Maternal Mortality Annual Report Released


TOPEKA – The Kansas Department of Health and Environment (KDHE) and the Kansas Maternal Mortality Review Committee (KMMRC) announce the release of the first annual report for maternal mortality including severe maternal morbidity. The report is available on the KMMRC website. The goal of the report is to identify statewide trends in maternal mortality and provide recommendations to prevent maternal mortality and improve the health of Kansas mothers.

The KMMRC is tasked with reviewing all maternal deaths that occur in Kansas. Over the last two years, the KMMRC reviewed cases that occurred during 2016-2018. Approximately one in four maternal deaths that occurred during 2016-2018 were determined by the KMMRC to be pregnancy-related. Twelve (92.3%) of the 13 pregnancy-related deaths were determined to be preventable with seven deaths indicating a good chance of prevention and five deaths indicating some chance. Racial and ethnic minority women were disproportionately affected. The proportion of pregnancy-related deaths that occurred among non-Hispanic Black women, Hispanic women, non-Hispanic women of other races far exceeded their representation among the population of women giving birth in Kansas. Obesity contributed to more than half of the deaths. Substance use disorder contributed to nearly one in four.

The recommendations included in this report focus on five primary categories: women and their families, health care providers, hospitals/facilities, system of care, and community. Each set of recommendations addresses specific areas of concern based on the KMMRC’s findings and proposes actions which, once implemented, are expected to prevent and reduce maternal mortalities.

The key KMMRC recommendations for pregnancy-related deaths are:

  • Screen, provide brief intervention, and referrals for:
    • Comorbidities and chronic illness
    • Intimate partner violence
    • Pregnancy intention
    • Mental health conditions (including postpartum anxiety and depression)
    • Substance use disorders
  • Increased communication and collaboration between providers, including referrals
  • Patient education and empowerment

The KMMRC and the Kansas Perinatal Quality Collaborative (KPQC) function together to improve maternal and perinatal health. Investing in the mother’s health leads to a healthier birth. The KMMRC focuses on reviewing pregnancy-associated deaths to identify gaps in health services and make actionable recommendations to prevent future deaths, improving maternal and perinatal health. The Kansas Perinatal Quality Collaborative (KPQC) utilizes the KMMRC’s recommendation to implement and support efforts intended to strengthen perinatal systems of care for mothers and infants, creating a culture of safety.

KDHE and the KPQC are planning to launch the Fourth Trimester Initiative, a stakeholder-driven public health quality improvement project to address maternal health needs in the state, especially during the postpartum period (up to 1 year after delivery). The initiative will focus on improving attendance at the postpartum visit as well as appropriate screening, referral, communications, and collaboration amongst a woman’s care team. More information about the KPQC and the Fourth Trimester Initiative can be found at

“We appreciate those who have contributed to this report,” said Rachel Sisson, Director for KDHE’s Bureau of Family Health. “Members from the KMMRC contributed their time and expertise to reviewing deaths and information for this report, and we hope it will be useful to providers and communities as we all work together to combat maternal morbidity and mortality.”

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