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Pregnancy Mortality Data—What Lies Below the Tip of the Iceberg?

Pregnancy Mortality Data—What Lies Below the Tip of the Iceberg?. Isabelle Horon, Dr.P.H. Director, Maryland Vital Statistics Administration June 9, 2010. Maternal Mortality Rates, U.S. Reasons for decline Shift from home to hospital deliveries

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Pregnancy Mortality Data—What Lies Below the Tip of the Iceberg?

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  1. Pregnancy Mortality Data—What Lies Below the Tip of the Iceberg? Isabelle Horon, Dr.P.H. Director, Maryland Vital Statistics Administration June 9, 2010

  2. Maternal Mortality Rates, U.S. Reasons for decline • Shift from home to hospital deliveries • Development of guidelines defining physician qualifications needed for hospital delivery privileges • Improved care for the poor • Medical advances • Antibiotics • Oxytocin to induce labor • Safe blood transfusion • Better management of hypertensive conditions during pregnancy • Legalization of induced abortion Add chart

  3. No improvement in recent years

  4. Why study pregnancy mortality? • Occur among young, apparently healthy women • At least half are believed to be preventable • Deaths represent only the tip of the iceberg of maternal morbidity • Death certificate data underestimate the problem • Comprehensive strategies to prevent deaths cannot be formulated without a clear understanding of the magnitude and causes of the problem

  5. Maternal Death • “The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” (WHO) • ICD10 codes A34, O00-O95, O98-O99 42 days Maternal death (maternal causes) Conception Delivery

  6. Reported maternal mortality rates underestimate the problem • Cause of death information reported on death certificates is often not complete • Physicians completing death certificates often fail to report that a woman was pregnant or recently pregnant, resulting in the misclassification of the underlying cause of death

  7. Hemorrhage • Induced abortion 4 days earlier

  8. Hemorrhage • History of preeclampia • Delivered full term, live born infant by • c-section 18 days earlier

  9. Cardiovascular disorder • Delivered full term infant 45 minutes • before she died

  10. Cardiovascular Disorder • Died in the ER • Post induced abortion

  11. Embolism • Pregnant w/ 3100 gm. fetus at time of death

  12. Accidental death • Car accident • Abruption • 2700 gm. infant died 2 days later

  13. Suicide • Became profoundly depressed after pregnancy loss • Committed suicide 6 mo. later

  14. Suicide • Severe postpartum depression • Sat on railroad tracks with 2 yo

  15. Homicide • 18 yo • Shot by boyfriend soon after learning of pregnancy

  16. “Maternal mortality rate” underestimates the problem • WHO definition limits the temporal and causal scope of pregnancy mortality • Includes only deaths occurring during pregnancy or within 42 days following termination of pregnancy • Includes only those causes related to, or aggravated by, the pregnancy or its outcome

  17. “Pregnancy-associated death” • Introduced by CDC in collaboration with the Maternal Mortality Special Interest Group of ACOG • “A death from any cause during pregnancy or within 1 calendar year of delivery or pregnancy termination, regardless of the duration or anatomical site of the pregnancy” • includes all maternal deaths, plus • deaths occurring 43-365 days following end of pregnancy • deaths from non-medical causes

  18. Pregnancy-Associated Death Pregnancy-associated death (any cause) 42 days 1 year Maternal death (maternal causes) Conception Delivery

  19. Enhanced Surveillance in Maryland • Sources of data • Death certificates • Linkage of records • Medical examiner records • Other sources

  20. Underreporting of Maternal Deaths, Maryland AJPH, March 2005

  21. Unreported Maternal Deaths, Maryland, 1993-2000.

  22. Unreported Maternal Deaths by Time of Death, Maryland, 1993-2000.

  23. Unreported Maternal Deaths by Cause of Death, Maryland, 1993-2000.

  24. Revision of U.S. Standard Death Certificate

  25. Revision of Maryland death certificate

  26. How effective are checkboxes?

  27. How effective are checkboxes?

  28. Unreported Pregnancy-Associated Deaths by Time of Death, Maryland, 2001-2008.

  29. Unreported Pregnancy-Associated Deaths by Cause, Maryland, 2001-2008.

  30. Horon and Cheng: “The Effectiveness of Pregnancy Checkboxes in Identifying Pregnancy Associated Deaths” (in press)

  31. NAPHSIS Survey • 36 jurisdictions responded • 31 had pregnancy checkbox on certificate • Data collection began before1989 in a few states; more began after 2003.

  32. Wording of pregnancy question • Conforms exactly to U.S. Standard (n=18) • Does not conform (n=13) • Pregnant within 42 days of death • Pregnant at delivery or within 90 days • Pregnant within last year • Pregnant in last 6 months • Additional detail collected • Problem with item on U.S. Standard Certificate • Unknown (n=5)

  33. Revision of U.S. Standard Death Certificate

  34. Enhanced surveillance • Linkage of records (n=16) • Other • Linkage with medical examiner records (n=3) • Linkage with review committee information (n=2) • Linkage with hospital discharge records (n=1) • Newspaper reviews • Maternal death reporting form

  35. Maternal and Pregnancy-Associated Mortality Rates for Selected States, 2006-2007. States

  36. Maternal Mortality Rates for Selected States, 2006-2007. Healthy People 2010 goal States

  37. What does this say about national pregnancy mortality data? Two sources of data within CDC • National Center for Health Statistics (NCHS) • Collects complete death certificate data from the states • Publishes maternal mortality data

  38. U.S. Maternal Mortality Rate, 2006 ?

  39. What does this say about national pregnancy mortality data? Two sources of data within CDC • National Center for Health Statistics (NCHS) • Collects complete death certificate data from the states • Compiles and publishes maternal mortality data • National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) • Attempts to collect broader range of mortality data • Requests that states voluntarily submit all pregnancy-associated death records and other related documents

  40. Pregnancy-associated homicide rates

  41. What does this say about national pregnancy mortality data? • When all states adopt the revised death certificate: • NCHS maternal mortality data should improve substantially • NCCDPHP expanded pregnancy mortality data is not likely to improve substantially

  42. Summary • Pregnancy mortality is still a problem • Causes broader than previously believed • Underreporting results in misconceptions • Magnitude of the problem of pregnancy mortality • Leading causes of death • Timing of death • Groups at high risk • Checkbox is only part of the solution to improving data • Multiple sources needed to identify all deaths • Care should be taken in forming conclusions based on incomplete data

  43. Take home message... • Comprehensive identification of pregnancy-associated deaths can only be accomplished by collecting information from multiple data sources and including all deaths occurring up to one year after pregnancy • Enhanced surveillance of pregnancy-associated deaths is necessary to: • Accurately document the magnitude and causes of pregnancy mortality • Identify groups at increased risk • Review factors leading to death • Plan prevention strategies • It is therefore a critical step in the reduction of pregnancy-associated mortality

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