Maternal Mortality Review

In 2023, TCA 63-15-103 authorized the creation of a Doula Services Advisory Committee. The Tennessee Department of Health will recruit three doulas to join the Doula Service Advisory Committee to make recommendations to the legislature on creating core competencies and standards for doula services, propose multiple options for a Medicaid reimbursement plan, propose incentive-based programs such as fee waivers, and examine outcomes, findings, and reports from existing doula-related pilot programs. 

In June 2023, the Maternal Mortality Review and Prevention, Review Procedures Rule (1200-15- 04) was amended and approved by the Government Operations Committee, allowing the program to contact family members to request their voluntary participation in an informant interview. Informant interviews provide greater context around factors and events leading up to the death. 

Tennessee Initiative for Perinatal Quality Care (TIPQC) initiated the Severe Maternal Hypertension bundle with 16 hospitals actively participating from across the state. In February of 2023, 750 blood pressure cuff kits were distributed to 25 birthing hospitals. The kits were distributed to women that are preeclamptic, and high-risk, to utilize at home. Since continuing with the project, 4,000 kits have been purchased and distributed to 34 different hospitals. In March of 2023, TIPQC printed 50,395 Postpartum Support International magnets that were distributed to 47 hospitals. TIPQC continues to host their Healthy Mom, Healthy Baby podcast. These podcasts have included perinatal mood and anxiety disorder training, Caring for Motherhood, maternal mental health support, a journey through postpartum depression and anxiety, birth trauma, and trauma-informed care. TIPQC’s new project is the Promotion of Vaginal Deliveries. The project aim is to promote safe vaginal delivery for all in the birthing population presenting with a nulliparous, term, singleton, vertex pregnancy and thus decrease NTSV cesarean delivery rates to < 23.6% (Health People Goal 2030) in all participating Tennessee birthing facilities by Summer of 2024. 

Implemented training focused on topics identified by the MMRC and the needs assessment including, but not limited to, recognizing pre-eclampsia and hemorrhage protocols. In collaboration with TIPQC, education efforts were divided. TIPQC educated delivery hospitals while THA provided a focus on non-delivery hospitals. In 2022, THA continued working with perinatal educators to conduct simulation training focused on identifying and treating pre-eclampsia. In 2022, THA Maternal Mortality Reduction project collaborated with TIPQC to engage non-OB as well as OB facilities using the ACOG AIM bundles and providing resources for healthcare staff and patients/families. On-site education and simulation for physicians and nurses on a proper assessment of pregnant and postpartum mothers for signs/symptoms of pre-eclampsia, eclampsia, and hypertension to be followed by postpartum hemorrhage. To date, THA has had a total of 155 Emergency Department staff at the 20 participating non-delivery hospitals undergo training. 

The Tennessee Department of Health received a $5 million competitive federal grant to fund community and clinical programs that improve Tennessee’s maternal health outcomes. The TDH Division of Family Health and Wellness received the Maternal Health Innovation grant from the U.S. Dept. of Health and Human Services to fund several initiatives in the next five years: Expand membership in the state maternal health task force which will create a maternal health strategic plan for Tennessee; Strengthen capacities for data collection and analysis to implement maternal health clinical quality improvement projects; Create materials to educate patients about the early warning signs of pregnancy emergencies; Collaborate with local community agencies on projects to address maternal health needs; Share and support the lived experiences of women who survived pregnancy complications, and the experiences of relatives for women who didn’t, through public outreach efforts; and Build a comprehensive maternal health website. 

In 2020, the Tennessee MMR team partnered with the CDC to explore the benefit of using Hospital Discharge Data System (HDDS). We searched 2018 to 2020 inpatient and outpatient records for potential pregnancy associated deaths not captured in our previous case identification using birth records, fetal deaths, pregnancy checkbox, and relevant ICD-10 codes. For 2018 deaths, we identified 28 extra cases not captured from our routine case identification process. Over a two-year period, the MMR program partnered with Division of Population Health Assessment and THA to get access to the provisional hospitalization discharge data. The goal of this partnership was to improve access to hospitalization data by shortening lag from 9 months to 5 months to meet the MMR’s review timeline. This earlier access helps the MMR program in reviewing all pregnancy-associated deaths and informs comprehensive recommendations for preventing maternal deaths. In 2022, the MMR program incorporated HDDS into the regular process for case identification of 2021 pregnancy-associated deaths. An additional 32 cases that were not captured in prior case identification were discovered; and 14 of these cases were verified true pregnancy-associated deaths. Of all 14 verified HDDS cases, 4 of them were pregnancy-related deaths with cardiovascular disease, COVID-19, and substance use disorders as the cause of death. Most (79%) of the pregnancy associated deaths identified by HDDS were deemed preventable.