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In managed care settings, primates are susceptible to a variety of health complications. A comprehensive understanding of the causes of mortality and their association with management practices is essential for enhancing the welfare of managed care populations such as François' langurs (Trachypithecus francoisi). However, literature addressing prevalent diseases or causes of death in such settings remains limited among François' langurs in managed care. To address this knowledge gap, we conducted an analysis of mortality causes in François' langurs (n = 97) who died of natural causes during a 16-year period (2007-2022) at the Trachypithecus francoisi Rare Animal Breeding Center in Wuzhou, Guangxi, China. Morphological diagnosis and organ system and etiological evaluations were performed. François' langurs were divided into six age-range groups, following previous studies: infant (≤ 1 year old), juvenile (1 to 2 years), sub-adult (2 to 4 years), adult (4 to 10 years), middle-aged (10 to 15 years), and geriatric (> 15 years). Results revealed that the primary causes of mortality in managed care François' langurs were pneumonia (n = 11, 12.22%), neoplasia (n = 7, 7.78%), ileus (n = 7, 7.78%), senility (n = 6, 6.67%), gastroenteritis (n = 6, 6.67%), cardiac disease (n = 5, 5.56%), hemorrhage (n = 5, 5.56%), intestinal adhesion (n = 4, 4.44%), and renal abscess (n = 4, 4.44%). The gastrointestinal system was most frequently implicated in deaths, followed by the respiratory system (n = 17, 18.89%), multisystem disease (n = 16, 17.78%), and cardiovascular system (n = 15, 16.67%). Regarding etiology, infectious or inflammatory (n = 32, 35.56%) and physiological factors (n = 17, 18.89%) were identified as the leading contributors to the high mortality rate. It is imperative for managers to recognize the distinct risk profiles associated with different age groups. Specifically, pneumonia was the principal cause of death in infant and juvenile langurs, while renal disease, neoplasia, gastroenteritis, and intestinal obstruction were the primary causes of death in adult and middle-aged François' langurs and advanced age and cardiac disease were the main causes of death in geriatric langurs.

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BACKGROUND: The rising trend in maternal mortality over the past three decades sets the United States (U.S.) apart from all other high-income countries. Multidisciplinary state and city Maternal Mortality Review Committees (MMRCs) conduct comprehensive reviews of maternal deaths, including assessments of preventability and contributing factors. OBJECTIVE(S): Assess preventability of and contributing factors to maternal mortality in the U.S. STUDY DESIGN: This study is a secondary analysis of cross-sectional, population-based data from the most recent, publicly available MMRC data from 40 state and 2 cities in the U.S. Preventability was analyzed among all deaths during pregnancy or within one year postpartum from any cause (pregnancy-associated deaths, PAD) and deaths during pregnancy or within one year postpartum from causes related to pregnancy or its management, but not from accidental causes (pregnancy-related deaths, PRD). We also explored preventability by cause-of-death and contributing factors grouped as community, patient-family, provider, facility, and health system factors. RESULTS: Of deaths that occurred after 2010, between 53%-93.8% of PADs and 45%-100% of PRDs were deemed preventable across the 42 states and cities. Across the ten states reporting PRD preventability by cause-of-death, MMRCs deemed preventable >90% of deaths from preeclampsia-eclampsia and mental health conditions, >80% of deaths from hemorrhage and cardiovascular conditions, about 70% of deaths from infection and thrombotic embolism, and about 40% of deaths from amniotic fluid embolism and stroke. A total of 3,345 contributing factors were described in MMRC reports from 14 states in relation to 739 PRDs. While collectively patient-family and provider factors were most frequently noted as contributing to PRDs, the contribution of such factors varied between 6%-56% and 18%-42.3%, respectively, across the states. Based on data from 20 MMRCs with available information, racism or discrimination were noted in relation to 37.7% of PRDs. CONCLUSIONS: A large proportion of PADs and PRDs in the U.S. are preventable. However, likely due to differences in MMRC membership, available data, and judgement employed to determine preventability, wide variation exists in the proportion of deaths deemed preventable and factors identified as contributing to such deaths across states. There is need to reevaluate the definitions, structure, and outputs for maternal death preventability assessments currently employed by a majority MMRCs to adequately inform state and national programming and policies.

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INTRODUCTION: Reducing preventable perinatal deaths is the focus of perinatal death surveillance and response programmes. Standardised review tools can help identify modifiable factors in perinatal deaths. AIM: This systematic review aimed to identify, compare, and appraise perinatal mortality review tools (PMRTs) in upper-middle to high-income countries. METHODS: Four major scientific databases were searched for publications relating to perinatal death reviews. There were no restrictions on date, study, or publication type. Professional websites for each country were searched for relevant material. The Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) checklist was used for quality appraisal of each tool. A narrative synthesis was used to describe and compare tools. FINDINGS: Ten PMRTs were included. Five PMRTs were from high-income countries, four from upper-middle income countries and one was designed for use in a global context. The structure, content, and quality of each PMRT varied. Each tool collected information about the antepartum, intrapartum, and neonatal periods and a section to classify perinatal deaths using a standardised classification system. All tools reviewed the care provided. Five tools included recommendation development for changes to clinical care. Four tools mentioned parent involvement in the review process. For quality appraisal, one review tool scored "high quality", six scored "moderate quality" and two scored "poor quality". CONCLUSION: There is little standardisation when it comes to PMRTs. Guidance on structuring PMRTs in a standardised way is needed. Recommendation development from a review is important to highlight changes to care required to reduce preventable perinatal deaths.

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Background: The process of morbidity and mortality review (MMR) is recognized as an essential component of quality improvement, patient safety, attitudes towards patient safety, and continuing education. Despite the common use of MMR for all disciplines of medical care, recommendations have not been published regarding the implementation of MMR in a community hospital setting in the United States. Objectives: Review the literature on MMR conferences. Describe the implementation of an MMR conference in a community hospital neonatal intensive care unit (NICU). Conclusions: The establishment of a case overview method of MMR is feasible for a community hospital NICU. It increases staff and physician group awareness and education over common and complex mortality and morbidity etiologies, improves staff participation with unit management, links case presentation with open discussion and action items, and identifies opportunities for systemic changes to improve patient care.

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Background Patient mortality reviews identify care, system, and process deficiencies. Patient deaths undergo quarterly review in our academic emergency department (ED), whereas in other departments, mortality reviews are requested by the pronouncing physician within 24 hours. In the ED, individual physicians encounter barriers to 24-hour reviews, including feasibility, the perception of futility, re-exposure to traumatic events, and a high frequency of pre-hospital and non-preventable deaths. This quality review aimed to determine the preventable death rate, contributing factors to ED patient mortality, cases requiring further review, and the capture rate of individual case submissions into the patient safety reporting system. Methods A retrospective chart review was performed on all patient deaths occurring in our ED from July 2019 to February 2020. All patients 18 years or older who were pronounced dead in the ED during our data collection period were included. Patients declared deceased pre-hospital, on an inpatient floor, or in the operating room were excluded. Deaths were assessed for characteristics such as sex, presence of a pulse upon arrival, diagnostics and interventions performed, and whether the cause of death was traumatic or medical. Deaths were categorized on a 5-point Likert scale ranging from "not preventable" to "likely preventable." The presence or absence of contributing factors and the need for further review were recorded. Results Of the 166 reviewed cases, 87% (n=144) were non-preventable due to a terminal condition upon arrival, 12% (n=20) were non-preventable despite maximal efforts, 0.6% (n=1) were non-preventable despite a medical or systems error, and 0.6% (n=1) were possibly preventable due to a medical or systems error. No cases were definitively preventable. Only 1.2% (n=2) of cases required further safety review. In 55% (n=91) of cases, the patient arrived without a pulse. Medical deaths (60%, n=100) outnumbered traumatic deaths (39%, n=64). The most utilized diagnostic test was ultrasound (67%, n=111), and the most utilized intervention was advanced cardiac life support (59%, n=98). Conclusion There is a high prevalence of unpreventable deaths in the ED (99%, n=164). Only two cases (1.2%) were identified for further patient safety review. Standard safety event reporting practices correctly identified all possibly preventable ED deaths.

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BACKGROUND: Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent 'events of omission', including failure to monitor patients' vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. METHODS: We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. RESULTS: Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92-0.98) and 0.97 (95% CI: 0.95-0.99)). CONCLUSION: The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement. TRIAL REGISTRATION: Retrospectively registered.

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Current guidelines and regulations require trusts to take full responsibility for deaths within their premises. Higher than expected deaths indicate poor standards of care or negligence. NHS Trusts need to put systems in place to ensure that they learn and extrapolate risk factors through in-depth review of care provided to patients prior to their deaths, curb and ultimately diminish relative mortality through improved practices, and improve care and safety for the whole organisation. Mortality reviews can provide insight into the standard of care that dying patients receive; this matters as NHS Hospitals are the main providers of terminal care, nationally.

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Mortality review is an important way to identify deficiencies and gaps in the healthcare system and can effectively improve the quality and safety of healthcare delivery.It analyzes and summarizes the relevant domes-tic and international literature and review the current development,methods and characteristics of different applica-tion areas of death case review at home and abroad,with a view to guiding healthcare departments or institutions to establish a scientific and standardized mortality review system.

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INTRODUCTION: Social determinants of health and adverse childhood experiences have been implicated as driving causes of maternal mortality but the empirical evidence to substantiate those relationships is lacking. We aimed to understand the prevalence and intersection of social determinants of health and adverse childhood experiences among maternal deaths in Colorado based on a review of records obtained for our state's maternal mortality review committee. METHODS: A 5-member interdisciplinary team adapted the Protocol for Responding to and Assessing Patients' Assets, Risk, and Experiences and the Adverse Childhood Experiences tools to create a data collection tool. The team reviewed records collected for the purpose of maternal mortality review for pregnancy-associated deaths that occurred in Colorado between 2014 and 2016 (N = 94). RESULTS: The review identified an overwhelming lack of information regarding social determinants of health or adverse childhood experiences in the records used to review maternal deaths. The most common finding of the social determinants of health was a lack of conclusive evidence in the record (35.1-94.7%). Similarly, the reviewers were unable to make a determination from the available records for 92.1% of adverse childhood experience indicators. DISCUSSION: The lack of social and contextual information in the records points to challenges of relying on medical records for identification of non-medical causes of maternal mortality. Maternal mortality review committees would be well served to invest in alternative data sources, such as community dashboards and informant interviews, to inform a more comprehensive understanding of causes of maternal mortality.

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BACKGROUND: Pseudomyxoma peritonei (PMP) arising from the appendix is a rare entity. Complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only established curative treatment, and is reputedly linked to high morbidity and mortality. We report, to our knowledge, the first case of delayed lethal Wernicke encephalopathy (WE) complicating CRS with HIPEC for an appendicular PMP. WE, caused by a thiamine deficiency, is characterized by ataxia, nystagmus and changes in consciousness. METHODS: A patient underwent complete CRS with HIPEC for a low grade mucinous appendicular tumor at the stage of PMP with a peritoneal index of 31, and was readmitted at POD 36 for persistent vomiting and vague neurological symptoms of mental confusion. The classic triad of WE appeared tardily. Although thiamine substitution was promptly applied, the patient died at POD53. CONCLUSION: WE is an uncommon and severe neurological disorder with a mortality rate up to 20 % and only 16 % of treated patients can fully recover. This diagnosis should always be anticipated in patients undergoing major surgery such as CRS- HIPEC. Efficient treatment should be quickly introduced in order to avoid a lethal outcome.

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The Family Violence Death Review Committee (FVDRC) is one of five Mortality Review Committees (MRCs) that sit within the Health Quality & Safety Commission, Aotearoa, New Zealand. A key goal of the work of these committees is the reduction of the unequal burden of disparities shouldered by Maori (Indigenous peoples). Guidance to the committees on interpreting and reporting Maori mortality comes from Te Pou (the pillar/post), a Maori responsiveness rubric published in 2019 by Nga Pou Arawhenua (the caucus of Maori MRC members). This guidance was called upon by the FVDRC in the preparation of its sixth report, "Men who use violence," published in 2020. In this article, the FVDRC reflects on how it strove to uphold responsibilities toward Te Titiriti o Waitangi1 in its sixth report to get the story right (Tika-to be correct or true), be culturally and socially responsive (Manaakitanga-hospitability, kindness, support), advance equity, self-determination and social justice (Mana-prestige, authority, spiritual power), and establish relationship for positive change (Mahi Tahi-working together). Opportunities for improved responsiveness in FVDRC reporting are identified, alongside suggestions for extending the guidance in Te Pou. Reflective practice on responsiveness to Maori/Indigenous peoples is recommended more generally for MRCs.

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In England, the national mortality review programme for people with intellectual disabilities, the LeDeR programme, was established in 2015. The programme supports local areas to review the deaths of all people with intellectual disabilities aged 4 years and over. Each death has an initial review; if indicated, a full multi-agency review takes place. The learning from the mortality reviews contributes to service improvements locally and nationally. This paper describes the programme's introduction and processes, exploring the challenges faced, and the successes achieved. It considers the background and rationale for the programme and the steps taken during its implementation, in order that others can learn from our experiences. Now the programme is established, its focus needs to shift so that we have a better understanding about how the findings of mortality reviews are leading to local and national service improvements and their impact.

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OBJECTIVE: Parent engagement in perinatal mortality review meetings following stillbirth may benefit parents and improve patient safety. We investigated perinatal mortality review meeting practices, including the extent of parent engagement, based on self-reports from healthcare professionals from maternity care facilities in six high-income countries. DESIGN: Cross-sectional online survey. SETTING: Australia, Canada, Ireland, New Zealand, UK and USA. POPULATION: A total of 1104 healthcare professionals, comprising mainly obstetricians, gynaecologists, midwives and nurses. METHODS: Data were drawn from responses to a survey covering stillbirth-related topics. Open- and closed-items that focused on 'Data quality on causes of stillbirth' were analysed. MAIN OUTCOME MEASURES: Healthcare professionals' self-reported practices around perinatal mortality review meetings following stillbirth. RESULTS: Most clinicians (81.0%) were aware of regular audit meetings to review stillbirth at their maternity facility, although this was true for only 35.5% of US respondents. For the 854 respondents whose facility held regular meetings, less than a third (31.1%) reported some form of parent engagement, and this was usually in the form of one-way post-meeting feedback. Across all six countries, only 17.1% of respondents described an explicit approach where parents provided input, received feedback and were represented at meetings. CONCLUSIONS: We found no established practice of involving parents in the perinatal mortality review process in six high-income countries. Parent engagement may hold the key to important lessons for stillbirth prevention and care. Further understanding of approaches, barriers and enablers is warranted. TWEETABLE ABSTRACT: Parent engagement in mortality review after stillbirth is rare, based on data from six countries. We need to understand the barriers.

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In the United States, maternal mortality, defined as all deaths during pregnancy, childbirth, and up to 365 days after the end of pregnancy, is among the highest of all developed nations. For every 1 maternal death, there are more than 100 life-threatening complications that occur related to pregnancy. However, maternal morbidity and mortality do not affect all mothers equally. Black and indigenous people are at the highest risk for pregnancy-related complications and death-they are up to 5 times as likely to die from childbearing than white women. To understand this nationwide epidemic, cases of maternal death must be thoroughly reviewed, including the medical, social, and societal circumstances surrounding them. The state of Hawai'i formed the Maternal Mortality Review Committee in 2016 to review cases of maternal mortality, collect accurate data, and develop strategies for prevention. Twenty-five maternal deaths occurred in the state of Hawai'i from 2015 to 2017. More than half of these deaths were deemed preventable. Combined data show that mental health disorders played a significant role in maternal mortality, and approximately a quarter of cases involved substance use. Twenty-three percent of maternal deaths occurred in Native Hawaiian and Pacific Islander women, even though they make up a smaller proportion of women in the state. The collection and analysis of these data are the first steps toward understanding and reducing maternal morbidity and mortality in Hawai'i. Most notably, the striking ethnic disparities in maternal deaths and the preventable nature of many cases demand our immediate attention.

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BACKGROUND: There is a lack of evidence about the effectiveness of the national clinical outcome review programmes in England. METHODS: We undertook a scoping review of the published literature for evidence of the impact of any of the current programmes or their predecessors, and asked programme leads to share examples of the impact of their work. Data were thematically analysed. FINDINGS: Evidence about impact related to clinicians' awareness and practice, structural aspects of healthcare, processes of care and patient outcomes. CONCLUSIONS: The national clinical outcome review programmes appear to have had significant impact, but none are funded to assess the outcome and impact of the recommendations they make or to deliver a programme of change. There is no structured and systematic way in which the findings and recommendations of each programme are taken forward, nor in which the findings from across programmes are collated and considered.

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OBJECTIVE: To improve consistency in New Zealand's Mortality Review Committees' (MRCs) analysis, interpretation and recommendations, specifically related to equity and Maori (the Indigenous peoples of Aotearoa New Zealand) mortality. DESIGN: A qualitative Plan-Do-Check-Act design informed by Maori expertise to develop a rubric and guidelines. The rubric and guidelines aimed to improve MRCs' capability to analyse mortality data, its interpretation and the recommendations for preventing deaths. SETTING: New Zealand's MRCs make recommendations to address preventable deaths. Variation existed between the MRCs' understanding of equity, and its application to reduce avoidable mortality for Maori, which subsequently influenced their analysis, reporting and the recommendations generated. Improving the quality and robustness of MRCs' recommendations and reporting are crucial for improving equity. PARTICIPANTS: Maori Caucus (comprising MRC members with Maori health and wellbeing expertise) designed the rubric and guidelines with input from the secretariat and other MRC Chairs and members. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULTS: The rubric comprises four key 'pou' (metaphorical posts or domains) 'Tika' (doing things right); 'Manaakitanga' (caring compassionately); 'Mana' (status, authority); and 'Mahi tahi' (working collaboratively); and criteria for three levels of practice. Evaluation of the efficacy of the use of the rubric and its implementation showed further education and support was required. CONCLUSIONS: A shared understanding of equity about mortality is required. Effective implementation of a quality-based rubric into practice requires careful planning and ongoing education and support for staff and committee members at multiple levels. Follow-up support is needed to support its implementation into practice.

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Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events, as well as prolonged morbidity in bereaved families and hospital staff. Perinatal mortality reviews can identify factors contributing to suboptimal care. An integrative literature review was carried out to study the different types of perinatal mortality reviews currently being done internationally, establishing a comparison and examining promising new developments. We start by outlining issues with the classification of perinatal deaths and the different types of perinatal mortality reviews carried out in high-income countries. We reflect on the challenges that are encountered in the current processes and we then comment on how these may be overcome. Current literature shows that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data to facilitate national and international benchmarking. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. Additionally, there is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Review tools and processes have been implemented in some countries to standardize perinatal mortality reviews, but there is still more work to be done. Involving the bereaved parents in the perinatal mortality review process is important and ways to achieve this are progressing. A structured approach to the perinatal mortality review process should be developed to facilitate sharing of experiences and challenges at national (or international) level. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

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OBJECTIVES: This review aims to describe the processes that have been used to implement child mortality reviews in LMICs and to identify the facilitators and barriers to their implementation and impact. This will help to inform healthcare professionals and managers planning to implement a child mortality review in their setting. METHODS: MEDLINE and Embase databases were searched for papers published between January 1996 and April 2019. Studies reporting the implementation of a child mortality review process in LMICs were considered eligible. A narrative approach was used to describe the stages in the audit process outlined in the WHO 'Operational guide for facility-based audit and review of paediatric mortality' which were completed, and to synthesise the barriers and facilitators to implementation and impact of the child mortality review process. RESULTS: From 776 potentially relevant articles, seven studies were included. In six studies, problems contributing to child deaths and possible solutions were identified, in four, these solutions were implemented, and in one, this implementation was monitored. Key factors influencing implementation and impact were attendance at meetings, use of a blame-free approach, allocating adequate human and financial resources to make changes, and level of engagement from leadership. CONCLUSIONS: Despite the common use of mortality reviews in paediatric departments, there are few studies published on this topic. The transition from identifying problems and solutions to implementing and monitoring action plans appears to be the most difficult aspect of the process, which requires commitment of adequate resources and strong leadership.

OBJECTIFS: Cette analyse vise à décrire les processus qui ont été utilisés pour mettre en œuvre des analyses de la mortalité infantile dans les PRFI et pour identifier les facilitateurs et les obstacles à leur mise en œuvre et à leur impact. Cela aidera à informer les professionnels de la santé et les gestionnaires qui prévoient de mettre en œuvre une analyse de la mortalité infantile dans leurs cadres. MÉTHODES: Les bases de données MEDLINE et EMBASE ont été recherchées pour les articles publiés entre janvier 1996 et avril 2019. Les études signalant la mise en œuvre d'un processus d'analyse de la mortalité infantile dans les PRFI ont été jugées éligibles. Une approche narrative a été utilisée pour décrire les étapes du processus d'audit décrites dans le "Guide opérationnel de l'OMS pour l'audit et l'analyse de la mortalité pédiatrique dans les établissements" qui ont été achevées, et pour synthétiser les obstacles et les facilitateurs à la mise en œuvre et à l'impact du processus d'analyse de la mortalité infantile. RÉSULTATS: Sur 776 articles potentiellement pertinents, sept études ont été incluses. Dans six études, des problèmes contribuant aux décès d'enfants et des solutions possibles ont été identifiés, dans quatre, ces solutions ont été mises en œuvre et dans une, cette mise en œuvre a été suivie. Les facteurs clés influençant la mise en œuvre et l'impact étaient: la participation aux réunions, l'utilisation d'une approche sans reproche, l'allocation de ressources humaines et financières adéquates pour apporter des changements et le niveau de l'engagement de la direction. CONCLUSIONS: Malgré l'utilisation courante des analyses de mortalité dans les services de pédiatrie, peu d'études ont été publiées sur ce sujet. La transition de l'identification des problèmes et des solutions à la mise en œuvre et au suivi des plans d'action semble être l'aspect le plus difficile du processus, qui nécessite l'engagement de ressources adéquates et un leadership fort.

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Mortality surveillance and cause of death data are instrumental in improving health, identifying diseases and conditions that cause a high burden of preventable deaths, and allocating resources to prevent these deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) network uses a standardized process to define, assign, and code causes of stillbirth and child death (<5 years of age) across the CHAMPS network. A Determination of Cause of Death (DeCoDe) panel composed of experts from a local CHAMPS site analyzes all available individual information, including laboratory, histopathology, abstracted clinical records, and verbal autopsy findings for each case and, if applicable, also for the mother. Using this information, the site panel ascertains the underlying cause (event that precipitated the fatal sequence of events) and other antecedent, immediate, and maternal causes of death in accordance with the International Classification of Diseases, Tenth Revision and the World Health Organization death certificate. Development and use of the CHAMPS diagnosis standards-a framework of required evidence to support cause of death determination-assures a homogenized procedure leading to a more consistent interpretation of complex data across the CHAMPS network. This and other standardizations ensures future comparability with other sources of mortality data produced externally to this project. Early lessons learned from implementation of DeCoDe in 5 CHAMPS sites in sub-Saharan Africa and Bangladesh have been incorporated into the DeCoDe process, and the implementation of DeCoDe has the potential to spur health systems improvements and local public health action.

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The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

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