Call to Action
org
Addressing maternal deaths due to violence:
the Illinois experience
Abigail R. Koch, MA; Stacie E. Geller, PhD
Background
The Illinois Department of Public
Health (IDPH) has conducted surveil-
lance and review of pregnancy-
associated deaths (deaths of women
while pregnant or within 1 year of
delivery or termination of pregnancy,
regardless of cause) since 1982. The
state’s 10 regionalized administrative
perinatal centers are responsible for
review of all pregnancy-associated
deaths to determine cause of death, the
relationship to pregnancy, and whether
the death was potentially preventable.1,2
For purposes of maternal mortality
review in Illinois, preventability is
defined as “any action or inaction on the
part of the health care provider, system,
or patient that may have caused or
contributed to progression to more
severe morbidity or death.”3
The MMRC, a multidisciplinary
statewide committee, was formed in
2000 to provide a secondary review of
selected cases.1,4 The cases selected for
MMRC review have mainly been
obstetric in nature and the focus of
these reviews is primarily on the clinical
care pathway of pregnant and early
From the Departments of Obstetrics and
Gynecology and Internal Medicine, College of
Medicine (Dr Geller), Center for Research on
Women and Gender (both authors), University of
Illinois at Chicago, Chicago, IL.
Received May 17, 2017; revised June 28, 2017;
accepted Aug. 16, 2017.
Supported by the Association of Maternal and
Child Health Programs. The funding source had
no involvement in the conduct of the action
described herein, writing of the report, or the
decision to submit the article for publication.
The authors report no conflict of interest.
Corresponding author: Abigail R. Koch, MA.
abbykoch@uic.edu
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.08.005
ajog.
THE PROBLEM: Homicide, suicide, and substance abuse accounted for nearly one fourth
of all pregnancy-associated deaths in Illinois from 2002 through 2013; standard statewide
maternal mortality review for preventability did not adequately address deaths due to
violence.
A SOLUTION: To address maternal death due to homicide, suicide, and substance abuse,
we formed a second statewide maternal mortality review committee (MMRC) for deaths
due to violence (MMRC-V) in 2014.
postpartum women with deaths directly preventable. In a previous analysis of Il-
or indirectly related to pregnancy.1,4 linois perinatal center review data, we
The Maternal Mortality Review Form found that pregnant and postpartum (up
(MMRF) used in these reviews by both to 1 year) women aged
29 years had a
the perinatal centers and the MMRC 2-fold risk for homicide compared with
captures information regarding the nonpregnant and nonpostpartum
woman, characteristics of her pregnancy women regardless of race, suggesting
and the outcome, cause of death, relat- that there may be a relationship between
edness to pregnancy, and potentially pregnancy and homicide in our state.5
preventable factors starting with a Until recently it was not recognized
woman’s entry to care through that pregnancy-associated homicide,
discharge.2 Consequently, reviews of suicide, and substance abuseerelated
maternal deaths due to homicide, sui- deaths comprise nearly one fourth of
cide, and substance abuse have been pregnancy-associated deaths in the state.
mostly uninformative due to the ob- Among 742 known pregnancy-
stetric focus of the MMRF and the re- associated deaths from 2002 through
view process. The MMRF is also 2013, 89 (12.0%) were due to homicide,
organized in a way that categorizes ho- 49 (6.6%) were due to suicide, and 45
micide as unrelated to pregnancy, except (6.1%) were related to substance abuse
in cases of “domestic violence trauma/ (Figure). In fact, these causes are more
neglect,” which was considered possibly common than any single obstetric cause
related to pregnancy. Likewise, by defi- including hemorrhage, emboli, and
nition, suicide was considered unrelated preeclampsia or eclampsia.5
to pregnancy, although “psychiatric dis- Among Illinois women who died from
orders leading to suicide” were also violent causes while pregnant or within a
considered possibly related to preg- year of pregnancy (Table 1), more than
nancy. Deaths due to overdose or other half of the homicide victims were <25
sequelae of substance abuse are not an years old, of non-Hispanic black race,
existing choice for cause of death on the and living in Cook County, where Chi-
MMRF but are often recorded as “other, cago is located. While nearly half of the
not related to pregnancy.” homicide victims died in the late post-
Occasionally reviewers wrote in a vi- partum period, 31 women (34.8%) died
olent cause of death as being directly while pregnant. We do not have com-
related to pregnancy but, on the whole, plete information on the means of death
these violent deaths are presumed to be or relationship between victim and
unrelated to pregnancy. Thus, it is un- perpetrator for all deaths due to violence
clear the relationship of violent maternal from 2002 through 2013, but during the
deaths to pregnancy and postpartum period 2008 through 2013 the most
in Illinois and which are potentially common means was gunshot wound
MONTH 2017 American Journal of Obstetrics & Gynecology 1
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(20 of 40; 50%) and 16 of 40 homicides 33.3%). Eleven of 25 deaths due to

FIGURE
(40%) were in the context of domestic substance abuse (44.0%) during that
Pregnancy-associated deaths violence. The women who died by sui- time period were attributed to multiple
due to violence in Illinois, 2002 cide and substance abuse were more substances including opiates, alcohol,
through 2013 evenly distributed across age groups and cocaine, and benzodiazepines. Opiates
geographic residence. Those women alone caused 9 additional deaths
were overwhelmingly of non-Hispanic (20.5%).
white race-ethnicity (n ¼ 36, 73.5% Illinois is hardly alone in the fre-
and n ¼ 31, 68.9% for suicide and sub- quency of pregnancy-associated deaths
stance abuse, respectively) and the ma- due to violence; reports from other states
jority died in the late postpartum period and jurisdictions confirm that violence is
(n ¼ 32, 66.7% and n ¼ 29, 64.4% for an important contributor to maternal
Proportion of total pregnancy-associated deaths suicide and substance abuse, respec- mortality and warrants a more in-depth
(n ¼ 742) due to violence in Illinois, 2002 tively). Among 15 suicides from 2008 review.6-11
through 2013. through 2013, the most common
Koch & Geller. Addressing maternal deaths due to violence. method was drug overdose (n ¼ 6, MMRC for Deaths Due to Violence
Am J Obstet Gynecol 2017. 40.0%) followed by hanging (n ¼ 5, The MMRC-V expands the state’s
expertise and capacity for state-level re-
view of maternal deaths. We started by
TABLE 1 convening a stakeholder group to adapt
Distribution of demographic and pregnancy-related characteristics the MMRC review process to be more
among pregnancy-associated homicides, suicides, and substance appropriate for deaths due to violence.
abuse deaths in Illinois, 2002 through 2013 This group included the IDPH Deputy
Homicides, Suicides, Substance abuse, Director and Director of the Office of
Characteristic n [ 89 n (%) n [ 49 n (%) n [ 45 n (%) Women’s Health and Family Services;
Age group, y
the Title V Director; a representative
from Illinois SectioneAmerican
<20 16 (18.0) 3 (6.1) 1 (2.2) Congress of Obstetricians and Gynecol-
20e24 41 (46.1) 15 (30.6) 7 (15.6) ogists; experts in the areas of intimate
25e29 17 (19.1) 12 (24.5) 10 (22.2) partner violence, community violence,
30e34 8 (9.0) 12 (24.5) 12 (26.7) maternal mental health, and substance
abuse in pregnancy; obstetric providers
35e44 0 (0.0) 7 (14.3) 15 (33.3)
including obstetrician-gynecologists,
Race-ethnicity maternal-fetal medicine specialists, and
Non-Hispanic white 21 (23.6) 36 (73.5) 31 (68.9) certified nurse midwives; perinatal cen-
Non-Hispanic black 46 (51.7) 6 (12.2) 11 (24.4)
ter administrators; and maternal health
researchers. The group met throughout
Hispanic 20 (22.5) 4 (8.2) 2 (4.4) 2015 to accomplish 3 specific tasks: (1)
Non-Hispanic other 2 (2.2) 3 (6.1) 1 (2.2) identify appropriate committee mem-
County of residence bers for the MMRC-V; (2) identify po-
tential types and sources of information
Cook 48 (53.9) 14 (28.6) 17 (37.8)
that would be required for a meaningful
Collar counties/other urban 31 (34.8) 19 (38.8) 21 (46.7) review of violent maternal deaths; and
Rural 8 (9.0) 16 (32.7) 7 (15.6) (3) revise the MMRF to capture relevant
Timing of death data from the data sources we identified.
During pregnancy 31 (34.8) 11 (22.9) 7 (15.6)
Committee Membership
0e6 d postpartum 7 (7.9) 1 (2.1) 7 (15.6) The group discussed what areas of
7e42 d postpartum 5 (5.6) 4 (8.3) 2 (4.4) expertise were needed for the MMRC-V.
43e365 d postpartum 41 (46.1) 32 (66.7) 29 (64.4) Some of the members agreed to join the
MMRC-V themselves and others iden-
Autopsy
tified a more appropriate person for
Yes 85 (96.6) 36 (75.0) 40 (88.9) ongoing committee membership.
No 3 (3.4) 12 (25.0) 5 (11.1) Because homicide, suicide, and sub-
Koch & Geller. Addressing maternal deaths due to violence. Am J Obstet Gynecol 2017. stance abuse are closely linked to the
social determinants of health, the review

2 American Journal of Obstetrics & Gynecology MONTH 2017

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committee needed to have a broad
membership with expertise in areas not
required for obstetric maternal mortality
review. The final MMRC-V membership
is shown in Table 2.
Data Sources
Identifying potential sources for infor-
mation about the circumstances sur-
rounding these deaths was critical as the
stakeholder group worked to adapt the
review process. With appropriate data-
sharing agreements in place, obtaining
information about maternal deaths from
the Illinois Violent Death Reporting
System and IDPH maternal and child
health case management database pro-
vides contextual information that
cannot be found in medical records. For
example, the case management database
can provide information about the
woman’s residential environment and
the Illinois Violent Death Reporting
System collects information on whether
there were any acute crises in the wom-
an’s life in the 2 weeks preceding her
death. Police and autopsy reports pro-
vide critical information about the
woman’s death. Although the maternal
death review section of the Illinois
Administrative Code requires that all
health care providers, hospitals, and
coroners must provide a complete copy
of the medical records within 30 days of
request,12 currently it is not possible to
obtain mental health care records in
Illinois.
Data Collection Tool
After identifying these sources of infor-
mation, the stakeholder group revised
the MMRF to collect information more
relevant to reviews of violent maternal
deaths. The final form is the MMRF for
Deaths Due to Violence (MMRC-V
form) (Appendix). We retained the sec-
tions from the original MMRF for de-
mographics and characteristics of the
pregnancy and its outcome. However,
the new form contains items on risk
screening for mental health, intimate
partner violence, and substance abuse
during pregnancy, at delivery hospitali-
zation, and postpartum; items about
psychosocial history and other social
determinants of health; and items on the
Call to Action
TABLE 2
Membership of Illinois Maternal Mortality Review Committee for
Deaths Due to Violence
Domain Representatives
Public health system State Title V director
Perinatal center administrators
Maternal and child health epidemiologist
Coroner/medical examiner
Health care providers Obstetrician/gynecologist
Maternal fetal medicine specialist
Nurse midwife
Emergency medicine
Psychiatrist
Psychologist
Advanced practice nurse specialized in addiction and pregnancy
Sexual Assault Nurse Examiner
Pathologist
Trauma specialist
Social services and Children and family services
community resources
Violence prevention advocate
Intimate partner violence prevention advocate
Child abuse prevention advocate
Social worker
Law enforcement
Koch & Geller. Addressing maternal deaths due to violence. Am J Obstet Gynecol 2017.
circumstances of death. While the group An important step to allow for
acknowledged that we may not be able to feedback of policy and program recom-
complete all items in all cases, it was mendations was for IDPH to amend state
agreed that these additions could be code to make the committee a standing
beneficial for the review committee and a subcommittee that reports directly to the
goal should be complete data collection. Perinatal Advisory Committee. This al-
The review section of the MMRC-V lows the MMRC-V to convey recom-
form was also revised. It was agreed mendations directly to the Perinatal
that, on principle, all violent deaths Advisory Committee. The MMRC-V re-
should be considered potentially pre- views cases under the protection of the
ventable so “not avoidable” was removed. State of Illinois Medical Studies Act,12
All cases were considered to be either which protects the discussions and
potentially preventable or undetermined findings from committee review from
(mainly due to incomplete information). discovery in legal proceedings. The goal
The form included potentially prevent- of maternal mortality review is to iden-
able factors relating to the woman, her tify modifiable factors that can prevent
family, systems of care, community fac- future deaths, not to assign blame. All
tors, the legal system, and the institutional members of the MMRC-V signed
environment. Finally, the form included a confidentiality agreements.
write-in section for recommendations
that must include a plan of action for all Review Process
cases determined to be potentially The MMRC-V decided to review all
preventable. maternal deaths starting with 2015, a
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TABLE 3
Sample recommendations by Illinois Maternal Mortality Review Committee for Deaths Due to Violence
Cause Domain Recommendation
Suicide Public health system Establish telemedicine services for mental health care in rural and underserved settings
Mandate autopsy for all suspected suicides
Social services Integrate screening for depression, substance use, and IPV into nonclinical settings such as WIC,
and home visiting
Expand services for high-risk women to include prenatal home visiting
Health care providers Retrain providers on effective and culturally competent screening practices, evidence-based practice
for antidepressant use during pregnancy, and trauma-informed care
Community Partner with community organizations to raise awareness of depression/suicide and available resources
Substance Public health system Engage Medicaid coordinators for referrals for addiction treatment services for women during pregnancy
abuse
Criminal justice system Advocate for noncriminalization of disclosure of substance use in pregnancy
Social services Leverage authority of DCFS to find assistance for women with substance use disorder
Health care providers Strongly encourage (mandate if possible to change legislation) use of Prescription Monitoring
Program database before prescribing scheduled substances
Community Increase education about and availability of naloxone in community and for ambulance drivers
DCFS, Department of Children and Family Services; IPV, intimate partner violence; WIC, Women, Infants, and Children food and nutrition service.
Koch & Geller. Addressing maternal deaths due to violence. Am J Obstet Gynecol 2017.

year that saw an increase in maternal
deaths in the state. Cases are abstracted
and distributed to committee members
for review in advance of the meeting. At
the meeting, the abstractor presents a
brief synopsis of each case prior to
committee discussion of that case. To
date the committee reviewed cases of
maternal suicide and substance abuse.
Reviews of homicide are limited given
that full records cannot be obtained until
legal proceedings are concluded, which
may take a number of years depending
on the circumstances.
The committee determines whether
the death was pregnancy-related or not.
Committee discussion focuses on po-
tential opportunities to intervene on the
circumstances surrounding the mortal-
ity and identifying the appropriate
resources to address those opportunities.
Due to the breadth of the issues identi-
fied in these cases, the committee relies
on the diverse expertise of its members
to gain insight into institutional pro-
cesses, community resources, and ca-
pacity of the health care system to
formulate recommendations. Unlike the
original MMRC, which has primarily
made recommendations for changes to
obstetric care and the regionalized
perinatal system, the MMRC-V identi-
fied potentially modifiable factors that
require cooperation with social service
agencies, community organizations, and
the criminal justice system in addition to
the systems of care for physical and
mental health (Table 3).
Lessons Learned
Among the notable lessons learned to
date is the degree to which interpersonal
violence, mental health issues, substance
use, and history of trauma intertwine in
these cases to ultimately lead to the
woman’s death. To this end, the IDPH
seeks to engage in partnerships with
other state agencies to increase the op-
portunities to address these complex
circumstances. Such relationships will
facilitate collaborative efforts among
MMRC-V, IDPH, and other state
agencies to implement committee rec-
ommendations (Table 3). For example, a
partnership with the Maternal, Infant,
and Early Childhood Home Visiting
Program can work to incorporate
depression, substance abuse, and inti-
mate partner violence screening into
their services both prenatally and post-
partum. We have also identified the need
to establish communication with the
Department of Corrections to ensure
that women receiving mental health and
substance abuse treatment in prison
during pregnancy and the postpartum
period are receiving appropriate referrals
upon their release.
The integration of systems of care for
women would provide all systems with
relevant information that could result in
fewer missed opportunities for preven-
tion. For example, the committee has
identified the need to educate hospital
emergency department (ED) providers
about appropriate triage for pregnant
women in crisis. A case in point was that
of one woman who died from substance
abuse overdose. She received no tradi-
tional prenatal care but visited EDs 15
times during her pregnancy and 52 times
in the postpartum period seeking pain
medication. Despite the frequency of her
ED visits and evidence from the state
Prescription Monitoring Program, there
was no indication that this woman was
ever referred to a substance abuse treat-
ment program. This amounted to 67
missed opportunities to alter her
outcome. Illinois is currently engaged in
developing educational opportunities
for ED providers to be trained in the care
of pregnant and postpartum women.

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Other recommendations arising from
review of this case include working
with Medicaid coordinators to identify
substance abuse treatment programs
that accept Medicaid and working
with law enforcement, first responders,
and community groups to increase
the availability of naloxone in the
community.
We have learned that reviewing
maternal deaths due to violence can be
more challenging, both logistically and
emotionally, than reviewing obstetric
maternal deaths. We have found that
acknowledging the difficulty of review-
ing these cases is an important way to
close our meetings. Nevertheless, Illinois
has demonstrated that by engaging
appropriate members and expanding the
information used for case review, it is
possible to conduct meaningful reviews
of these deaths and make recommenda-
tions to prevent future deaths.
REFERENCES
1. Kilpatrick SJ, Prentice P, Jones RL, Geller S.
Reducing maternal deaths through state
maternal mortality review. J Womens Health
(Larchmt) 2012;21:905-9.
2. Geller SE, Koch AR, Martin NJ, Rosenberg D,
Bigger HR. Assessing preventability of maternal
mortality in Illinois: 2002-2012. Am J Obstet
Gynecol 2014;211:698.e1-11.
3. Geller SE, Cox SM, Kilpatrick SJ.
A descriptive model of preventability in maternal
morbidity and mortality. J Perinatol 2006;26:
79-84.
4. Geller SE, Koch AR, Martin NJ,
Rosenberg D. Comparing two review pro-
cesses for determination of preventability of
maternal mortality in Illinois. Matern Child
Health J 2015;19:2621-6.
5. Koch AR, Rosenberg D, Geller SE. Higher risk
of homicide among pregnant and postpartum
females aged 10-29 years in Illinois, 2002-2011.
Obstet Gynecol 2016;128:440-6.
6. Chang J, Berg CJ, Saltzman LE, Herndon J.
Homicide: a leading cause of injury deaths
among pregnant and postpartum women in the
United States, 1991-1999. Am J Public Health
- 2005;95:471-7.
MONTH 2017 American Journal of Obstetrics & Gynecology
Call to Action
7. Palladino CL, Singh V, Campbell J, Flynn H,
Gold KJ. Homicide and suicide during the peri-
natal period: findings from the National Violent
Death Reporting System. Obstet Gynecol
2011;118:1056-63.
8. Dannenberg AL, Carter DM, Lawson HW,
Ashton DM, Dorfman SF, Graham EH. Homicide
and other injuries as causes of maternal death in
New York City, 1987 through 1991. Am J Obstet
Gynecol 1995;172:1557-64.
9. Metz TD, Rovner P, Hoffman MC, Allshouse AA,
Beckwith KM, Binswanger IA. Maternal deaths
from suicide and overdose in Colorado, 2004-
2012. Obstet Gynecol 2016;128:1.
10. Kavanaugh VM, Miller FM. The contribution of
violence to pregnancy-related deaths in Virginia.
J Obstet Gynecol Neonatal Nurs 2012;41:S138.
11. Austin AE, Vladutiu CJ, Jones-Vessey KA,
Norwood TS, Proescholdbell SK, Menard MK.
Improved ascertainment of pregnancy-
associated suicides and homicides in North
Carolina. Am J Prev Med 2016;51:S234-40.
12. Illinois General Assembly. Maternal death
review. 7 Ill Reg 287, Eff Dec. 22, 1982; Amend
25 Ill Reg 16491, Eff Jan. 1, 2002. Available
at: www.ilga.gov/commission/jcar. Accessed
November 5, 2016.
5
Call to Action Supplemental Materials
ABSTRACT
Addressing maternal deaths due to violence:
the Illinois experience
Homicide, suicide, and substance abuse accounted for nearly one
fourth of all pregnancy-associated deaths in Illinois from 2002
through 2013. Maternal mortality review in Illinois has been primarily
focused on obstetric and medical causes and little is known about the
circumstances surrounding deaths due to homicide, suicide, and
substance abuse, if they are pregnancy related, and if the deaths are
potentially preventable. To address this issue, we implemented a
process to form a second statewide maternal mortality review com-
mittee for deaths due to violence in late 2014. We convened a
stakeholder group to accomplish 3 tasks: (1) identify appropriate
committee members; (2) identify potential types and sources of in-
formation that would be required for a meaningful review of violent
maternal deaths; and (3) revise the Maternal Mortality Review Form.
Because homicide, suicide, and substance abuse are closely linked to
the social determinants of health, the review committee needed to
have a broad membership with expertise in areas not required for
obstetric maternal mortality review, including social service and
community organizations. Identifying additional sources of informa-
tion is critical; the state Violent Death Reporting System, case
1.e1 American Journal of Obstetrics & Gynecology MONTH 2017
ajog.org
management data, and police and autopsy reports provide contextual
information that cannot be found in medical records. The stakeholder
group revised the Maternal Mortality Review Form to collect infor-
mation relevant to violent maternal deaths, including screening his-
tory and psychosocial history. The form guides the maternal mortality
review committee for deaths due to violence to identify potentially
preventable factors relating to the woman, her family, systems of
care, the community, the legal system, and the institutional envi-
ronment. The committee has identified potential opportunities to
decrease preventable death requiring cooperation with social service
agencies and the criminal justice system in addition to the physical
and mental health care systems. Illinois has demonstrated that by
engaging appropriate members and expanding the information used,
it is possible to conduct meaningful reviews of these deaths and make
recommendations to prevent future deaths.
Key words: maternal mortality review, pregnancy-associated homi-
cide, pregnancy-associated substance abuse, pregnancy-associated
suicide