Nearly all pregnancy-related deaths of Iowa residents between 2019 and 2021 were preventable, according to the most recent state Maternal Mortality Review Committee report.
The first report released by the committee in nearly four years reviewed 20 deaths that occurred during pregnancy or up to a year postpartum that it determined were “pregnancy-related,” meaning the pregnancy could be directly tied to the cause of death.
The committee found 19 of those deaths were preventable.
“It really feels like a really disheartening statistic,” said Stephanie Radke, the chair of the committee and an OB/GYN at University of Iowa Health Care. “What's important for people to understand is that when we evaluate a death, and we are having a conversation about preventability, it gets boiled down to a yes [or] no, but it's really more on a scale of like, ‘Was this possibly preventable? Was this likely preventable? Was this most certainly preventable?’”
According to the report, six deaths were due to infection, four deaths were due to hemorrhage, four deaths were due to an embolism and six deaths were from other conditions, like cancer, cardiovascular conditions or hypertension disorders.
They disproportionately affected women who are Hispanic and Black and on Medicaid, with the majority occurring postpartum.
Radke said the high rate of infection-related deaths and overall increase in maternal deaths in the report's time frame is likely due to the COVID-19 pandemic.
“We saw nationally, a big spike in maternal mortality in 2021 and in that year, nationally, I think 50% or close to it, of deaths were from infection nationwide,” she said. “And then early data available from 2022 and 2023 has suggested nationally that the rate of pregnancy-related death has gone back down, sort of back where we were … pre-pandemic.”
The report found Iowans of childbearing age have a higher prevalence of chronic and pregnancy-diseases, such as gestational diabetes and obesity, as well as tobacco use, compared to national figures, which can contribute to pregnancy complications.
It also looked at “pregnancy-associated” maternal deaths, where the deaths were not directly linked to the pregnancy, and found that of those 16 deaths, 15 were preventable.
The report is the first issued by Iowa’s committee since July 2021. The state’s previous report found all pregnancy-related deaths occurring between July 2018 and 2019 were preventable.
The role of maternal mortality committees
Most states have maternal mortality review committees, which are made up of professionals who do in-depth reviews of deaths involving pregnant and postpartum people to figure out any underlying systemic contributing factors and if they were preventable.
“It's what you don't learn just even putting the birth and a birth and a death certificate together,” said Kay Johnson, a policy consultant on child and maternal issues. ”What was the care process like? What kind of prenatal care did they get? Where did they get it? What conditions did they enter pregnancy with?”
The Centers for Disease Control and Prevention funds support for committees in 46 states, including Iowa.
Iowa’s committee started in 1970. It’s coordinated by the Iowa Medical Society (IMS) in partnership with the Iowa Department of Health and Human Services.
"They're really there to get under the hood and understand, are there opportunities here to make changes in the system?”Elisabeth Burak, a senior fellow at the Georgetown Center for Children and Families
The majority of Iowa’s 16 committee members listed on the most recent report are OB/GYNs and family practice physicians but also include the director of a hospital psychiatry residency program, a pathologist, an anesthesiologist and the violence prevention coordinator at Iowa HHS.
"They're really there to get under the hood and understand, are there opportunities here to make changes in the system?” said Elisabeth Burak, a senior fellow at the Georgetown Center for Children and Families. “Are there investment changes? Are there quality improvements, changes we can make to improve care for pregnant and postpartum women during this really vulnerable time and a family's life?”
The detailed reviews by these committees can help uncover issues leading to systemic changes that save lives, she said.
For example, maternal mortality review committee findings were behind the federal government’s decision in 2021 to offer states additional funding to extend their Medicaid postpartum coverage from 60 days to 12 months, Burak said.
In the most recent report, Iowa’s committee makes a number of recommendations directed at healthcare providers, facilities, systems and communities. They include increased screening for mood disorders, better guidelines for hemorrhage prevention and ensuring at a systemic level that “women of reproductive age have access to the full range of family planning services to support optimal pregnancy planning and timing.”
The report also recommends that providers should be more conscious of “patient-specific needs, including cultural, religious and social influences” and make sure they are aware of their own personal biases.
The recommendations are to make sure Iowa is in line with national standards of care, Radke said.
“We want to think about, are all of our facilities prepared to manage a catastrophic hemorrhage, an eclamptic seizure? And then in all facilities, are we really identifying risk factors?” she said.
The importance of timely reports
Since the U.S. Supreme Court’s Dobbs v. Jackson Women's Health Organization decision in 2022, which ended the constitutional right to abortion, maternal mortality review committees have had increased attention in states like Iowa that have severely restricted or banned abortion as a way to measure how abortion restrictions are affecting maternal health.
“These [committees] can do a lot to tell those stories about what are some preventable deaths that may have occurred because of the fear among the health care community or OB providers or others that they might be crossing a line,” Burak said.
In recent years, media reports have unearthed cases in Georgia and Texas of maternal deaths linked to medical providers’ hesitancy to provide abortion care for fear of violating state laws.
"Because while we're waiting, or while we're sitting on data, more babies and moms could be dying of preventable causes.”Kay Johnson, policy consultant on child and maternal issues
Some states with abortion restrictions, like Texas and Idaho, have moved to restrict or disband their committees, a move Burak said can impact the effort to reduce maternal deaths.
“That just puts us kind of in the dark, in terms of understanding more about what the state can do,” she said.
According to records obtained by IPR, Iowa’s committee has reviewed maternal deaths occurring through at least January 2023, but it could be years before it releases another report.
Robert Kruse, the state medical director, said the question of how often the committee plans to publish reports is part of an ongoing discussion.
“Our due diligence is ensuring de-identification of these [cases] to ensure that confidentiality is maintained,” he said.
Under the government reorganization law that the Iowa Legislature passed last year, Iowa’s maternal mortality review committee will soon move from an IMS subcommittee to a subcommittee under Iowa HHS’s newly formed state mortality review committee.
It’s a move Kruse expects will be completed in the next few months. He said the new subcommittee “would have the same kind of expertise that we've had under the previous maternal mortality review committee.”
It’s not unusual for smaller states, like Iowa, that have few maternal deaths, to choose to release a report every two or three years instead annually, Johnson said.
“When you have a really small number of deaths, it's very hard to not be transparent,” she said. “If three women died, and they're going to talk about it, it's going to be clear who they were.”
However, Johnson said, it’s still important states release information on maternal deaths on a timely basis.
"Because while we're waiting, or while we're sitting on data, more babies and moms could be dying of preventable causes,” she said.
