Case Review Process

Maternal Mortality Review | Case Review Process | Reports | To Learn More

Case Identification:teamworld

  1. Through the International Classification of Diseases (ICD), Tenth Revision, specifically those deaths identified with a cause code in the “pregnancy, childbirth and the puerperium” categories.
  2. By matching birth or fetal death certificate with maternal death certificate information, regardless of cause of death.
  3. By selecting cases where a Commonwealth of Virginia death certificate indicates the decedent was pregnant within three months of the death.  This is a check box on Virginia’s death certificate.

Records Collected:medicalrecords

  • Vital statistics (death certificates, birth certificates, fetal death records)
  • Prenatal records
  • Hospital records (outpatient and inpatient stays)
  • Other provider/specialist records: these records may be from preconception/family planning clinics, or primary care providers, etc
  • Autopsy reports and case findings from hospital, coroner, or other medical examiner
  • Police/investigative reports
  • Social services reports
  • Mental health records
  • Substance abuse treatment records
  • Medical transport records
  • Court records
  • News articles, where relevant

Team Review:team-gold

The Team reviews de-identified case summaries.  Team discussion and deliberation are governed by these values:

  • Multidisciplinary review
  • A public health approach
  • Retrospective review
  • Consensus decision-making

The Team collaboratively completes a Contributors to Mortality form.  This discussion includes the Team’s decision about the following primary dimensions of maternal deaths:

  • the underlying cause of death;
  • the preventability of the maternal death, which is broadly defined as a death that may have been averted by one or more changes in clinical care, facility infrastructure, community and/or systems response to patient factors;
  • the degree to which the death was pregnancy related;
  • factors that potentially contributed to the death;
  • recommendations for prevention and intervention.