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Maternal MortalityInternationalUnited StatesWashington State

Thomas R. Easterling, MDProfessor

Maternal-Fetal MedicineUniversity of Washington

Seattle, WA

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Georgia

Ivory CoastNigeriaCameroon

NamibiaBotswanaSouth AfricaSwazilandZimbabweMozambiqueMalawi

Georgia

Afghanistan

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Hemorrhage

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

HypertensionIndiaMMR 323≤ 10%

MexicoMMR 5720-30%

ColumbiaMMR 76

≥30%

ChileMMR 4120-30%

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

AbortionHypertension

Hemorrhage

Hemorrhage

Hypertension

Hemorrhage

Hypertension

Hypertension

Hemorrhage

Embolism

Embolism

Embolism

Africa - South Asia• MMR 300-600/100,000• 9% Hypertension

Latin America - Caribbean• MMR 50-100/100,000• 25% Hypertension

Canada• MMR 6.1/100,000• 14% Hypertension

Netherlands• MMR 8.8/100,000• 39% Hypertension

Latin America-Caribbean

Africa Asia

Developed Countries

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Delay in Diagnosis• Asymptomatic until severe• Technology required• Skilled operator

Delay Reaching Care• Roads• Access to vehicles• Social customs

Delay Appropriate Care• MgSO4• Blood pressure control• Delivery

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Lucknow Nagpur VelloreDeliveries 4652 9600 8702MMR 319 376Booked 3.2% 65% 100%Eclampsia Rate 5.4% 2.6% 0.6%Case-Fatality Rate 14.7% 8.1%* 6.1%

Treatment of Preeclampsia Low Resource Settings

Lucknow

Vellore

Nagpur

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Eclampsia Rate /10,000 births

High-income Countries Low-income Countries

>10Xreduction

minimalreduction

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Eclampsia Case Fatality Rate (%)

High-income Countries Low-income Countries

>10Xreduction minimal

reduction

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Perinatal Advisory CommitteeMaternal Mortality Subcommittee

• Thomas Benedetti• Sherilynn Casey

(2004)• Kathy Chapman• Jane Dimer• Thomas Easterling• Leslee Goetz• Ann Lima• Nancy O’Brien Abel

• Dale Reisner• Melissa Schiff• Polly Taylor• Danae Steele (2001)• Carla Syverson• Cathy Wasserman• Jeanette Zaichkin (2001)

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Introduction

• Concerns were raised in late 1990s about maternal mortality in WA and whether it was increasing.

• Death certificates at that time were known to undercount maternal deaths.

• Perinatal Advisory Committee convened a subcommittee to explore maternal mortality surveillance in 1999.

• Initial findings presented in 2001 and again in 2004, but methodology was incomplete.

• Ascertainment methodology now complete for 1990-2005.

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Definitions

• A Pregnancy-Associated Death is the death of a woman while pregnant or within a year of delivery or termination of pregnancy from anycause.

• A Pregnancy-Related Death is the death of a woman while pregnant or within a year of delivery or termination of pregnancy from any cause related to or aggravated by pregnancy or its management.

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Pregnancy-Related Mortality in Washington

0.02.04.06.08.0

10.012.014.016.0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Deat

hs p

er 1

00,0

00 L

iveb

irths

3 Year Maternal Mortality Ratio Maternal Mortality Ratio

On Average 7 deaths reported per year

Maternal Mortality Ratio – 8.3 deaths per 100,000 live births

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Pregnancy-Related Deaths by CauseWashington, 1990-2005

MMR 7-8/100,000

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Preventability of Pregnancy-Related DeathsWashington, 1990-2005

Cause of DeathTotal

DeathsPreventable

Deaths

Possibly Preventable

Deaths

Not Preventable

DeathsInfection 19 1 16 2Cardiac/Cardiovascular 19 2 8 9Deep Vein Thrombosis 13 0 2 11Amniotic Fluid Embolism 12 1 2 9OB Hemorrhage 12 5 6 1Hypertension 9 9 0 0CNS/CVA 7 0 1 6Anesthesia 2 2 0 0Other Cause 9 2 5 2Don't Know 3 0 3 0Total 105 22 43 40

Pregnancy-Related Mortality Ratio = = 8.3 per 100,000 livebirths105

1,272,309

If remove 22 preventable deaths =

If remove 65 preventable and possibly preventable deaths

831,272,309 = 6.5 per 100,000 livebirths

=40

1,272,309 = 3.1 per 100,000 livebirths

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Maternal MortalityWashington State

2009-2012preliminary analysis

Births 350,306

Minimum MaximumPregnancy Related Deaths 32 47MMR/1000,000 live births 9.1 10.6

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Washington

1990 to2005

2009 to2012

7-8 9.1

Washington State

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Maternal MortalityWashington State

2009-2012preliminary analysis

Births 350,306

AFE CNS CV Arryth CM MI pHTNN 1 3 14 2 7 2 1MMR 0.29 0.86 4.0 0.57 2.0 0.57 0.29/year 0.25 0.75 3.5 0.5 1.75 0.5 0.25

Hem Ectopic Inf H1N1 PreE PEN 3 4 1 2 2 3MMR 0.86 1.14 0.29 0.57 0.57 0.86/year 0.74 1.0 0.25 0.5 0.5 0.75

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015

Hemorrhage*

9.4%0.75/yr

Hypertension9.4%

0.75/yr

Infection*3.1%

0.25/yr

AFE3.1%

0.25/yr

Pulm Emb9.4%

0.75/yr

CM22%%1.75/yr

CardioVasc44%

3.5/yr

Washington State 2009-2012CVA9.4%

0.75/yr

Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015