The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619
KATHLEEN E. WALSH
MAURA T. HEALEY Secretary
Governor
Robert Goldstein, MD, PhD
KIMBERLEY DRISCOLL Commissioner
Lieutenant Governor
Tel: 617-624-6000
www.mass.gov/dph
September 30, 2024
Steven T. James
House Clerk
State House Room 145
Boston, MA 02133
Michael D. Hurley
Senate Clerk
State House Room 335
Boston, MA 02133
Dear Mr. Clerk,
Pursuant to Section 4590-1503 Maternal and Child Health of the FY24 General Appropriations
Act (GAA), please find enclosed a report from the Department of Public Health entitled 2020-
2021 Report on Maternal Mortality in Massachusetts.
Sincerely,
Robert Goldstein, MD, PhD
Commissioner
Department of Public Health
2020-2021 Report on
Maternal Mortality in
Massachusetts
Title
July 2024
Date
(this page has intentionally been left blank)
Contents
Legislative Mandate ...................................................................................................................................... 5
Executive Summary ....................................................................................................................................... 6
Key Findings .................................................................................................................................................. 6
Recommendations ........................................................................................................................................ 6
Purpose ......................................................................................................................................................... 8
Maternal Mortality and Morbidity in the United States and Massachusetts ............................................... 8
Maternal Mortality Definitions ..................................................................................................................... 9
Inclusive language ....................................................................................................................................... 10
The Massachusetts Maternal Mortality and Morbidity Review Committee (MMMRC) ............................. 11
History of Maternal Mortality Review in Massachusetts ............................................................................ 11
Funding ....................................................................................................................................................... 11
The Maternal Mortality Review Process ..................................................................................................... 12
Frequency of committee reviews................................................................................................................ 14
Limitations................................................................................................................................................... 14
Findings ....................................................................................................................................................... 15
Overall Findings ........................................................................................................................................... 15
Findings by Sociodemographics .................................................................................................................. 16
Race/ Ethnicity .................................................................................................................................... 16
Age ...................................................................................................................................................... 16
Insurance ............................................................................................................................................. 16
Education ............................................................................................................................................ 16
County of Residence ........................................................................................................................... 16
Causes of Death .......................................................................................................................................... 18
Timing of Death........................................................................................................................................... 18
Pregnancy-Relatedness ............................................................................................................................... 20
Preventability of Deaths .............................................................................................................................. 21
Circumstances Surrounding Death and Manner of Death .......................................................................... 21
Conclusions and Recommendations ........................................................................................................... 22
Addendum: Maternal Mortality Review Committee and Team Members ................................................. 28
Current Committee Members ..................................................................................................................... 28
MDPH Contributors ..................................................................................................................................... 28
3
4
Legislative Mandate
The following report is hereby issued pursuant to 4590-1503 Maternal and Child Health of the
FY24 GAA as follows:
4590-1503 Maternal and Child Health
provided further, that not less than $350,000 shall be expended for the operations of and hiring
additional personnel for the Massachusetts maternal mortality and morbidity review committee
to enhance the committee's ability to comprehensively review deaths and complications that
occur during or within 1 year of pregnancy and make related remedial policy and practice
recommendations; provided further, that the committee shall convene regularly to encourage
consistent case review and reporting of findings and recommendations; provided further, that
the department of public health shall submit to the committee, in a timely manner, aggregated
and patient-level maternal morbidity and mortality data for review and utilization in developing
recommendations to improve perinatal and maternal health outcomes; provided further, that
not later than March 1, 2024, the committee shall submit a report to the joint committee on
public health, the house and senate committees on ways and means, the pregnancy and birth
equity task force of the Massachusetts caucus of women legislators and the commission on the
status of women on its findings and recommendations; provided further, that the department
shall publish the committee's report on its website.
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Executive Summary
Since 1997, the Massachusetts Department of Public Health (DPH) has convened the Maternal
Mortality and Morbidity Review Committee (MMMRC) to review maternal deaths, study the
incidence of pregnancy complications, and make recommendations to improve maternal
outcomes and eliminate preventable maternal deaths. This document fulfills the requirements
of Section 4590-1503 in the FY24 GAA.
The MMMRC, with support from the Maternal Mortality and Morbidity Review Team (MMMRT)
at DPH, uses various data sources to identify all deaths of people while pregnant or within a
year of the end of a pregnancy (pregnancy-associated deaths), regardless of the cause of death.
The MMMRC reviews the deaths to identify the cause of death, determine if the death was
pregnancy-related and/or preventable, identify contributing factors, and develop
recommendations to prevent future deaths.
Key Findings
• The MMMRC identified 73 pregnancy-associated deaths during 2020-2021, including 25
deaths determined to be related to pregnancy.
• Pregnancy-associated deaths, whether related to pregnancy or not, are not equally
experienced by all groups.
o The Massachusetts pregnancy-associated mortality ratio (PAMR), defined as
total number of pregnancy-associated deaths per 100,000 live births, was 53.8
overall, but was nearly twice as high for Black non-Hispanic people (93.8) as for
White non-Hispanic people (46.6).
o The overall pregnancy-related mortality ratio (PRMR), defined as the number of
pregnancy-related deaths per 100,000 live births, was 18.4, but was nearly twice
as high for Black non-Hispanic people (36.1) as for White non-Hispanic people
(18.1) and more than twice as high as for Hispanic people (14.1).
• Nineteen percent of the pregnancy-associated deaths occurred during pregnancy, 23%
occurred within 42 days after the end of pregnancy, and 58% percent occurred between
43 days and 1 year of the end of the pregnancy. Over half (60%) of pregnancy-related
deaths occurred from end of pregnancy to 42 days after the end of pregnancy
• Eighty-four percent of pregnancy-related deaths were considered preventable.
• Discrimination contributed or probably contributed to 44% of pregnancy-related deaths.
• Mental health conditions also contributed or probably contributed to 44% of pregnancy-
related deaths, while substance use disorder contributed or probably contributed to
more than half (56%) of pregnancy-related deaths.
• Lack of care continuity and coordination were the largest contributing factors, impacting
almost half (48%) of pregnancy-related deaths.
Recommendations
Based on their review of the 25 pregnancy-related deaths in 2020-2021, the MMMRC
developed specific, actionable recommendations. These recommendations fall within the
following general categories: increasing the availability and quality of autopsy information for
MMMRC reviews; supporting efforts to promote and ensure respectful and trauma-informed
6
perinatal care; supporting efforts to improve continuity and coordination of care; and
promoting and supporting integrated and risk-appropriate maternal care.
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Purpose
The purpose of this report is to describe the work of the Massachusetts Maternal Mortality and
Morbidity Review Committee (MMMRC), to provide an update on findings from MMMRC
reviews of pregnancy-associated deaths occurring in 2020 and 2021, and to present a summary
of recommendations from the MMMRC.
Maternal Mortality and Morbidity in the United States and
Massachusetts
Pregnancy-related death, defined as death while pregnant or within one year of the end of
pregnancy from a cause related to or aggravated by pregnancy, has been increasing in the
United States in recent decades. The CDC’s Pregnancy Mortality Surveillance System ,which
monitors the rate of pregnancy-related deaths nationally, shows an increase from 7.2 deaths
per 100,000 live births in 1987 to 17.6 deaths per 100,000 live births in 2019 (the latest
pregnancy-related data available nationally). 1 PMSS data reveal striking racial and ethnic
inequities in pregnancy-related deaths: during 2017–2019, the pregnancy-related mortality
ratios (PRMRs) stratified by race and ethnicity were: 62.8 deaths per 100,000 live births among
non-Hispanic Native Hawaiian or Other Pacific Islander persons; 39.9 deaths per 100,000 live
births among non-Hispanic Black persons; 32.0 deaths per 100,000 live births among non-
Hispanic American Indian or Alaska Native persons; 14.1 deaths per 100,000 live births among
non-Hispanic White persons, and 11.6 deaths per 100,000 live births among Hispanic persons.1
Pregnancy-associated deaths have similarly increased in Massachusetts in recent years.
Pregnancy-associated deaths, defined as deaths during pregnancy or within one year of the end
of pregnancy from any cause, ranged between 23 and 30 deaths per 100,000 live births during
2002-2011 in Massachusetts, but increased to more than 35 deaths per 100,000 live births
during 2016-2019. 2
Severe maternal morbidity (SMM) is defined as unexpected complications of labor and delivery
that result in significant short- or long-term consequences to the birthing person’s health. SMM
has increased nationally from 69.8 per 10,000 delivery hospitalizations in 2010 to 88.2 per
10,000 delivery hospitalizations in 2020.3 In 2020, the rate of SMM among Black, non-Hispanic
individuals was 139.0 per 10,000 delivery hospitalizations, almost twice the rate observed for
White, non-Hispanic individuals (69.9). A recent report from DPH demonstrated that SMM
nearly doubled in Massachusetts from 2011 to 2020, from 52.3 per 10,000 deliveries in 2011 to
1
Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System.
https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
2
Declercq ER, Cabral HJ, Liu CL, et al. Prior Hospitalization, Severe Maternal Morbidity, and Pregnancy-Associated
Deaths in Massachusetts From 2002 to 2019. Obstet Gynecol. Dec 1 2023;142(6):1423-1430.
doi:10.1097/aog.0000000000005398
3
Health Resources and Services Administration. Severe Maternal Morbidity: Trends and Disparities. Available at:
Severe Maternal Morbidity: Trends and Disparities (hrsa.gov).
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100.4 per 10,000 in 2020, an average increase of 8.9 percent a year. 4 Black non-Hispanic people
consistently experienced the highest rates of labor and delivery complications among all races
and ethnicities in Massachusetts. In 2011, the gap between SMM rates for Black non-Hispanic
and White non-Hispanic individuals was two-fold. By 2020, the SMM rate for Black non-Hispanic
people was 2.5 times higher than that of White non-Hispanic people, a 25 percent increase in
the gap over the decade.6
Definitions
The MA MMMRC uses the Centers for Disease Control and Prevention (CDC) definitions as
described in Review to Action. 5
• A pregnancy-associated death is a death during or within one year of pregnancy,
regardless of the cause or outcome of the pregnancy. These deaths make up the
universe of maternal mortality; within that universe are pregnancy-related deaths,
pregnancy-associated but not related deaths, and deaths that are pregnancy-associated
but undetermined if pregnancy-related. This is the number used as the numerator in the
calculation of the pregnancy-associated mortality ratio (PAMR).
• A pregnancy‐related death is a death during or within one year of pregnancy, from a
pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of
an unrelated condition by the physiological effects of pregnancy. Included within this, a
preventable pregnancy-related death is a pregnancy‐related death for which the
MMMRC determines there was at least some chance of the death being averted by one
or more reasonable changes to patient, family, provider, facility, system, or community
factors. This is the number used as the numerator in the calculation of the pregnancy-
related mortality ratio (PRMR).
• A pregnancy‐associated, but not related death is the death of a person during or within
one year of pregnancy, from a cause that is not related to pregnancy or exacerbated by
pregnancy.
• A pregnancy-associated, but unable to be undetermined if pregnancy-related death is
the death of a person while pregnant or within one year of termination of pregnancy
from a cause that cannot be determined or conclusively categorized by the MMMRC as
either pregnancy-related or not pregnancy related. For example, a person dies at six
months postpartum from a self-inflicted cause with an unknown mental health history.
4
Data Brief: An Assessment of Severe Maternal Morbidity in Massachusetts: 2011-2020.
https://www.mass.gov/doc/an-assessment-of-severe-maternal-morbidity-in-massachusetts-2011-2020/download
5
Review to Action: Working Together to Prevent Maternal Mortality. https://reviewtoaction.org/learn/definitions
9
As part of the review process, the MMMRC categorizes each pregnancy‐associated death into
one of the following sub‐categories as defined above (see Figure 1):
• Pregnancy‐related death
o Pregnancy‐related death that was preventable
o Pregnancy‐related death that was not preventable
• Pregnancy‐associated, but not related death
• Unable to determine pregnancy-relatedness of the death
Figure 1. Maternal mortality definitions
Inclusive language
To be more inclusive, accurate, and equity‐focused, we use gender‐neutral terms such as
“individuals” or “people” in this report wherever possible, rather than terms such as “women”
or “mothers.” Some of our terminology is still gendered, such as “maternal,” which is in the
review committee’s name and the larger field of this work. We include both “maternal” and
“perinatal” in the report. “Perinatal” refers to the period around pregnancy, birth, and
postpartum (or after pregnancy) and is most accurate not only for reasons of gender identity
inclusion, but also because it includes situations in which a pregnancy doesn’t end in a birth and
the pregnant person does not identify as a parent.