William M. Callaghan, MD, MPHChief, Maternal and Infant Health Branch

Division of Reproductive HealthCenters for Disease Control and Prevention

Oklahoma Every Mother Counts InitiativeApril 24, 2015

Maternal Death and Severe Morbidity Review

 

National Center for Chronic Disease Prevention and Health Promotion

Division of Reproductive Health

I have no conflicts of interest to disclose.

Overview

• How do we account for maternal deaths in the United States?

• What is the difference between state and national review?

• Ideas for severe morbidity. Is state-level review the answer?

• Can we do it better?

28460

11

850

8

http://www.mchlibrary.info/history/childrensbureau.html#pubs

Maternal Mortality:1900-2010

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 20100

100

200

300

400

500

600

700

800

900

1000

Death

s p

er

10

0,0

00

liv

e

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ths

Factors Contributing to the Decline of Maternal Mortality in the 20th

Century

• Improved standard of living • Improved obstetric training and delivery practices• Hospital deliveries• Use of aseptic techniques• Contraception• Medical advances

– Antibiotics– Blood transfusion– Oxytocin– Better management of hypertensive disorders

Role of Maternal Mortality Review• 1930: Maternal Welfare Committee, Philadelphia County Medical Society• 1933: Maternal Mortality in New York City: A study of all Puerperal Deaths, 1930-1932• AMA Committee on Maternal and Child Care

– “Guide for Maternal Death Studies”

• Terminology and definitions

• Classification of causes

• Organization and operation of maternal mortality review committees

• Locations• Composition• Case finding• Analysis

• Findings for action

• Future expansion to maternal morbidity

• Colonial period births, deaths and marriages recorded by local clergy

• Nineteenth century births and deaths accounted for by census

• 1880 Census Bureau accepts vital registrations from states and cities

• 1933 complete state-based reports to Census Bureau• 1946 National Office of Vital Statistics in the Public Health

Service• 1960 National Center for Health Statistics• 1987 NCHS incorporated into CDC

Hetzel AM. History and Organization of the Vital Statistics System. Hyattsville, Md: National

Center for Health Statistics; 1997. Appendix II

Definitions• WHO ICD-9

– Maternal Death

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes• Cause of Death in pregnancy chapter (630-676)• Maternal mortality rate (MMR)

Definitions• WHO ICD-10

– Maternal Death • The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes

– Late Maternal Death - New

• Used for mortality beginning 1999• Pregnancy chapter O00-O99

2003 and beyond: Pregnancy checkbox

2002: 21 states with checkbox or prompt2005: 35 states with checkbox or prompt2010:41 states and DC with checkbox or prompt (5 different question formats)

Recent Trend

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

4

6

8

10

12

14

16

18

20

Death

s per

100,0

00 liv

e

bir

ths

CDC WONDER http://wonder.cdc.gov/

Xu , JQ, et al. Deaths: Final data for 2007. NVSR 58 (19). NCHS 2010

Pregnancy-Mortality Surveillance System

• ACOG/CDC Maternal Mortality Study Group (1986)

• Pregnancy-associated– All deaths during pregnancy and within the 1 year

following the end of pregnancy

• Pregnancy-related (subset of pregnancy-associated)– Complication of pregnancy– Aggravation of a unrelated condition by the

physiology of pregnancy– Chain of events initiated by the pregnancy

• Pregnancy Mortality Surveillance System (PMSS)

• Pregnancy-related mortality ratio (PRMR)

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

5

10

15

20

25

US MMR and PRMR

PRMRMMR

Death

s p

er

100,0

00 liv

e b

irth

s

MMR, United States, 1999-2013

Quintile 1:<10

Quintile 2:10-12

Quintile 3: 12-14.5

Quintile 4: 14.6-18.6

CDC WONDERQuintile 5: 18.7-37.9

Suppressed

Obstet Gynecol 2003;101:289–96

Obstet Gynecol 1996;88:161-7

Obstet Gynecol 2010;116(6):1302-9

Obstet Gynecol 2015;125:5–12

“PMSS Team”

• Carol Bruce, Team Lead• Bill Callaghan, Branch Chief• Andreea Creanga, Senior Scientist• Kristi Seed, Contractor (full time)• Carla Syverson, Contractor• Danielle Suchdev, Epidemiologist

<3 FTEs

Yearly Operations

PMSS DATA REQUEST & RECEIPT

PMSS CODING & DATA ENTRY

ON-GOING ABORTION DATA REQUEST & RECEIPT STARTING W/ 2011 DATA

PMSS & ABORTION DATA REVIEW

ANALYSIS

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

Pregnancy-related mortality by year and race-ethnicity: United States, 2006-2010

Non-Hispanic white

Non-Hispanic black

Hispanic Other All women0.0

6.0

12.0

18.0

24.0

30.0

36.0

42.0

12.0

38.9

11.714.2

16

2006 2007 2008

2009 2010 2006-2010

Years

Pre

gn

an

cy -

rela

ted

m

ort

ali

ty r

ati

o*

* Number of pregnancy-related deaths per 100,000 live births.

Pregnancy-related mortality ratios by age, race and ethnicity: United States, 2006–2010.

* Number of pregnancy-related deaths per 100,000 live births.

Non-Hispanic

white

Non-Hispanic

black

Hispanic Other All women0.0

30.0

60.0

90.0

120.0

150.0

<20 20-24 25-29 30-34 35-39 ≥40Age groups (years of age)

Pre

gn

an

cy -

rela

ted

m

ort

ali

ty r

ati

o*

Cause-specific proportionate pregnancy-related mortality: United States, 1987–2010.

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1987-1990 1991-1997 1998-2005 2006-2010

Pe

rce

nt

of

de

ath

s

Hemorrhage Mortality

1987-1990

1991-1997

1998-2005

2006-2010

0

5

10

15

20

25

30

35

28.7

18.2

12.5 11.4

2.4 2.1 1.8 1.8

Proportionate Mortal-ityCause-specific Mor-tality

Proportionate=percent of all deathsCause specific=deaths from hemorrhage per 100,000 live births

Hemorrhage and decrease in ectopic deaths

Creanga et al., Obstet Gynecol 2011;117: 837-43

01

.52

.53

.50

.51

.02

.03

.04

.0E

ctop

ic p

regn

an

cy m

ort

alit

y ra

tio*

2003-071980-84 1985-89 1990-94 1995-99 2000-04

All womenWhite womenBlack women

*Five-year moving averages per 100,000 live births

Pregnancy-Associated Mortality in Oklahoma, 2007-2013

Accident; 18.3%

Medical not Ob-stetric; 16.3%All Ob-

stetric causes; 47.0%

Other; 5.0%

Suicide; 4.0%

Assaults; 9.4%

Most Frequent Cause of Death, Ok-lahoma 2007-2013

Mortality per 100,000 Live Births

Year N

Pregnancy Associate

dPregnancy

Related

Not Pregnan

cy Related

200737 67.34 20.02 47.32

200821 38.35 18.26 20.09

200940 73.34 27.50 45.84

201030 56.39 34.48 21.91

201123 44.02 32.53 11.48

201223 43.61 24.65 18.96

201328 52.48 28.12 24.37

TOTAL202 53.65 26.51 27.14

The surveillance cycle

Identify cases

Act

Review cases

Analyse the results

Evaluate and refine

Maternal Morbidity

Morbidity: The Problem

• Maternal morbidity is difficult to define– Broad range of complications and conditions– Broad range of severity

• Maternal morbidity cannot be captured by a defined set of metrics– We need to start somewhere

Healthy mom

Death

Severe Maternal Morbidity: Near Miss

• Life-threatening events at delivery hospitalization– ‘‘a very ill pregnant or recently delivered woman who

would have died had it not been but luck and good quality care was on her side’’ (Mantel et al. Br J Obstet Gynecol, 105:985-90, 1998)

– “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” (Say et al. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287-96 doi: 10.1016/j.bpobgyn.2009.01.007 )

• Variety of data sources to identify cases based on indicators

• Near miss by expert opinion

Geller et al., JAMWA, 2002

Severe Maternal Morbidity: Near Miss

• 5 factor scoring system identified women with “near miss” morbidity– Organ system failure– Extended intubation– ICU admission– Surgical intervention– Transfusion ≥4 units blood

Geller et al., J Clin Epidemiol, 2004

Severe Maternal Morbidity: Near Miss• Overcomes the issue of severity

• Requires multiple sources or a dedicated perinatal database for identification– Most scoring system factors not available in

administrative databases– Less useful in smaller institutions– Cumbersome for state-level and national surveillance

• Organ system failure performs well by itself (Se 95%; Sp 88%)– Indicators of such in administrative data are attractive

candidates

• Transfusion ≥4 units and/or ICU admission is nearly as sensitive as the 5-factor system (Se 100%; Sp 78%)

• Geller et al. construct has been validated (You et al., Am J Perinatol 2013;30:21-4)

•Nationwide Inpatient Sample database•Aim to capture indicators of organ system failure•Use mortality hospitalizations to identify morbidity not previously considered•Length of stay >90th percentile for diagnosis-identified cases by mode of delivery

• >2 days vaginal• >3 days repeat cesarean• >4 days primary cesarean

•Include postpartum admissions

Callaghan et al. Obstet Gynecol 2012;120:1029-36

Maternal morbidityICD-9-CM

CodesDiagnosis code

Procedurecode

 

Acute renal failure 584, 669.3 x  

Cardiac arrest/ventricular fibrillation 427.41, 427.42, 427.5 x  

Heart failure during procedure or surgery

669.4x, 997.1 x  

Shock 669.1, 785.5x, 995.0, 995.4, 998.0 x  

Sepsis 038.0-038.9, 995.91, 995.92 x  

Disseminated intravascular coagulation

286.6, 286.9, 666.3 x  

Amniotic fluid embolism 673.1 x  

Thrombotic embolism 415.1x, 673.0, 673.2, 673.3, 673.8 x  

Puerperal cerebrovascular disorders 430, 431, 432.x, 433.x, 434.x, 436, 437.x, 671.5, 674.0, 997.2, 999.2

x  

Severe anesthesia complications 668.0, 668.1, 668.2 x  

Pulmonary edema 428.1, 518.4 x  

Adult respiratory distress syndrome 518.5, 518.81, 518.82, 518.84,799.1 x  

Acute myocardial infarction 410.xx x  

Eclampsia 642.6x x  

Blood transfusion 99.00-99.09   x

Hysterectomy 68.3-68.9   x

Ventilation 93.90, 96.01-96.05, 96.7x   x

Sickle cell anemia with crisis 282.62, 282.64, 282.69 x  

Intracranial injuries 800.xx, 801.xx, 803.xx, 804.xx, 851.xx-854.xx x  

Internal injuries of thorax, abdomen, and pelvis

860.xx—869.xx x  

Aneurysm 441.x x  

Operations on heart and pericardium 35.xx, 36.xx, 37.xx, 39.xx   x

Cardio monitoring 89.6x   x

Temporary tracheostomy 31.1   x

Conversion of cardiac rhythm 99.6x   x

Callaghan et al. Obstet Gynecol 2012;120:1029-36

Severe Morbidity

• Between 1998-1999 and 2008-2009 severe morbidity during delivery hospitalization increased ~75% (7.4-12.9 per 1,000 deliveries).– blood transfusions, acute renal failure, and

aneurysms all more than doubled

• Severe morbidity at postpartum hospitalizations more than doubled (1.4-2.9 per 1000 deliveries).– 13 of 25 indicators of severe morbidity at least

doubled.

• Large proportions of women who died in hospital had indicators for severe morbidity– e.g. 1/3 had transfusion; nearly 2/3 had ventilation

• Severe morbidity 100 times more common than mortality

• Facility surveillance AND REVIEW:• Transfusion ≥4 units• ICU admission

Obstet Gynecol 2014;123:978-81

https://www.npeu.ox.ac.uk/downloads/files/mbrraceuk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf

Alignment• The “M” in MFM• Every Mother Initiative (AMCHP)• Alliance for Innovation in Maternal Health (AIM)

http://www.safehealthcareforeverywoman.org/maternal-safety.html

http://www.safehealthcareforeverywoman.org

Alignment

Alignment

https://www.cmqcc.org/ob_hemorrhage

Alignment

https://www.cmqcc.org/preeclampsia_toolkit

Alignment

http://www.albany.edu/sph/cphce/mch_nyspqc_hypertensive_resources.shtml

Alignment

Alignment

http://www.nj.gov/health/fhs/professional/documents/maternal_mortality_review_team.pdf

Frieden TR. Am J Public Health 2010;100:590-95

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank Youwgc0@cdc.gov

National Center for Chronic Disease Prevention and Health Promotion

Division of Reproductive Health