A probing 90-question review promises to unravel the stubborn knot of questions about why as many as 139 women died from pregnancy-related complications in New York state between 2003 and 2005 and why New York City continues to be a leader in maternal mortality.

For more than two years, a voluntary maternal mortality review conducted in the state has been struggling with its own life-and-death problem: the disappearance of New York City hospital participation.

The New York City Health and Hospitals Corporation -- a coalition of city-owned care and treatment facilities that represent a large portion of the city's maternal deaths along with the largest population of African- American patients -- has backed out of the review process.

As a result Donna Montalto, who heads the New York state review, says a report due out in 2009 won't have enough hospitals participating to a make a meaningful analysis of maternal deaths in the state.

The Health and Hospitals Corporation, a public hospital system that includes 11 acute-care hospitals and several home care, diagnostic and treatment facilities, withdrew from the review in 2006. Two years before, 13 maternal deaths occurred in its hospitals, representing nearly half of all the maternal deaths in the city that year, state health department data indicate. Three years later in 2007, the number of deaths fell to six.

"We chose not to participate in the Safe Motherhood Initiative simply because we already participate in a number of established monitoring and review processes, measures and collaboratives," Pamela McDonnell, a spokesperson for the Health and Hospitals Corporation, replied via e-mail.

'Damaging' Departure of Data

The fact that the city's hospitals with the largest number of black patients will be missing is especially damaging to the study, says Montalto, director of New York's American College of Obstetricians and Gynecologists, which launched the Safe Motherhood Initiative in 2001 in conjunction with the New York State Department of Health. In addition to conducting the review, the team of medical specialists that run the initiative also train physicians volunteering to study curriculums on averting maternal mortality.

Montalto is now working with the Healthcare Association of New York State, an association of the state's hospitals, to educate and encourage all hospitals to participate. In 2004, black women were nearly four times as likely to die in childbirth as white women nationwide, and had a maternal death rate of 34.7 per 100,000 live births compared to 9.3 deaths per 100,000 live births for white women.

These types of reviews are path-breaking analyses of maternal death causes and recommendations are active in at least nine states, including New York state for now.

Designed to discover and interpret major risk factors, Montalto's State Maternal Mortality Review surveys -- among many data -- the deceased woman's occupation, primary language, education, insurance coverage, prenatal care, method of delivery and history of sexually transmitted diseases. It asks if the pregnancy was intended or unintended. It might also help explain why African-American women represent a disproportionate amount of maternal deaths.

While all hospitals are required to report maternal deaths to state agencies, this voluntary review effort strives to present a detailed account of the life of the woman and her care in the ward and make recommendations on enhancing quality of care in obstetrics and gynecology.

New York Leads Cities in Maternal Deaths

New York City leads all other U.S. cities in the number of maternal mortalities, and between 1989 and 1998, the state had the highest rate of maternal mortalities per 100,000 live births -- 28.7 -- in the nation, the Atlanta-based Centers for Disease Control and Prevention reported in 1999.

The Health and Hospitals Corporation represents the inner city population, Montalto says. "They would have a wealth of data considering their hospital demographic, which includes the Harlem Hospital population."

Montalto says the New York-Presbyterian Healthcare System, a major network of private hospitals operating top city facilities, has also backed out.

A spokesperson from New York-Presbyterian said yesterday she could neither confirm nor deny that her organization withdrew from the study without further research.

Unlike studies conducted by the Centers for Disease Control, which de-contextualize a mother's death -- erring on the side of numbers instead of in-depth analysis and interpretation of what went wrong -- the review report discusses pregnancy outcomes by race and specific risk determinants, such as in-hospital maltreatment and the woman's pre-existing health issues, which are then matched along a roster of social and health conditions associated with maternal deaths.

The first New York Safe Motherhood report came out in 2005 and interpreted 33 deaths between August 2003 and June 2005. A team of specialists conducted on-site reviews of 21 of the deaths, with black women representing the majority, or nearly 60 percent. The team of specialists found that 43 percent of the pregnancies were already at high risk -- for example, due to obesity and heart disease -- and that mothers could benefit from knowing their risk sooner. A big issue concerning Montalto: less than half of the cases -- about 37 percent -- received adequate prenatal care.

Probing Black Women's Deaths

But one chart shows that black women with adequate prenatal care died at a rate comparable to that of white women with inadequate prenatal care -- which hints at a medical mystery a small field of researchers are trying to explain. While some analysts emphasize a lack of health care and poverty to explain high maternal mortality rates among black women, newer studies have indicated that regardless of a black woman's income and education levels, black women are more likely to die having a baby than white and Latina women.

Now, a network of progressive experts is trying to pinpoint how stress and racism places black mothers and their children at greater harm in the ward. Still, Montalto says most black mothers in the study did not have continuous prenatal care and this is an urgent part of the picture.

Ultimately, the findings she helped co-author were considered tentative, so the second review, slated for 2009, raised hopes of better insights that investigators could use to guide health care facilities and doctors.

Since the initial report, the proportion of hospitals where maternal deaths occurred at all and that reported to the Safe Motherhood Initiative went from half to a third, says Montalto.

Nationwide, an estimated 1,000 U.S. women die of pregnancy-related complications every year, according to a 2006 maternal mortality review summary by government agencies including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists.

In the fall, the consortium will release its maternal and fetal statistics online as a part of a transparency initiative, says McDonnell, the Health and Hospital Corporation spokesperson, but the information will not probe causes of death or the identities of the mothers. Officials at the Health and Hospitals Corporation have set a goal of zero maternal deaths, using intervention and management procedures to respond to crisis.

"We also conduct mock codes and drills to ensure consistency with response to obstetric and medical emergencies," says McDonnell.

Montalto says hospital legal teams fear being marked for having a higher risk population and more maternal mortalities so they avoid the review, which they fear may not adequately guard confidentiality.

While New York City's big hospitals must have every maternal death reviewed by state authorities, Montalto says the reviews tend to be inappropriately sympathetic to errors, similar to "having your mom come in and review your homework."

Members of this separate, state review group -- the Perinatal Center Team -- could not be reached for comment.

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