Improving outcomes:

Maternal
Mortality
IN PHILADELPHIA

Maternal Mortality in Philadelphia | 1

 We dedicate this report
to the memory of the
mothers who have been
lost, with sympathy and
respect for their families
and loved ones.

2 | Maternal Mortality in Philadelphia

TA B L E O F C O N T E N T S

Executive Summary........................................................................................................................2

About Maternal Mortality Review Committees....................................................................4

Maternal Mortality Data, 2013–2018..........................................................................................5

Pregnancy-associated Deaths...........................................................................................5

Pregnancy-related Deaths.................................................................................................10

Drug-related Deaths.............................................................................................................14

Maternal Mortality Progress Report........................................................................................ 17

Recommendations.........................................................................................................................18

Address root causes of health inequity in the health care system.................. 18

Tailor behavioral and mental health services to meet the specific

needs of pregnant and postpartum women..............................................................19

Improve access to preventive, preconception and prenatal care..................... 20

Direct more attention to the postpartum period.....................................................21

Heighten awareness of high-risk pregnancy and postpartum

complications in non-obstetric care settings.......................................................... 22

Strengthen coordination of services between health care

and social service settings.............................................................................................. 23

Build infrastructure to identify and support women with

history of intimate partner violence............................................................................ 24

Moving Forward..............................................................................................................................25

References..........................................................................................................................................25

Maternal Mortality in Philadelphia | 1

EXECUTIVE SUMMARY
Maternal mortality has gradually increased in the United States over the past 30 years, and has
more recently become a focus of national attention. Philadelphia has been a leader in addressing
maternal mortality by creating the nation’s first non-state-based Maternal Mortality Review
Committee (MMRC) in 2010. The Philadelphia MMRC gathers multidisciplinary stakeholders from
across the city in order to better understand the causes of maternal mortality and to provide
recommendations for policy and programmatic change.

The Philadelphia MMRC’s current In this report, maternal mortality Consistent with how the
report is based on aggregated data will be referred to as either cases self-identified, this report
from 110 deaths that occurred “pregnancy-associated” or refers to the population studied as
between 2013 and 2018. The “pregnancy-related” deaths. “pregnant and postpartum women.”
aim of this report is to describe Pregnancy-associated deaths However, we acknowledge not
the current state of maternal are any deaths that occur during all pregnant people identify as
mortality in Philadelphia and to or within one year of the end of women, and transgender and
highlight the Philadelphia MMRC’s a pregnancy. Pregnancy-related nonbinary birthing people may
recommendations to reduce it. deaths are a subset of those deaths face unique barriers in accessing
which are caused by, related to, quality health care.
or aggravated by the pregnancy or
its management.

2 | Maternal Mortality in Philadelphia

 KEY FINDINGS

PREGNANCY-RELATED DEATHS BEHAVIORAL HEALTH ACCIDENTAL OVERDOSES

Of the 110 pregnancy-associated Mental and behavioral health Accidental drug-related deaths,
deaths that occurred from issues played an important role which have risen dramatically
2013 to 2018, 26 (or 23.6%) were among the pregnancy-associated in Philadelphia, have also
determined by the Philadelphia deaths. Forty-five percent of the increased greatly among pregnant
MMRC to be pregnancy-related pregnancy-associated deaths and postpartum women.
deaths. had a history of mental health Deaths due to accidental drug
issues and 58% had a history of overdoses increased from 25%
a substance use disorder. of Philadelphia’s pregnancy-
HIGHER THAN AVERAGE associated deaths (from 2010 to
Philadelphia’s rate of pregnancy- 2016) to 39% (from 2017 to 2018).
related deaths from 2013 to 2018 PRENATAL CARE
was approximately 20 per 100,000 Twenty-one percent of women
live births, which is higher than who had a pregnancy-associated
the 2018 national rate of 17.4 per death did not any prenatal care.
100,000 live births. This is about 4 times higher than
the general pregnant population.

CAUSES
Forty-six percent of the
pregnancy-related deaths were
due to cardiomyopathies or other The pregnancy-associated deaths described in this report are just
cardiovascular conditions, 23% the tip of the iceberg when looking at the overall state of maternal
to embolisms (either amniotic health in Philadelphia. Significant racial inequities in maternal
or thrombotic), 12% to infectious
health outcomes demand attention to the underlying issues, which
processes, 8% to hemorrhage, and
12% to other causes.
could be accomplished by addressing implicit bias and systemic
racism. Making sure that pregnant and postpartum women
with cardiovascular conditions and substance use disorders are
RACIAL INEQUITY engaged in comprehensive care is important to reducing maternal
Racial inequities exist among mortality and morbidity in our city.
pregnancy-related deaths in
Philadelphia. Non-Hispanic Black Focus on these and other contributing factors is key to improving
women made up 43% of births
the maternal health outcomes for Philadelphia’s women.
in Philadelphia from 2013-2018
but accounted for 73% of the
pregnancy-related deaths.

Maternal Mortality in Philadelphia | 3

A B O U T M AT E R N A L M O R TA L I T Y R E V I E W C O M M I T T E E S

Traditionally, maternal mortality surveillance uses vital statistics Through a process of obtaining medical and social service
data, such as birth and death certificates, to look at trends and records, conducting family interviews (when possible), and
disparities in maternal mortality. While this method is generally gathering multidisciplinary members to discuss deaths, MMRCs
effective in identifying deaths, it can lack context and adequate can better identify and understand pregnancy-associated
details of the events surrounding the woman’s death. State and and pregnancy-related deaths as well as develop policy and
local Maternal Mortality Review Committees (MMRCs) were programmatic interventions to prevent future deaths.
developed to improve maternal mortality surveillance.

Philadelphia is the poorest of the nation’s ten largest cities, with about 26%
of its 1.58 million people living in poverty. About 22,000 Philadelphia women
The Case for give birth annually, with an average of four to five pregnancy-related deaths
each year. Despite having some of the finest academic medical centers in
a Maternal the nation, the city’s pregnancy-related death rate is above the national
Mortality Review average. Philadelphia sought to address this problem by creating its own
county-level MMRC. In October 2010, the Philadelphia MMRC brought
Committee together representatives from the six-remaining labor-and-delivery hospitals
in the city, along with members from city agencies and non-governmental
in Philadelphia organizations, in order to identify, track, and review its pregnancy-
associated deaths. This, in turn, has helped Philadelphia identify gaps in
local healthcare systems and community resources that have contributed
to pregnancy-associated deaths. The process has helped focus limited
resources to address these issues, with a goal of reducing maternal mortality
Pregnancy- and improving overall maternal health and well-being.
associated deaths:
Deaths that occur during or Since the creation of the Philadelphia MMRC, Philadelphia has gained
within one year of the end of knowledge and insight into the contributing factors of maternal mortality
a pregnancy, regardless of through its review of 185 pregnancy-associated deaths. Philadelphia’s MMRC
the outcome of the pregnancy
processes continue to be refined: from better and timelier identification of
or the cause or manner of the
birthing person’s death. pregnancy-associated deaths, to obtaining new sources of data and records,
to better methods for obtaining family interviews, and adding new team
Pregnancy- members with different perspectives and backgrounds.
related deaths:
A subset of pregnancy- The Philadelphia MMRC commits to further improving its maternal
associated deaths and are mortality surveillance through the implementation of the Maternal
“caused by, related to, or
aggravated by the pregnancy Mortality Review Information Application (MMRIA), a data collection
or its management.” system developed by the Centers of Disease Control and Prevention (CDC),
that standardizes data collection from MMRCs across the country and to
translating recommendations into action through the development of a
coordinated action team.

4 | Maternal Mortality in Philadelphia

OV E R A L L M AT E R N A L M O R TA L I T Y DATA: 2013–2018

Pregnancy-associated Deaths
The Philadelphia MMRC was formed in 2010, and it began by reviewing
pregnancy-associated deaths that occurred in 2009.

Between 2013-2018, there were Figure 1.1 Pregnancy-Associated Deaths of Philadelphia Residents, 2009–2018
110 pregnancy-associated deaths
30
of Philadelphia residents —
30
an average of 18 deaths per year.
25 26
25
25 26
25
20 22
22 20
20
18 20 18
15 17
18 18
17 15 15
15
15 15
10 11
10 11
5
5
0
0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
An average of 4.3 deaths per year Figure 1.2 General Categories of Pregnancy-Associated Deaths, 2009–2018
from 2013-2018 were determined
to be pregnancy-related. The 30
Philadelphia MMRC limited 30
the discussion of ‘pregnancy 25 9
relatedness’ to the natural 25 9
6
20 3 10
deaths (i.e. the medical cases), 6
3 1 10
opting not to postulate whether 20 7 6
6 1
deaths associated with drug 15 7 5 6 6 3
6 2
15 5 7 6
use, suicide, or homicide were 5 2 4 7 2
3 13 3
4 7
directly or indirectly linked to 10
5 21 2 4 7 3
4 3 13 7
4 1 6
the pregnancy.) 10 5 4 31 7
2 2 6
4 5 6 41
5 9 9 10 2
4 6 4 6 4 6
5 9 9 10 4 5 5
2 3 6
0 4 5 6 4 5
2 3
0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
OTHER (not related to pregnancy)
HOMICIDE
OTHER (notOR SUICIDE
related to pregnancy)
HOMICIDE OR SUICIDE
DUE TO DRUG USAGE
64 63
DUE TO DRUG USAGE
PREGNANCY-RELATED
64 63
PREGNANCY-RELATED
33 57
Maternal33
Mortality57
in Philadelphia | 5

Undetermined: 1
Undetermined:
Suicide: 6 1 1% Natural: 45
 7 6
6
5 pregnancy)
15 OTHER (not related to 6 3
2
7
HOMICIDE
5 2
OR SUICIDE 4 7 3 13
4
10 DUE TO DRUG USAGE1 4 3 7
PREGNANCY-ASSOCIATED DEATHS 2 6 64 63
PREGNANCY-RELATED 5 2 1
4 6 4
5 9 9 10
Accidental deaths are currently Figure 1.3 M
 anner of Death for 6
4 Pregnancy-Associated
5 (n=110) 6
4 Deaths, 2013–2018 5
2 33 3 57
the most common manner 0
for Philadelphia’s pregnancy- 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Undetermined: 1
associated deaths. Of the 52
Suicide: 6 (not related to pregnancy)
OTHER 1% Natural: 45
accidental deaths from 2013-2018
(not depicted), 71% were due to HOMICIDE
Homicide: 6 OR SUICIDE
5%
drug intoxication, 21% were due DUE TO DRUG USAGE 5%
Accident: 52 64 63
PREGNANCY-RELATED
to motor vehicle crashes, 4% were
due to fire, and 4% were 41%
due to other accidents. 33 57
Natural deaths, which include all
47%
non-injurious deaths due to a Undetermined: 1
disease or medical condition 1%
Suicide: 6 Natural: 45
(e.g. all infectious disease
Homicide: 6 5%
processes, all cancers, all
5%
cardiovascular diseases), are the Accident: 52
second most common manner
41%
for Philadelphia’s pregnancy- 60% 54%
associated deaths.
50% 59
47%
40%

Fifty-four percent of the Figure 1.4 T

30%  ime from End of Pregnancy until Death for Pregnancy-Associated Deaths,
23%
pregnancy-associated deaths 2013–2018 (n=110) 18%
from 2013 to 2018 occurred 20% 25
20
more than six weeks after the 10% 5%
end of pregnancy. 60% 6 54%
0
50% Undelivered/ 0–1 Days 2–42 Days 59 Days
43–364
still pregnant
40%

30% 15-19 20-24 25-29 30-34 35-39 40+

23%
18%
20% 25
PREGNANCY- 20
ASSOCIATED 7%
10% 18% 5% 27% 24% 16% 7%
DEATHS
6
0
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
still pregnant

ALL BIRTHS 7% 22% 28% 27% 13% 3%

15-19 20-24 25-29 30-34 35-39 40+

PREGNANCY-0% 20% 40% 60% 80% 100%

ASSOCIATED 7% 18% 27% 24% 16% 7%
DEATHS

BLACK* WHITE* ASIAN* OTHER* HISPANIC *Non-Hispanic

58%
ALL BIRTHS
PREGNANCY- 7% 22% 28% 27% 13% 3%
6 | Maternal Mortality in Philadelphia
ASSOCIATED 58% 31% 3% 8%
DEATHS

0% 20% 40% 60% 80% 100%

 40% 23%
30% 18%
20% 25
23%
30%
23% 18%
20
20%
10% 25 5% 18%
20% 25 20
6 PREGNANCY-ASSOCIATED DEATHS
10%
0 5% 20
10% 5%
Undelivered/ 6
0–1 Days 2–42 Days 43–364 Days
0 6
Figure stillCategories
1.5 Age pregnant for Pregnancy-Associated Deaths, 2013–2018 (n=110)
Fifty-two percent of the 0
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
pregnancy-associated deaths still pregnant
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
still pregnant
15-19 20-24 25-29 30-34 35-39 40+
occurred in women younger
than 30. Seven percent of the 15-19 20-24 25-29 30-34 35-39 40+
pregnancy-associated deaths 15-19 20-24 25-29 30-34 35-39 40+
PREGNANCY-
occurred in women 40 years and ASSOCIATED 7% 18% 27% 24% 16% 7%
PREGNANCY-
DEATHS
older, with none occurring in PREGNANCY-
ASSOCIATED 7% 18% 27% 24% 16% 7%
women over 44 years. ASSOCIATED
DEATHS 7% 18% 27% 24% 16% 7%
DEATHS

ALL BIRTHS 7% 22% 28% 27% 13% 3%

ALL BIRTHS 7% 22% 28% 27% 13% 3%

ALL BIRTHS 7% 22% 28% 27% 13% 3%
0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

BLACK* WHITE* ASIAN* OTHER* HISPANIC *Non-Hispanic

Non-Hispanic Black women Figure 1.6 R
 ace/Ethnicity of Pregnancy-Associated Deaths, 2013–2018 (n=110)
58%
accounted for 58% of the BLACK* WHITE* ASIAN* OTHER* HISPANIC *Non-Hispanic
PREGNANCY- *Non-Hispanic
pregnancy-associated deaths 58%BLACK* WHITE* ASIAN* OTHER* HISPANIC
ASSOCIATED
58% 58% 31% 3% 8%
from 2013 to 2018, even though PREGNANCY-
DEATHS
PREGNANCY-
ASSOCIATED 58% 31% 3% 8%
they accounted for approximately ASSOCIATED
DEATHS 58% 31% 3% 8%
43% of Philadelphia births during DEATHS
this same time period.
ALL BIRTHS 43% 26% 7% 6% 18%

ALL BIRTHS 43% 26% 7% 6% 18%

ALL BIRTHS 43% 26% 7% 6% 18%
0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

Seventy-five percent of women Figure 1.7 Insurance Status during Pregnancy of Pregnancy-Associated Deaths,
with pregnancy-associated 2013–2018 (n=110)
NONE: 7
deaths were known to have
Medicaid at the time of their NONE: 7
UNKNOWN:
NONE: 7 12 6%
pregnancy. It is important
UNKNOWN: 12 11% 6%
to note that for those women PRIVATE:
UNKNOWN: 9 12
6%
who died in the postpartum 11%
PRIVATE: 9
MEDICAID: 8% 11%
period (especially after 6 weeks PRIVATE: 9 82
postpartum), their insurance MEDICAID: 82 8%
MEDICAID: 82 8% 75%
status may have changed.
75%
75%

1ST TRIMESTER Maternal

2ND TRIMESTER 3RD TRIMESTER NONEMortality
UNKNOWN in Philadelphia | 7

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER NONE UNKNOWN

PREGNANCY- 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER NONE UNKNOWN
 MEDICAID: 82 8%
UNKNOWN: 12 6%
11% 75%
PRIVATE: 9

PREGNANCY-ASSOCIATED DEATHS 8%
MEDICAID: 82

75%
Thirty-two percent of all Figure 1.8 T
 iming of Prenatal Care Initiation of Pregnancy-Associated Deaths,
pregnancy-associated deaths 2013-2018 (n=76)
(≥28 weeks gestation) occurred in
women who started prenatal care 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER NONE UNKNOWN

late (third trimester) or not at all.

This compares to 14% of all women PREGNANCY-
who had a live birth in Philadelphia ASSOCIATED 37% 28% 11% 21% 3%
DEATHS
and had late or no prenatal care. 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER NONE UNKNOWN

PREGNANCY-
ASSOCIATED 37% 28% 11% 21% 3%
ALLDEATHS
BIRTHS 52% 29% 7% 5% 6%

0% 20% 40% 60% 80% 100%

ALL BIRTHS 52% 29% 7% 5% 6%
Fifty-eight percent of the women Figure 1.9 R
 eported History of Maternal Substance Use, Mental Health Diagnosis and
who suffered a pregnancy-associated Intimate Partner Violence in Pregnancy-Associated Deaths, 2013-2018
60%
0%
(n=110) 20% 40% 60% 80% 100%
death had a documented history of
50% Substance Use
substance use excluding tobacco.
58%
40% Mental Health
Forty-five percent of the women who 60% Diagnosis
suffered a pregnancy-associated 30% 45%
50% Substance Use
death had a documented history of
20% 58%
mental health diagnosis.
40% Mental Health Intimate Partner
Diagnosis Violence
10%
In 21% of the pregnancy-associated 30% 45% 21%
deaths, there was some form of 0%
documentation that the woman 20%
Intimate Partner
had experienced intimate partner Violence
10%
violence in her lifetime. 21%
0%
Information on substance use
history, mental health diagnosis, PERPETRATOR AND VICTIM: 26 24% NONE: 41
and intimate partner violence is 37%
often missing or underreported
so these numbers are likely an
VICTIM ONLY: 22 20%
underestimation of the true extent. PERPETRATOR AND VICTIM: 26 24% NONE: 41
19% 37%

PERPETRATOR
VICTIM ONLY: 22ONLY: 21 20%

19%

PERPETRATOR ONLY: 21

10
10

8 | Maternal Mortality in Philadelphia 9 9

8
8
10
6 10
 30% 45%

20%
Intimate Partner
10%
PREGNANCY-ASSOCIATED
ViolenceDEATHS
21%
0%
Sixty-three percent of the Figure 1.10 History with Child Protection Services, 2013-2018 (n=110)
pregnancy-associated deaths
occurred in women who had
a documented history with
Philadelphia’s child protection
services – either as an alleged PERPETRATOR AND VICTIM: 26 24% NONE: 41
victim of child abuse or neglect, 37%
as an alleged perpetrator of
child abuse or neglect, or both.
This information is mostly VICTIM ONLY: 22 20%
limited to non-expunged 19%
records known to Philadelphia’s
Department of Human Services,
PERPETRATOR ONLY: 21
so these numbers are likely
an underestimation of the
true extent.

10
10

9 9
8
8

6
6 6
5 5
4
4 4

3
2
2

0
2007* 2008* 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Cardiovascular 7
Cardiomyopathy 5
Amniotic Fluid Embolism 4
Infection 3
Hemmorhage 2
Thrombotic Embolism 2
Cerebrovascular Accident 0
Cancer 0
Anesthesia 0
Other 3
0 1 2 3 4 5 6 7

Maternal Mortality in Philadelphia | 9

35%
31%
30%
8
 0% 21%
0%

Pregnancy-related Deaths PERPETRATOR AND VICTIM: 26 24% NONE: 41

PERPETRATOR AND VICTIM: 26 24% 37%41
NONE:
Among the 110 pregnancy-associated deaths that occurred during 2013-2018, 26 were determined
37% to be pregnancy-related.
Pregnancy-related deaths are determined by an advisory team that is part of the Philadelphia MMRC. The Advisory Team is
VICTIM ONLY: 22 20%
comprised of ten current MMRC members, most of whom are health care providers 20%
working in the field of Obstetrics and
VICTIM ONLY: 22
Gynecology. The Advisory Team members were asked to look at each natural death (i.e., 19% medical deaths or deaths not due to
19%
an injury) and rank on a scale of 1 to 5 how likely they felt the death to be related to the pregnancy (1=very likely, 3=equivocal,
5=very unlikely). Scores from each Advisory Team member
PERPETRATOR were
ONLY: 21 added together, and deaths with an average score of less
than 3 got recorded as pregnancy-related. PERPETRATOR ONLY: 21

Pregnancy-related deaths Figure 2.1 Pregnancy-Related Deaths of Philadelphia Women, 2007–2018

decreased from an estimated
10
average of 9 per year (2007 to 10
10
2010) to 4.3 per year (2011 to 2018). 10
9 9
8
*2007 and 2008 numbers are estimates 9 8 9
8
based on initial surveillance and 8
death certificate information. The 6
pregnancy-associated deaths from 6 6
6
these years were never reviewed by 6 6
5 5
the Philadelphia MMRC. 4
4 5 4 5
4
4 4
3
2
2 3
2
2
0
0 2007* 2008* 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2007* 2008* 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Forty-six percent of pregnancy- Figure 12.2 Causes of Death for Pregnancy-Related Deaths, 2013-2018 (n=26)
related deaths were due to Cardiovascular 7
cardiomyopathies or other Cardiovascular
Cardiomyopathy 5 7
cardiovascular conditions, 23% AmnioticCardiomyopathy
Fluid Embolism 4 5
to embolisms (either amniotic Amniotic Fluid Embolism
Infection 3 4
or embolic), 12% to infectious Infection
Hemmorhage 2 3
processes, 8% to hemorrhage and Hemmorhage
Thrombotic Embolism 2
2
12% to other causes. Thrombotic Embolism
Cerebrovascular Accident 0 2
Cancer 0
Cerebrovascular Accident
Only one of the hemorrhage Cancer 0
Anesthesia
deaths was a peripartum
Other 0
Anesthesia 3
hemorrhage, and this occurred 33
Other 0 1 2 4 5 6 7
to a woman who belonged
0 1 2 3 4 5 6 7
to a faith-healing group (two
separate churches of a total of
35%
approximately 3,000 adherents in 31%
35%
Philadelphia who do not believe 30% 31%
8
in any medical care whatsoever). 30%
25% 23% 23% 8 23%
25% 23% 23% 23%
20% 6 6 6
10 | Maternal Mortality in Philadelphia 20% 6 6 6
15%
15%
10%
10%
 Thrombotic Embolism
Hemmorhage 2
Infection 3
Cerebrovascular Accident
Thrombotic Embolism 0 2
Hemmorhage 2
Cancer 0
Cerebrovascular Accident
Thrombotic Embolism 2
Anesthesia
Cancer 0 PREGNANCY-RELATED DEATHS
Cerebrovascular Accident 0
Other 0
Anesthesia 3
Cancer 0
Seventy-seven percent of Figure 2.3 T ime Other
from End0 0of Pregnancy
1 Until 3 3for Pregnancy-Related
2 Death 4 5 6
Deaths, 7
Anesthesia
pregnancy-related deaths 2013-2018 (n=26)
Other 0 1 2 33 4 5 6 7
occurred after delivery, with 23%
35% 0 1 2 3 4 5 6 7
occurring more than six weeks 31%
after the end of the pregnancy. 35%
30%
31%
8
30%
35%
25% 23% 23% 23%
8
31%
25%
30%
20% 23%
6 23%
6 23%
6
8
20%
25%
15% 6
23% 6
23% 6
23%
15%
20%
10% 6 6 6
10%
15%
5%
5%
10%
0%
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
0%
5% still pregnant
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
0% still pregnant
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
Thirty percent of pregnancy- Figure 2.4 A
 ge Categories
still pregnant of Pregnancy-Related Deaths, 2013–2018 (n=26)
15-19 20-24 25-29 30-34 35-39 40+
related deaths occurred in
women who were of advanced 15-19 20-24 25-29 30-34 35-39 40+
maternal age (i.e. 35 years old PREGNANCY- 15-19 20-24 25-29 30-34 35-39 40+
or greater). ASSOCIATED 8% 8% 23% 31% 15% 15%
PREGNANCY-
DEATHS
ASSOCIATED 8% 8% 23% 31% 15% 15%
PREGNANCY-
DEATHS
ASSOCIATED 8% 8% 23% 31% 15% 15%
DEATHS

ALL BIRTHS 7% 22% 28% 27% 13% 3%

ALL BIRTHS 7% 22% 28% 27% 13% 3%

ALL BIRTHS 7% 22% 28% 27% 13% 3%

0% 20% 40% 60% 80% 100%
0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

BLACK* WHITE* ASIAN* OTHER* HISPANIC *Non-Hispanic
Significant racial inequities Figure 2.5 Race/Ethnicity of Pregnancy-Related Deaths, 2013-2018 (n=26)
58% *Non-Hispanic
BLACK* WHITE* ASIAN* OTHER* HISPANIC
exist among pregnancy-related PREGNANCY-
58%
deaths in Philadelphia—Black ASSOCIATED BLACK* WHITE* ASIAN* OTHER*
73% HISPANIC 19% *Non-Hispanic
4% 4%
PREGNANCY-
DEATHS
women are 4 times more likely 58%
ASSOCIATED 73% 19% 4% 4%
to die from pregnancy related PREGNANCY-
DEATHS
ASSOCIATED 73% 19% 4% 4%
causes than White women. DEATHS
Non-Hispanic Black women
made up for 43% of live births ALL BIRTHS 43% 26% 7% 6% 18%
in Philadelphia but accounted ALL BIRTHS 43% 26% 7% 6% 18%
for 73% of the pregnancy-related
deaths from 2013 to 2018, as ALL BIRTHS0% 43%
20% 40% 26%60% 7% 6%
80% 18% 100%
compared to non-Hispanic 0% 20% 40% 60% 80% 100%
White women who made up
0% 20% 40% 60% 80% 100%
26% of Philadelphia births and MEDICAID: 15
accounted for 19% of pregnancy- NONE: 4 MEDICAID: 15
related deaths. 15%
NONE: 4 MEDICAID: 15
UNKNOWN: 1 Maternal Mortality in Philadelphia | 11
15%
NONE: 4 4%
UNKNOWN: 1
PRIVATE: 6 15%
4%
UNKNOWN:
PRIVATE: 6 1 58%
 ASSOCIATED 73% 19% 4% 4%
PREGNANCY-
DEATHS
ASSOCIATED 73% 19% 4% 4%
ALLDEATHS
BIRTHS 43% 26% 7% 6% 18%

PREGNANCY-RELATED DEATHS
0% 20% 40% 60% 80% 100%
ALL BIRTHS 43% 26% 7% 6% 18%
Fifty-eight percent of women Figure 2.6 I nsurance Status
ALL BIRTHS 43%of Pregnancy-Related Deaths,
26% 2013-2018 (n=26) 18%
7% 6%
with pregnancy-related deaths
0% 20% 40% 60% 80%15
MEDICAID: 100%
had Medicaid insurance, and
another 15% had no insurance NONE: 4 0% 20% 40% 60% 80% 100%
at the time of their pregnancy. 15%
UNKNOWN: 1 MEDICAID: 15
It is important to note that for
4%
those women who died in the NONE: 4 6 MEDICAID: 15
PRIVATE:
postpartum period (especially 15%
NONE: 4 58%
after 6 weeks postpartum), UNKNOWN: 1
15%
23%
4%
their insurance status may UNKNOWN: 1
PRIVATE: 6
have changed. 4%
PRIVATE: 6 58%
23%
58%
23%

Fifty-four percent of the Figure 2.7 P

 re-Pregnancy
UNDERWEIGHTBody Mass Index
NORMAL Status of OBESE
OVERWEIGHT Pregnancy-Related
UNKNOWN Deaths,
pregnancy-related deaths 2013-2018 (n=26)
occurred in women who were
PREGNANCY-
documented as obese in their 12% 15%NORMAL
RELATED UNDERWEIGHT 12% OVERWEIGHT 54%UNKNOWN
OBESE 7%
pre-pregnancy BMI, as compared DEATHS
UNDERWEIGHT NORMAL OVERWEIGHT OBESE UNKNOWN
to 25% of women who had a live
PREGNANCY-
delivery in Philadelphia from RELATED 12% 15% 12% 54% 7%
2013 to 2018. PREGNANCY-
DEATHS
RELATED 12% 15% 12% 54% 7%
DEATHS
ALL BIRTHS 4% 43% 24% 25% 4%

ALL BIRTHS0%
4% 20%43% 40% 60%
24% 80%
25% 100%
4%
ALL BIRTHS 4% 43% 24% 25% 4%

POSITIVE: 2 0% 20% 40% 60% 80% 100%

0% 20% 40% 60% 80% 100%

UNKNOWN: 2
Figure 2.8 HIV Status of Pregnancy-Related Deaths, 2013-2018 (n=26)
Eight percent of the Philadelphia
women who experienced a POSITIVE: 2

pregnancy-related death were NEGATIVE:

POSITIVE: 222 8% 8%
known to be HIV+. This is UNKNOWN: 2

multiple times more than the UNKNOWN: 2

overall perinatal HIV rate in NEGATIVE: 22 8% 8%
Philadelphia (0.03% of live births NEGATIVE: 22 8% 8%
from 2013 to 2017). 85%

85%
85%

Good chance
12 | Maternal Mortality in Philadelphia
8% of death being
preventable
Good chance
Little or 8% of death being
 UNDERWEIGHT NORMAL OVERWEIGHT OBESE UNKNOWN

PREGNANCY-
RELATED 12% 15% 12% 54% 7%

Preventability of DEATHS

Pregnancy-Related Deaths
A critical role of the MMRC ALL
is determining
BIRTHS 4% the preventability
43% of each24%
pregnancy-related
25% 4%

death. Understanding which deaths could have been prevented allows for the gaps in
care and community resources to be 0% addressed.
20% The Philadelphia
40% MMRC
60% determines
80% 100%

if a pregnancy-related death could have been prevented through its Advisory Team.
The Advisory Team members are asked to look at each pregnancy-related death and
POSITIVE: 2

rank on a scale of 1 to 3 their opinion about the likelihood that the health care system
UNKNOWN: 2
could have altered the outcome of death (1= good chance, 2=some chance, and 3=little
to no chance). Scores from each22Advisory Team member
NEGATIVE: 8% are
8% added together, and the

average score determines the team’s opinion about the degree of preventability for each
pregnancy-related death.

85%

Based on the comprehensive review Figure 2.9 Preventability of Pregnancy-Related Deaths, 2013-2018 (n=26)
of the 26 pregnancy-related deaths
between 2013-2018, the Philadelphia
MMRC determined that 46% of the Good chance
deaths had little or no chance of 8% of death being
having the outcome altered, 46% were preventable
deemed as having some chance of
preventability, and 8% had a good Little or
no chance
chance of the death being preventable Some
by the health care system. 46% chance
46%

15

Maternal Mortality in Philadelphia | 13

12 13
 85%

Drug-related Deaths
Good chance
8% of death being
preventable
Good chance
8%
The Philadelphia MMRC considers drug-related deaths to be a subset Little or
of pregnancy-associated of death
deaths, but one being
in which
no chance preventable
‘pregnancy-relatedness’ is not determined. Drug-related deaths include all deaths that were caused directly by
Some drug use –
46% chance
whether due to the sequelae of drug use (e.g. endocarditis) or the result of an acute, accidental overdose.
Little or 46%
no chance Accidental drug-related deaths have risen
Philadelphia has been one of several epicenters of the nation’s opioid epidemic. Some
dramatically in Philadelphia over the past decade (from 387 in 2010 to46%
1150 in 2019) and have also increased greatly among
chance
pregnant and postpartum women. 46%

Between 2009 and 2016, Figure 3.1 Drug-Related, Pregnancy-Associated Deaths of Philadelphia Women,
accidental drug overdoses 2009–2018
accounted for 25% of pregnancy-
15
associated deaths. This
increased to 39% between
2017-18. Preliminary data from 12
15 13
2019 and early 2020 suggest that
this upward trend is continuing
persistently. 129 13

69 7
6 6
5
4 4 4 7
63
6 6
1 2
5
03 4 4 4
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
1 2
0
Sixty-six percent of drug-related Figure 3.2 Time
2009 2010from2011
End of Pregnancy
2012 Until Death
2013 2014 for 2015
Drug-Related,
66%Pregnancy-
2016 2017 2018
deaths occurred after the Associated Deaths, 2013-2018 (n=38)
25
25
traditional 6 weeks postpartum
20 66%
period.
25 6
15 25
20 26%
10 6
15 10
5 26% 8%
10 0 3
0 10
5 Undelivered/ 0–1 Days 2–428%
Days 43–364 Days
still pregnant
0 3
0
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
still pregnant
BLACK* WHITE* OTHER* HISPANIC *Non-Hispanic

DRUG-RELATED,
14 | Maternal Mortality in Philadelphia
PREGNANCY- BLACK* WHITE* OTHER* HISPANIC *Non-Hispanic
ASSOCIATED 42% 47% 3% 8%
DEATHS
DRUG-RELATED,
 15
20 26%
10 6
15 10
5 26% 8% DRUG-RELATED DEATHS
10
10 0 3
0
5 8%
Undelivered/ 0–1 Days 2–42 Days 43–364 Days
still pregnant 0 3
From 2013 to 2018, non- Figure
0 3.3 Race/Ethnicity of Drug-Related, Pregnancy-Associated Deaths, 2013-2018
Hispanic White women ages Undelivered/ 0–1 Days 2–42 Days 43–364 Days
15 to 49 (women of childbearing still pregnant
age) were more than 2.5 times BLACK* WHITE* OTHER* HISPANIC *Non-Hispanic
more likely to die from accidental
drug overdoses in Philadelphia DRUG-RELATED,
PREGNANCY- BLACK* WHITE* OTHER* HISPANIC *Non-Hispanic
than non-Hispanic Black 42% 47% 3% 8%
ASSOCIATED
women of childbearing age. DEATHS
DRUG-RELATED,
However, among the drug- PREGNANCY-
ASSOCIATED 42% 47% 3% 8%
related, pregnancy-associated
DEATHS
deaths during this same time
period, non-Hispanic White DRUG-RELATED
DEATHS IN
and Black women died in 24% 65% 10%
WOMEN OF
nearly equal proportions. CHILDBEARING
DRUG-RELATED
AGE
DEATHS IN
WOMEN OF 24% 65% 10%
CHILDBEARING0% 20% 40% 60% 80% 100%
AGE

0% 20% 40% 60% 80% 100%

Seventy-nine percent of Figure 3.4 Insurance Status of Pregnancy-Associated, Drug-Related Deaths of

the women who experienced Philadelphia Women, 2009–2018 (n=38) MEDICAID:30

a drug-related death had UNKNOWN: 5

Medicaid at the time of their 13%
NONE: 2 MEDICAID:30
pregnancy. It is important to 5%
UNKNOWN:
PRIVATE: 1 5
note that for those women 3% 13%
who died in the postpartum NONE: 2
5% 79%
period (especially after 6 weeks PRIVATE: 1
postpartum), their insurance 3%
status may have changed. 79%

Opioids 87%

Benzo
Opioids 61% 87%

Benzo
Cocaine 37% 61%

2 Cocaine
or more 37% 74%

0% 20% 40% 60% 80% 100%

2 or more 74%Mortality in Philadelphia | 15
Maternal

0% 20% 40% 60% 80% 100%

 3%

79% MEDICAID:30
UNKNOWN: 5
DRUG-RELATED DEATHS 13%
NONE: 2
5%
PRIVATE: 1
Among the 38 drug-related Figure 3.5 Toxicology 3%
Results of Drug-Related, Pregnancy-Associated Deaths, 2013-
deaths between 2013-2018, 2018 (n=38)
79%
toxicology reports showed
74% of the women had two or
more drug classes (opioids,
benzodiazepines, cocaine) Opioids 87%
detected concurrently in their
post-mortem toxicology. Benzo 61%

Cocaine 37%
Opioids 87%

2 or more 74%
Benzo 61%

0% 20% 40% 60% 80% 100%

Cocaine 37%

87%
2 or more
47% 61%26% 74%24% 37%
of these women had at least of these women had at least of these women had cocaine
one0%opioid in their20%
system at one benzodiazepine
40% 60% in their 80%in their post-mortem
100%
the time of their death. post-mortem toxicology toxicology
FENTANYL HEROIN OXYCODONE

47% 26% 24%

FENTANYL HEROIN OXYCODONE

When looking more specifically at the different types of

opioids found in women who died from a drug-related death
(not depicted in the graph above), 47% of these women had
fentanyl in their system at the time of death, 26% had heroin,
and 24% had oxycodone (18% had more than one type of
opioid found concurrently in the toxicology results).

16 | Maternal Mortality in Philadelphia

Maternal Mortality
PROGRESS REPORT
The Philadelphia MMRC proposed multiple The Check and Connect Opiate Education Work Group,
recommendations to address maternal mortality and which includes the Health Federation of Philadelphia,
morbidity in its first report (released in 2015), even though the Perinatal Centers of Excellence (state-funded
there was no dedicated funding or formal system in place medication-assisted treatment programs for pregnant
and postpartum women led by Jefferson’s MATER
at the time to drive these recommendations. Since then,
program, Penn’s Mothers Matter and Temple’s WEDGE
both well-established and newly developed maternal child
program), and the Philadelphia MMRC, developed a
health collaboratives have been addressing the 2015
citywide educational program focused on screening
MMRC report’s recommendations. Numerous successful
and brief intervention for perinatal substance use for
initiatives have resulted from these collaboratives, all Philadelphia delivery hospitals and their perinatal
including the creation of a centralized referral system for care providers. Providers have reported that they are
home visiting services; a prenatal lab-sharing agreement learning to more effectively screen pregnant women
to facilitate health information exchange between all for behavioral health concerns and substance use
delivery hospitals; Medicaid reimbursement for immediate disorders, provide brief interventions, and ensure
postpartum long-acting reversible contraception (LARC); warm handoffs to behavioral health and medication-
and a citywide educational program focused on screening, assisted treatment services.
brief intervention, and referral to treatment (SBIRT) for
substance use disorders in pregnancy. Greater investment The Philadelphia Labor and Delivery Leadership Group
in collaborative preventive initiatives are needed to further (PLDLG), a work group developed as a result of the 2015
MMRC report, is comprised of labor and delivery directors,
develop innovative interventions that can improve how
nurse managers, and patient safety officers from each
women are cared for during pregnancy and postpartum.
delivery hospital. The PLDLG convenes monthly to
improve delivery-related maternal care in Philadelphia,
The Philadelphia Maternal and Infant Community and the collaborative receives organizational support
Action Network, a collective impact network led by from the PDPH to help carry out its goals, which include:
the three Healthy Start programs in Philadelphia, facilitating health information exchange through a
secured $1.3 million in funding from the William Penn prenatal lab sharing agreement, reducing maternal
Foundation to create a centralized intake and referral morbidity by sharing best practices related to labor, and
system to streamline access to home visiting services supporting implementation of immediate postpartum
for pregnant women and infants. LARC programs.

The Pennsylvania Maternal Mortality Review The Philadelphia LARC Coalition was prompted by
Committee was established in 2018 due to the collective the 2015 Philadelphia MMRC report recommendation
efforts and assistance from the Philadelphia MMRC, to remove financial barriers to access of long acting
the Pennsylvania Section of the American College reversible contraception (LARC) in the immediate
of Obstetricians and Gynecologists (ACOG) and state postpartum period. Title X providers, local medical
legislators. Five members of the Philadelphia MMRC schools, and public advocates facilitated changes in
are represented on the Pennsylvania MMRC. Pennsylvania Medicaid reimbursement in 2016 to remove
barriers and increase access to immediate postpartum
LARC insertion for Medicaid-insured women.

Maternal Mortality in Philadelphia | 17

RECOMMENDATIONS
While maternal mortality surveillance Examining how to address these During each MMRC meeting, PDPH
using vital statistics data captures contributing factors is a relatively staff recorded recommendations
trends and disparities, state and local new area of scientific inquiry and developed in response to each case,
MMRCs comprehensively examine oftentimes, there are no established and several themes emerged from
a full range of contributing factors evidence-based practices or guidelines this extensive case review process.
across many sectors. to implement. Rather, MMRCs are Based on these themes coupled
tasked to use the review process with surveillance data and relevant
and their subject matter expertise peer-reviewed research, the MMRC
and experience to develop new recommends the following:
recommendations.

1
Address root causes of health inequity in the health care system.
Non-Hispanic Black women are
about four times more likely to
» P
 DPH plans to continue to invest in women of color-led community-
based organizations focused on promoting maternal health issues such
die of pregnancy related causes as mental health awareness and treatment and breastfeeding.
than non-Hispanic White women
in Philadelphia. Racial inequity in Specifically, the Philadelphia MMRC recommends:
maternal deaths is multifactorial and
is influenced by systemic racism » H
 ospitals should implement the Alliance for Innovation on Maternal
and discrimination for Black women Health (AIM) safety bundle focused on reduction of Peripartum Racial/
who access systems of healthcare. Ethnic Disparities.1
Equipping the health care system to
build a culture of equity will improve » T
 he Commonwealth of Pennsylvania should expand support to perinatal
the quality of care being offered to all quality improvement entities, including the Pennsylvania Quality Care
pregnant and postpartum women, Collaborative, for statewide education, training, and technical assistance
especially Black women, and thus addressing racial and ethnic inequities in maternal mortality.
improve maternal health overall.

18 | Maternal Mortality in Philadelphia

2
Tailor behavioral and mental health services to meet the specific
needs of pregnant and postpartum women.
Since 2017, accidental drug Specifically, the Philadelphia MMRC recommends:
overdoses have risen to nearly
half of all pregnancy-associated » Health care providers and hospital systems should:
deaths of Philadelphia women.
• Universally screen women using a validated questionnaire for
Furthermore, almost half of women
substance use disorder at the initial prenatal visit and upon
who died had a history of mental
presentation to labor and delivery.2,3
illness. During MMRC discussions
of these deaths, it was noted that • Create streamlined care coordination for pregnant women with
the current health care delivery substance use disorders, including the development of standardized
model for mental and behavioral protocols to facilitate referral for pain management and medication-
health services does not meet the assisted treatment.3
unique needs of pregnant women
and those with young families. • Adopt PDPH recommendations for safe prescribing of
Specifically, MMRC members often opioids to prevent new addiction.4
noted that there is a lack of mental
and substance use programs that are » The Commonwealth should:
easily-accessible, trauma-informed,
• Revise privacy laws to remove communication barriers between
and gender-specific in Philadelphia.
physical health and mental and behavioral health providers.

• Reduce barriers to integration of physical and behavioral health along

with social services for pregnant and parenting women.

Maternal Mortality in Philadelphia | 19

3
Improve access to preventive, preconception and prenatal care.
Thirty-two percent of all pregnancy » P
 DPH plans to establish a cardiology task force to make city-wide
associated deaths (≥28 weeks recommendations on enhanced care for women identified to be at
gestation) occurred in women high risk of cardiomyopathy or infarction.
who started prenatal care late
(third trimester) or not at all. Of all
The Philadelphia MMRC also recommends:
pregnancy-related deaths, 69% had
multiple medical co-morbidities » T
 he Commonwealth should simplify enrollment into Medicaid once
including obesity, HIV, hypertension pregnancy is established.
and other cardiovascular conditions,
renal disease, and diabetes that » Managed Care Organizations should:
contributed to pregnancy and
• 
Provide transportation and facilitate childcare services for pregnant
postpartum complications (data
women to reduce barriers for women seeking care.
not depicted).
• 
Reimburse for doula and community health worker services
The MMRC medical advisory to support women in the perinatal period.7
committee determined that up to
54% of pregnancy related deaths » Health care providers should:
could have been prevented by the • 
Adopt a patient centered framework such as “One Key Question” to
health care system to some extent. routinely assess pregnancy intention and goals and offer personalized
Optimization of chronic medical counseling and care based on response8
conditions prior to pregnancy
through regular preventive care • 
Follow best practices in engaging women in effective gestational weight
visits and early diagnosis of gain counseling and tobacco cessation during pregnancy.
pregnancy complications through
consistent access to prenatal » P
 renatal care sites should modify policies so that women can initiate
care are essential in preventing prenatal care at any gestational age.
similar deaths and reducing severe
maternal morbidity. Studies5,6
have demonstrated that barriers
to accessing prenatal care include
lack of access to transportation,
health insurance, and childcare,
as well as perceived discrimination
and poor social supports.

20 | Maternal Mortality in Philadelphia

4
Direct more attention to the postpartum period.
Fifty-four percent of pregnancy- Currently, women with Medicaid Therefore, it’s possible that many
associated deaths occurred after lose their insurance 60 days after women who died more than 60 days
the traditional six-week postpartum delivery. Of all pregnancy associated after delivery did not have access
period, a time when women of deaths, 75% of women had Medicaid health insurance. It is important for
limited resources often lose access and 6% had no insurance at the time the health care and health insurance
to services such as housing, health of their pregnancy. An analysis of fields to redefine the postpartum
insurance, family support programs the 2005–13 Medical Expenditure period as a continuum rather than as
and subspecialty medical care. This Panel Survey found that prior to a defined six-week period. Supporting
percentage was even higher (66%) implementation of the Affordable policy changes, including continued
with the drug related deaths. Care Act (ACA), nearly 60 percent access to health insurance,
of pregnant women experienced medication-assisted treatment
a month-to-month change in programs and other support services
insurance type in the nine months will allow this clinical shift to occur.
leading to delivery, and half were
uninsured at some point in the six
months following birth.9

Specifically, the Philadelphia MMRC recommends:

» The Commonwealth should:

• 
Extend Medicaid eligibility for the postpartum period from 60 days to one year after delivery. 10
• 
Pass legislation establishing paid parental leave, including maintenance of full benefits and 100% pay
for at least 6 weeks after delivery.11

» Managed Care Organizations should:

• 
Reimburse for home visiting and community health worker services in order to engage women with
family support programs and medical care with increased frequency in the first year following delivery.
• 
Reimburse for remote hypertension monitoring programs such as Heart Safe Motherhood.12

» Health care providers should:

• 
Individualize postpartum care timing and content based on medical and social determinants of health.13
• 
Establish at a minimum, a six-month postpartum visit for women to include substance use disorder
and depression screening, weight management, contraception counseling, and medical follow-up of
any pregnancy complications (e.g. diabetes and hypertension).13

Maternal Mortality in Philadelphia | 21

5
Heighten awareness of high-risk pregnancy and postpartum
complications in non-obstetric care settings
Thirty-seven percent of the women » P
 DPH plans to educate community-based home-visiting and family-
who suffered a pregnancy-associated support programs on early warning signs of maternal morbidity to ensure
death interacted with the medical timely referral for clinical treatment.
system in the month prior to their
death (data not depicted). Unclear
Additionally, the Philadelphia MMRC recommends:
policies and practices for identifying
and treating pregnant and » H
 ospitals should establish clear policies for emergency departments
postpartum women for substance to seek immediate Obstetric consultation for pregnant and postpartum
use, depression, domestic violence, women (up to a year post-pregnancy) who present with specific
and well-established pregnancy and symptoms that may suggest complications.
post-partum complications can also
contribute to poor health outcomes.
» N
 on-obstetric care providers should address family planning
Postpartum complications, such
considerations associated with high-risk pregnancy and provide
as peripartum cardiomyopathy,
timely referral to family planning services.
are not well understood by the
general public—leading to missed
opportunities for prevention during
the key “fourth trimester” period.

22 | Maternal Mortality in Philadelphia

6
Strengthen coordination of services between health care and social
service settings.
Many opportunities exist for Specifically, the Philadelphia MMRC recommends:
preventing maternal mortality
» Health care providers should:
through strengthened care
coordination between health • 
ensure that postpartum and primary care visits as well as appointments
care and social service settings, for relevant specialties (for example, cardiology, psychiatry) are
specifically in the postpartum scheduled prior to discharge from the hospital.13
period. Improved care coordination • 
universally screen women for unmet social needs during prenatal care.15
between the inpatient and outpatient
setting will allow for reduction » H
 ospitals, clinics, and community health centers should work with
in uncoordinated services and community based home visiting programs and mental and behavioral
improved health across a woman’s health centers to ensure that comprehensive follow-up and care
life course. There is an agreement coordination occurs—particularly for those women at high risk for
amongst MMRC members that a lack complications due to chronic medical health conditions and behavioral
coordination of services for pregnant health issues.
and postpartum women considerably
undermine efforts to reduce » H
 ospitals and Managed Care Organizations should work together to
maternal mortality and morbidity in offer collaborative prenatal and postpartum care coordination and case
the Philadelphia community. This management services.
observation is consistent with other
MMRCs across the country.14 » T
 he Commonwealth should develop infrastructure so that all women are
offered short-term home visiting services in the postpartum period.16

Maternal Mortality in Philadelphia | 23

7
Build infrastructure to identify and support women with history of
intimate partner violence.
Twenty-one percent of pregnancy- They are also at greater risk for Additionally, there is a long-standing
associated deaths had a history of further violence, death due to history of intimate partner violence
intimate partner violence (IPV). IPV abuse compared to non-pregnant nonprofits partnering with medical
is a pattern of behaviors used to gain women, and are more likely to providers to provide counseling,
power and control over a partner or report substance abuse, depression, advocacy and crisis intervention
ex-partner. IPV, also called domestic and other adverse pregnancy in medical settings. This can
violence, can occur in all dating/ outcomes. Furthermore, women reduce the burden on the medical
romantic relationship, regardless of who experience IPV are also at staff and ensure a higher level of
the race, age, or income status of the high risk for reproductive coercion confidentiality for the survivor
individual. Intimate partner violence and unintended pregnancy.18 by providing a supportive person
is a gender- based crime, as studies Notably, survivors are more likely that would not be required to
widely identify women as victimized to disclose IPV to a provider after document in the medical chart.
more often.17 Research has found being asked repeatedly. Therefore, Governmental, educational, and
that pregnant women with histories maternal and child health clinical health care institutions along with
of IPV are less likely than other providers are uniquely positioned community-based organizations
pregnant women to report having to identify IPV because they should support Philadelphia’s
had discussions with a provider come into regular contact with citywide, coordinated systems’
about IPV during their prenatal care women during pregnancy and response to relationship violence.
and are more likely to be late to the postpartum period.19
prenatal care.

Specifically, the Philadelphia MMRC recommends:

» Hospitals and health care providers should partner with local IPV agencies to:
• 
implement annual trainings for all staff in contact with pregnant and postpartum women in
best practices in IPV screening, appropriate Philadelphia-specific referrals and counseling options
• 
implement a coordinated response to IPV focused on obstetric triage services and emergency rooms.19

» W
 omen’s health providers should have an annual training on reproductive coercion,
stealth birth control, human trafficking, and how to support individuals affected by these issues.

» C
 hild health providers should complete additional training in intimate partner violence
and screen at all well child visits.

» C
 ity departments and non-profit organizations focused on housing should provide increased access
to safe and affordable emergency and transitional housing services for victims of intimate partner violence.

24 | Maternal Mortality in Philadelphia

MOVING
In September 2019, the Merck for Mothers organization, through its
Safer Childbirth Cities Initiative, awarded a three-year grant to the Health

FORWARD
Federation of Philadelphia in support of Philadelphia’s MMRC and the
formation of a structured community action team to be known as The OVA:
Organizing Voices for Action. This grant enabled the formation of a coalition
to implement and support innovative citywide interventions that specifically
address the leading contributors to maternal mortality in Philadelphia
Creation of the as identified by the Philadelphia MMRC. In addition to strengthening the
Philadelphia maternal mortality surveillance process through adoption of
Philadelphia Maternal CDC recommended data collection, specific recommendations emerging
Mortality Community from this report will drive collaborative efforts.
Action Team (The OVA)
The OVA will build upon existing collaboratives focused on these goals,
infuse funding into pilot projects with the potential to improve maternal
health, and work across sectors to integrate community voices and
solutions into policies and programs. It will work as a strong partnership to
promote safe pregnancies, childbirth, and postpartum periods for all women
in Philadelphia.

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5 Heaman, M. I., Sword, W., Elliott, L., Moffatt, M., https://www.acog.org/clinical-information/policy- violence and utilization of prenatal care in the United
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AOG.0000558900.52686.63 Maternal Mortality in Philadelphia | 25
 ACKNOWEDGEMENTS
Report authors:
Aasta Mehta, MD, MPP
Roy Hoffman, MD, MPH
Susan Tew, MPH, BSN, RN
My-Phuong Huynh, MPH, CPH

Report contributors:
Thomas Farley, MD, MPH
Stacey Kallem, MD, MSPH

The Philadelphia Department

of Public Health expresses its
gratitude to the members of
the Maternal Mortality Review
Committee, both current and
former. Your contributions to
the process are invaluable.

26 | Maternal Mortality in Philadelphia