The meeting always begins with a moment of silence for the moms who are dead, a reminder to consider the humanity behind the data they are about to discuss.
And then the doctors, midwives and mental health experts dive into the records to find the reasons pregnant women and new mothers died in Colorado. They review medical files, prescriptions, coroners’ reports and, sometimes, suicide notes.
Half of all deaths in this state among pregnant women and those within the first year after giving birth are the result of self-harm — defined as suicide and overdose. While maternal deaths from homicide and car crashes are declining in Colorado, mental health-related deaths, including opioid overdoses, are on the rise.
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And as the overall death rate of pregnant women is dropping in other industrialized nations — it is rising in the United States.
The key to figuring out why — and to saving lives from pregnancy-related medical complications, drug abuse and suicide — is maternal-mortality review committees that investigate those deaths with nuance, said Colorado physicians and policymakers.
Was the new mom on Percocet when she crashed the car? Did her doctor refer her to a mental health counselor for depression before she killed herself? Did a physician fail to diagnose preeclampsia until it was too late?
Also, where did the woman who overdosed fill her opioid prescriptions? Was a car crash that killed the mom of a 10-month-old baby related to the fact that she stopped taking her seizure medication during pregnancy and had a seizure while driving? Was the opioid overdose of a new mom linked to her choice to stop using during pregnancy but then relapsing and dying because her body no longer had the same tolerance?
“Every maternal death is a tragedy,” said Shivani Bhatia, maternal health coordinator for the Colorado Department of Public Health and Environment, which houses the review committee. “And it’s a complex story of what happened.”
The point isn’t to blame a particular person, but to discover where the system might have failed.
Colorado’s maternal-mortality review committee has been meeting since at least 1993, but it was not made official until the legislature took action this year. Colorado was well behind the pack, following 41 states that already codified their committees in statute.
The law formalizing the panel, from Rep. Janet Buckner, an Aurora Democrat, requires the committee to report to lawmakers about its findings and recommendations; allows greater access to confidential records, such as mental health documents; and gives committee members protection against subpoenas.
The committee has been waiting three years after a woman’s death to review it, allowing time for potential criminal, civil or malpractice cases to settle, because the doctors and others on the panel could have been called to testify on their review.
That means Colorado data on maternal deaths is on a multiyear lag, hardly a sense-of-urgency approach to an escalating issue, said those who asked for the state law, including the Colorado Children’s Campaign and the state health department.
The committee’s latest report, released in 2017, examined 145 maternal deaths from 2008-13. In that six-year period, the rate of maternal deaths — defined as deaths of women during pregnancy or up to one year after — nearly doubled, from 24.3 deaths per 100,000 live births to 46.2.
At the same time, the death rate from car crashes dropped from 12.9 to 4.6 out of 100,000 live births. And the death rate from mental health-related events rose from near zero to 10.8.
Of the 145 deaths, 44 were the result of injury, including car crashes and homicides. A similar number, 40 deaths, were the result of mental health conditions, including suicides, prescription-drug abuse and recreational-drug abuse.
Among the deaths directly related to pregnancy, the causes included suicide due to postpartum depression, heart conditions and hemorrhage.
The committee determined that 80 percent of the deaths were preventable, mainly through better medical care, mental health care or substance-abuse treatment.
In a seperate, 2016 study from the University of Colorado Anschutz Medical Campus, researchers found that the leading causes of maternal death in Colorado were suicide and overdose. The research looked at 211 deaths from 2004-2012.
The study found that 37 women died from a drug overdose and 26 died by suicide, most commonly by hanging. Opioids were the most common drug detected in toxicology reports.
Colorado lawmakers this year also approved funding that could put reproductive services — birth control or prenatal care — inside methadone clinics and substance-abuse specialists inside OB-GYN offices.
The flexibility will allow the state to initiate pilot programs for both ideas, making it easier for pregnant women with drug problems to get help without visiting separate doctor’s offices for prenatal care and drug addiction.
And through related legislation, the state Department of Human Services can receive unspent state Medicaid funds intended for substance-abuse treatment for programs to help pregnant women and new moms. Among the ideas: child-care centers at drug-treatment facilities, so that women can focus on recovery instead of holding their infants on their laps as they talk to therapists.
Colorado has five residential treatment centers for pregnant women and new moms. They allow infants to stay, too, but not all of them provide child care.
The state Medicaid department, which provides insurance coverage for low-income adults and children, is working to increase options for pregnant women who have substance-abuse disorders.
Under a program called “special connections,” women can qualify for drug treatment during pregnancy and for up to a year afterward. The benefit, which costs the Medicaid department about $1.8 million per year, was expanded to a year postpartum, up from just 60 days, in 2006.
The Colorado Department of Health Care Policy and Financing, which includes Medicaid, also is working to get federal permission to allow residential drug-treatment centers to have more than 16 beds. The bed cap goes back to the 1950s, when federal regulators wanted to cut down on massive institutions to treat people with mental illness.
Allowing treatment centers to grow would decrease overhead costs and provide more beds across Colorado, said Susanna Snyder, maternal-child health-policy specialist at the state health care department. The state now has 80 beds for maternal drug treatment, and treatment for pregnant and postpartum women is the only residential substance-abuse benefit for adults that is covered by Medicaid.
Colorado is awaiting federal permission to expand that benefit to other adults, which would include moms who have older children.
Sixteen women and their infants live at The Haven Mother’s House, a Victorian home in Denver that once housed military officers at Fort Logan. The year-long program offers drug-addiction treatment and mental health counseling, and it is the only residential program in the state that includes a licensed child-care center, said program director Daniele Wolff.
If federal officials lift the bed cap, the Haven Mother’s House could fit up to 26 women and their babies, she said. Many of the women who live there are referred for treatment from doctors and have Medicaid coverage or are sent by the Department of Corrections.
All of the initiatives are meant to help pregnant women as early as possible, in order to prevent them from becoming a topic of discussion at the maternal-mortality committee.
The immediate postpartum period is one of the best times to help a mom, Snyder said. “There is nothing more motivating than having a new baby in your arms to realize you want to change your life,” she said.
The combined efforts of legislation, grant funds and federal concessions — many of them spurred by the opioid epidemic but also on target to treat other drug abuse and alcohol addiction — are unprecedented, said Kim McConnell, substance use disorder administrator at the state Medicaid department.
She hopes they put Colorado on a path to lower death rates from overdose, particularly among pregnant women and new moms.
The committee expects to meet eight times this year to review four to six deaths per meeting. Each woman’s case takes about 40 minutes.
The records are “de-identified” and “abstracted” so that committee members do not know the names of the women, said Dr. Bronwen Kahn, committee co-chair and director of the Center for Maternal Fetal Health at Rose Medical Center.
“We take de-indentification and confidentiality very seriously,” she said.
With every case, the committee tries to answer two questions for the national Centers for Disease Control and Prevention:
Was the death related to pregnancy, such as medical complications, including hypertension or bleeding, or might it have happened regardless?
And was it preventable?
“The point is not finger-pointing,” Kahn said. “It’s usually three or four levels where things failed in order to allow a terrible outcome.”
In Colorado, black women, younger mothers and women in rural areas are more likely to die during pregnancy or in the year after. Nationwide, the higher death rates for black women are “hair-raising,” Kahn said. Black women in America are 243 percent more likely than white women to die of pregnancy-related causes.
“It takes a long time for the momentum for that set of problems to swing around,” Kahn said.