Minnesota School of Public Health and Director of the University's Rural Health Research Center. Her research contributes evidence for clinical and policy strategies to advance racial, gender, and geographic equity.
      Julia D. Interrante, MPH, is a doctoral student in the Division of Health Policy and Management at the University of Minnesota. Her work examines the effects of policies around reproductive health on maternal and child outcomes.
      Amanda Corbett, MPH, is a Research Fellow at the University of Minnesota Rural Health Research Center. Ms. Corbett is a qualitative researcher whose research interests include social determinants of health, population and community health, and maternal and family health equity.
      Sarah Heppner, MS, leads the Federal Office of Rural Health Policy's Policy Research Division. Her professional interests include using health services research to understand the impact of policies on access to care in rural communities and rural health disparities.
      Jennifer Burges, MPH, is a Public Health Analyst at the Federal Office of Rural Health Policy (FORHP). Ms. Burges is the program coordinator for the Rural Health Research Centers and coordinates the research focused programs within FORHP.
      Carrie Henning-Smith, PhD, MPH, MSW, is an Assistant Professor and Deputy Director of the University of Minnesota Rural Health Research Center. Dr. Henning-Smith uses quantitative and qualitative research methodologies to study policy-relevant issues for rural populations.