Maternal Mortality

Maternal deaths are devastating events with profound and prolonged effects on families and other survivors, as well as a public health issue of critical importance. The United States is one of the only countries in the world that has seen a rise in maternal mortality rate since 2000. For many years, New York State's maternal mortality rate mirrored that increase. In recent years, following NYSDOH's efforts, this trend has begun to reverse.

Still, there is work to do. Black birthing people in the U.S. die at more than double the rate of Caucasian birthing people. The number of maternal deaths in New York State and the persistent disparities in maternal mortality rate between Black and Caucasian New Yorkers are both of urgent concern.

NYSDOH remains committed to addressing systemic inequities and creating safer birth experiences for New Yorkers. To support this work, NYSDOH has established the New York State Maternal Mortality Review Board (MMRB) and the New York State Maternal Mortality & Morbidity Advisory Council (MMMAC). Both groups help to identify common factors contributing to death and develop the recommendations needed to improve the health and safety of pregnant New Yorkers statewide.

This page offers information and resources for soon to be, pregnant, or post-partum New Yorkers, as well as the multitude of providers who care for them.

New York State Maternal Mortality Review Initiative


In response to this public health issue, NYSDOH created the Maternal Mortality Review Initiative in 2010 to perform a comprehensive review of maternal deaths.

Public Health Law Section 2509, enacted in 2019, requires the establishment of the state maternal mortality review board and a biennial report to the Commissioner of Health. The law provides the committee with the authority to collect data for a maternal death case review. It also ensures the confidentiality of the case reviews.

In 2019, the NYSDOH established the Maternal Mortality Review Board (MMRB) to examine information related to pregnancy-associated deaths and to issue findings and recommendations to advance the prevention of maternal mortality. The Board's multidisciplinary members volunteer their time to review maternal deaths and develop recommendations to improve maternal outcomes to prevent future deaths. The mission, vision, and goals of the MMRB are as follows:


To increase awareness and knowledge of the issues surrounding pregnancy-associated deaths and to promote change among individuals, communities, and health care systems to reduce the number of deaths.


No New York State family or community suffers a loss of a mother due to a preventable pregnancy-associated death.


To conduct a timely, comprehensive, multidisciplinary review of all pregnancy-related and select pregnancy-associated cases within 2 years of the date of death to identify actionable recommendations to prevent future deaths.

Public Health Law Section 2509 also allows New York City (NYC) to establish its own board. In NYS, two boards review pregnancy-associated deaths. The NYS Maternal Mortality Review Board, led by NYSDOH, reviews all pregnancy-associated deaths in NYS that occur outside of NYC. The NYC Maternal Mortality and Morbidity Review Committee (M3RC) led by the New York City Department of Health and Mental Hygiene, reviews pregnancy-associated deaths that occur within NYC. These committees' collective efforts form a comprehensive review of pregnancy-associated deaths in NYS. The NYSDOH combines the review of both committees into a statewide report with recommendations.


  1. Maternal Mortality Review Initiative staff identifies potential pregnancy-associated deaths.
  2. MMRI staff gathers records for each pregnancy-associated death.
  3. Abstractors enter information and prepare case summaries using a standardized review tool: CDC's Maternal Mortality Review Information Application (MMRIA).
  4. MMRB member reviewers examine the case abstraction and prepares to present the case to the MMRB.
  5. During the MMRB meetings, Board members review and discuss each case summary and determine pregnancy-relatedness, preventability, and contributing factors leading to death, as well as proposing focused recommendations for action.


Pregnancy-associated death:
A death during pregnancy or within one year of the end of pregnancy.
Pregnancy-related death:
A death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.
Pregnancy-associated, not related death:
A death during pregnancy or within one year of the end of pregnancy from a cause that is not related to pregnancy
Pregnancy-associated, unable to determine relatedness death:
A death during pregnancy or within one year of the end of pregnancy where it cannot be determined from the available information whether the cause of death was related to pregnancy.

Contact Information

  • New York State Maternal Mortality Review Team
    Phone: (518) 473-9883
    Fax: (518) 474-1420
  • Marilyn Kacica, MD, MPH
    Medical Director,
    Division of Family Health
    New York State Department of Health
  • Joanne Guo, M.S.
    Director, Maternal Mortality Review Initiative
    Division of Family Health
    New York State Department of Health