Severe Maternal Morbidity (SMM) Data Dashboard

The Wisconsin Pregnancy Risk Assessment Monitoring System (PRAMS) collects information from people about their attitudes and experiences before, during, and after pregnancy.

The end of the PRAMS survey asks, "We would love to hear more about your story! Is there anything else you would like to share with us about your experiences around the time of your pregnancy?"

Many mothers share their thoughts and stories. These comments provide valuable insights into many maternal health topics, including severe maternal morbidity.

Some mothers shared about their labor and delivery experiences with medical complications and how those experiences impacted them.

“I had pre-eclampsia, ketoacidosis, low potassium, hyperemesis and the amniotic sac started to detach from my uterine wall. My daughter was three weeks early. I hemorrhaged and needed to be life flighted for emergency surgery. My baby is healthy though.”

“I consented to a trial of labor after c-section, was started on low dose Pitocin after my water broke at 38 weeks and four days. After seven hours my uterus ruptured, and I needed an emergency c-section. Baby spent two nights in NICU. I struggled with mild PTSD and anxiety postpartum from this traumatic delivery.”

Some mothers shared how support from providers was helpful or how they wished they had more support.

“I experienced postpartum hemorrhage after my baby was born so I stayed in the hospital longer than I expected. I have met several different care workers during those days. I believe that health care workers who are warm hearted and sympathetic can help new mothers recover sooner and better. I have met some nurses who were indifferent to my suffering, that was pretty sad experience. I really feel thankful to those care providers who were careful and kind.”

“Despite all the pain that I went through the services that I received at the hospital from everyone was amazing. All my nurses were super nice (& probably deserve to be paid way more than what they are making, I say this because taking care of people is not an easy job & it should never be taken lightly). They took very good care of me & my baby. They definitely made sure that all my questions & concerns were answered & dealt with properly.”

“I had a c-section, major blood loss during triggered [atypical hemolytic uremic syndrome] and kidney failure. This was why there was no skin to skin immediately or breastfeeding (I had wanted to pump & bottle feed, but too much other stuff was going on to add another). The post-delivery health issues are also the reason for my mild concerns about money & stress vs being a new parent."

The Wisconsin Maternal Mortality Review Team (MMRT) reviews all deaths that occur during or within one year of the end of pregnancy. The team is composed of experts who represent organizations involved in the care of pregnant and postpartum people in Wisconsin. The MMRT makes recommendations for each pregnancy-related, preventable death. These recommendations are intended to prevent future similar deaths. MMRT recommendations address several topics, including SMM.

Several recommendations share things that health care systems should do to prepare for adverse events during delivery.

• All facilities should implement postpartum hemorrhage bundles with emergency management plan checklists, including drills.
• Facilities should have simulations for management of postpartum hemorrhage at least yearly for all providers.
• Facilities should have 24/7 access to in person or virtual interpreters to aid in emergency situations.
• Birthing centers delivering a high volume of patients should have access to necessary trauma services and blood bank capability.

Some recommendations address care access and management for pregnant people who at higher risk for delivery complications.

• Federal and state governments should direct funding to connecting rural care to tertiary and quaternary care through consultation and transport systems for high-risk services.
• Insurers and hospital systems should pay for appropriate length of stay for diagnosis and management of acute complications during stay.
• Providers should refer patients with high-risk pregnancies to primary care for wraparound services for care coordination to help with appointments, medication and navigating systems for continued care.

Some recommendations stress the importance of education around pregnancy, delivery, and postpartum complications.

• Communities, providers, and health systems should provide information on maternal early warning signs using the Hear Her campaign materials.
• Providers should educate patients with chronic heart disease and obesity (because of risk of heart disease and pulmonary embolism) about warning signs and symptoms (i.e. severe chest pain, shortness of breath) and when to call 911 or present to the emergency room in the patient's preferred language and in a culturally relevant manner.

Several recommendations address specific conditions, including cardiac complications, hemorrhage, and sepsis.

• All providers should have heightened awareness of cardiac disease in pregnancy and practice with suspicion for sudden cardiac death at every interaction with the health care system.
• Facilities should provide ongoing education regarding identification, management and treatment of postpartum hemorrhage (PPH) to providers.
• Hospitals should continue to use new technology and advances to treat postpartum hemorrhage that can be done bedside instead of being taken to the operating room when possible (e.g., the intrauterine balloon or hemorrhage device can be placed in a recovery room and without general anesthesia using IV opioids).
• Facilities should implement early sepsis protocols and broad spectrum antibiotics when appropriate, including Surviving Sepsis Protocols for COVID-19.

Severe maternal morbidity (SMM)

One commonly used method to measure SMM comes from the CDC (Centers for Disease Control and Prevention). This measure of SMM includes twenty-one different diagnoses or procedures that are documented during a delivery hospitalization. Note: this measure of SMM does not capture critical health outcomes that occur during the prenatal period or the postpartum period beyond the delivery hospitalization.

Among the twenty-one SMM conditions, the most commonly occurring condition is blood transfusions. While blood transfusion is included in the CDC definition, the quantity of blood is not available in the hospital record, meaning deliveries with only a blood transfusion may not truly qualify as an SMM. For this reason, delivery hospitalizations that required only a blood transfusion were not included in the dashboard. The SMM data within the dashboard represent all conditions from the CDC definition of SMM except blood transfusions.

SMM is calculated as a rate per 10,000 delivery hospitalizations. The number of SMM events is divided by the total number of delivery hospitalizations, and the resulting number is multiplied by 10,000.

Regions and urban vs rural counties

The maps in the dashboard show data based on where an individual lived at the time of their delivery. Urban versus rural counties are defined by the Wisconsin Office of Rural Health. Regions are defined by the Division of Public Health to align with the division’s regional offices.

Insurance

Insurance is defined at the time of delivery based on the primary source of payment listed within the hospital health care record.

Race and ethnicity

The race and ethnicity groupings used in the dashboard are not mutually exclusive, meaning that a person may be included in multiple groups. American Indian or Alaska Native includes everyone who identified as American Indian or Alaska Native, including those who also identified as Hispanic or another race. Hispanic includes everyone who identified as Hispanic.

Other data concepts

Rates

The data in this dashboard are shown as rates. A rate compares two different types of measurements, using the word “per” to describe the relationships between them. In the case of SMM, the number of SMM events is being compared to the number of delivery hospitalizations. SMM is calculated as a rate per 10,000 delivery hospitalizations. The number of SMM events is divided by the total number of delivery hospitalizations, and the resulting number is multiplied by 10,000.

Confidence intervals

Hovering over a data point within the dashboard gives a pop-up box with an interpretation of that data point. The pop-up box also gives two numbers that represent the 95% confidence interval. While a data point is the best estimate of the truth based on the information available, we cannot know with certainty that it is the true value for the entire population. A confidence interval is a range of numbers that likely contain the true value. The range of a confidence interval is impacted by the number of people included in the data, how much each person’s data differs from others, and the level of certainty that the range contains the true value (in this case, 95% certain).

Health outcomes may differ across populations due to differences in several risk factors, including social and environmental factors. The University of Wisconsin Population Health Institute’s Model of Health shows how community conditions impact health. It important to remember that blame for adverse health outcomes should not be placed on the individuals or populations who experience them. 

Age is an important factor in determining the risk for health problems during pregnancy, and older age groups have higher rates of SMM. Changes in the body associated with aging lead to older populations having a greater chance of pregnancy complications. The stress of pregnancy may worsen pre-existing complications as well. Pregnancies among older individuals may require closer monitoring and specialized care. 

A person’s insurance coverage can impact their access to health care and their experiences while receiving care, ultimately impacting health outcomes. Insurance coverage and type can determine when, where, and with whom a person is able to receive care, greatest impacting communities with health care service shortages or other barriers to quality care. Additionally, medical procedures not covered fully by health insurance can prevent people from getting the medical attention they need. Confusion around insurance policies may contribute to delayed care and interrupted care coordination. 

While race or ethnicity does not have any impact on the biology of a person, it can shed light on how different populations experience health care as well as social and economic conditions. Some populations may experience systemic barriers to quality care, safe housing, economic opportunities, and more—both historically and currently—that impact health outcomes like SMM. When we see differences between racial and ethnic groups we can better understand where to place resources to improve the conditions populations are living in and increase access to health care inside and outside the hospital.

Data sources, including the ones used to create this data dashboard, may be limited in their ability to show data for all populations or for smaller geographies. Additional maternal health data may be also available that is not shown on the data dashboard. 

If you have any questions around maternal health data or would like to request data, email DHSFHSData@dhs.wisconsin.gov.

Additional data and information related to maternal, infant, child, and adolescent health can be found on the Family Health Data webpage. This webpage contains resources that are freely available from state and national data sources. You will also find a guide for using WISH (Wisconsin Interactive Statistics on Health) to show you how to do your own data queries on a wide-range of health indicators in our state and communities.