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Maternal Mortality in Georgia: Through the Public Health Lens Presenter: Maria Fernandez Healthy Mothers, Healthy Babies Annual Meeting Oct 7, 2014

Maternal Mortality in Georgia Through the Public Health Lens

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Healthy Mothers Healthy Babies 2014 Annual Meeting & Conference October 7th, 2014 Presented by: Maria Fernandez Georgia Department of Public Health

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Page 1: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Mortality in Georgia: Through the Public Health Lens

Presenter: Maria Fernandez

Healthy Mothers, Healthy Babies Annual Meeting

Oct 7, 2014

Page 2: Maternal Mortality in Georgia Through the Public Health Lens

IN 2013

85 WOMEN DIED

MATERNAL MORTALITY

G E O R G I A RA N K S

# 50

N A T I O N A L LY

AWHONN 2013

Page 3: Maternal Mortality in Georgia Through the Public Health Lens

Overview

Inform Protect Prevent

COLLECTIVE IMPACT

Page 4: Maternal Mortality in Georgia Through the Public Health Lens

Evolution of Maternal Mortality Definition

1975 1980 1985 1990 1995 2000 2005 2010

2003-present5 supplemental fields added to death certificate to determine death timing in relation to pregnancy.

1992Other states add separate pregnancy question to track time of death.

1900-1979: ICDDeath of a pregnant woman or recently pregnant woman as a result of complications of pregnancy or childbirth.

1979: ICD ExpansionExplicit ICD codes broadened. Parameters added to focus on time of death within 42 days post-partum.

1999-2003ICD-10 change include direct obstetric deaths, indirect obstetric deaths, late maternal death and pregnancy-related death. Results in CDC DRH, NVSS and ICD using different terms for similar concepts.

Page 5: Maternal Mortality in Georgia Through the Public Health Lens

INFORM:

Epidemiology of Maternal Mortality

Page 6: Maternal Mortality in Georgia Through the Public Health Lens

Worldwide Maternal Mortality: 2013

Page 7: Maternal Mortality in Georgia Through the Public Health Lens

Worldwide Maternal Mortality: 1990-2013

North & South America

North & South America

Page 8: Maternal Mortality in Georgia Through the Public Health Lens

United States Maternal Mortality: 1987-2010

Page 9: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Mortality: United States

50,000suffer severe morbiditiesdue to pregnancy-related complications

For women in the United States, each year:

650die

due to p regnancy-

re la ted compl i ca t ions

This means that for every 1 woman who dies due to a pregnancy-related condition, another 76 women experience a severe co-morbidity. 70%

in20

years

Page 10: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Rate 2002-2012

Source: Georgia Vital Statistics

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

10

20

30

40

50

60

70

Rati

o (

Per

1,0

00

) live b

irth

s

Page 11: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Initiatives

Page 12: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Initiatives

Partnership with Emory University

Medicaid Policy Changes

Maternal Mortality Review Committee

1

2

3

Working with Emory to expand midwifery training programs

• P4HB to increase family planning• Payment for LARCs at delivery

Partnership with the Georgia OB/Gyn Society to lead the MMRC

Page 13: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Review Committee

Page 14: Maternal Mortality in Georgia Through the Public Health Lens

MMRC Members

Chair- Dr. Michael Lindsay

Clinicians

Public Health

Practitioners

Mental Health

Providers

Coordinator: Debbie

Sibley

Chart Abstractors

Sub Committee

Page 15: Maternal Mortality in Georgia Through the Public Health Lens

Purpose of the MMRC

• Identify all maternal deaths in Georgia• Review maternal deaths that are/may be

pregnancy-related• Determine modifiable factors related to

the death• Develop non-punitive actionable

recommendations• Reduce maternal death

Page 16: Maternal Mortality in Georgia Through the Public Health Lens

Case review criteria

Maternal Death• Death must have occurred to a woman

who was either pregnant at time of death or within one year

Pregnancy-Related Maternal Death• Suicides and drug overdoses within six

months • Motor vehicle accidents within six months• Intentional and unintentional injuries not

routinely reviewed

Page 17: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Death

Pregnancy Associated Mortality

Pregnancy Related

Mortality

Page 18: Maternal Mortality in Georgia Through the Public Health Lens

Maternal death identification process

Deaths Identified

Check Mark Death Certificate

Mandatory Reporting

Vital Records Linkage

Page 19: Maternal Mortality in Georgia Through the Public Health Lens

DeathSelect cases for

abstractionCommittee recommend-

ations

MMRC Process

Page 20: Maternal Mortality in Georgia Through the Public Health Lens

Limitations on identification process

Identification of maternal deaths are complicated

• What happens if a mom was a resident of a different state at delivery?

• Do you capture deaths related to induced terminations?

Death certificates are not always complete and/or accurate

Fetal death certificates are not routinely completed

Page 21: Maternal Mortality in Georgia Through the Public Health Lens

Findings from MMRC

Georgia 2012 Maternal Mortality

Page 22: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Mortality, Georgia 2012

Pregnancy-Associated Pregnancy-Related

N = 61

N = 24

85total

Page 23: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by timing of death Georgia, 2012

Whi

le P

regn

ant

1-42

day

s po

st-p

artu

m

43-3

65 d

ays

post

-par

tum

0

10

20

30

40

50

60

17 16

52

8 5

48

9 114 Total

Pregnancy-AssociatedPregnancy-RelatedF

req

uen

cy

Page 24: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by race Georgia, 2012

Fre

qu

en

cy

White Black Hispanic Other0

5

10

15

20

25

30

35

40

45

Pregnancy Associated

Pregnancy Related

Total

Page 25: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by age Georgia, 2012

Fre

qu

en

cy

Less than 20 yrs old

20-24 yrs old

25-29 yrs old

30-34 yrs old

35+ yrs old0

5

10

15

20

25

30

TotalPregnancy Asso-ciatedPregnancy Related

Page 26: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by education Georgia, 2012

Less

than

12

year

sHS

Som

e Co

llege

Colle

ge

Colle

ge+

0

5

10

15

20

25

30

Pregnancy Associated

Pregnancy Related

Total

Fre

qu

en

cy

Page 27: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by marital status Georgia and payor, 2012

Married Single 0

10

20

30

40

50

60

22

37

10

14

Pregnancy-AssociatedPregnancy-RelatedSeries3

Medicaid Private Self pay Other0

5

10

15

20

25

30

35

40

45

50

31

51

13

13

2

0

0

Pregnancy-AssociatedPregnancy-RelatedSeries3

Page 28: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by occupation: Georgia, 2012

35

2

10

17

35

15

26

20

0

5

9

4 1

0

1

1

1

Chart Title

Pregnancy-Associated

Pregnancy-Related

Page 29: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by mode of delivery: Georgia, 2012

N=68

Vaginal Cesarean0

5

10

15

20

25

30

35

40

27

37

22

26

5

11

TotalPregnancy AssociatedPregnancy Related

Page 30: Maternal Mortality in Georgia Through the Public Health Lens

Leading Causes of Maternal Mortality

Page 31: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by cause of death:

Worldwide

Hemorrhage Infection Eclampsia Obstructed Labor

Unsafe Abortion

0

5

10

15

20

25

30

25%

15%

13%

7%

13%

Perc

enta

ge o

f all p

regnancy

-rela

ted

death

s

Page 32: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by cause of death:

United States

Cardi

ovas

cula

r di

seas

e

Infe

ctio

n

Non-c

ardi

ovas

cula

r di

seas

e

Cardi

omyo

path

y

Hemor

rhag

e

Thro

mbo

tic p

ulm

onar

y em

bolis

m

Hyper

tens

ive

diso

rder

of p

regn

ancy

cere

brov

ascu

lar ac

cide

nt

amni

otic fl

uid

embo

lism

anes

tesia

com

plicat

ions

0

2

4

6

8

10

12

14

1615%

14%13%

12% 12%

10% 9%

6%5%

1%

Perc

ent

of

all p

regnancy-r

ela

ted d

eath

s

Page 33: Maternal Mortality in Georgia Through the Public Health Lens

Maternal mortality by cause of death: Georgia

Cardiac Embolism Seizure disorder Hemorrhage Hypertension Drug overdose0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

21%

17%

13%

8% 8% 8%

Perc

ent

of

all p

regnancy r

ela

ted d

eath

s

Page 34: Maternal Mortality in Georgia Through the Public Health Lens

An In-Depth Review of Initially Identified Cases

Page 35: Maternal Mortality in Georgia Through the Public Health Lens

Chronic Diseases Apparent During the Prenatal Period, Georgia 2012

N = 34

Depression Diabetes Epilepsy Hypertension Sickle Cell Other0

2

4

6

8

10

12

5

4

6

10

2

11

Page 36: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Mortality by pre-pregnancy weight: Georgia 2012

(N=17)

Normal Overweight Obese Morbidly Obese0

1

2

3

4

5

6

7

TotalPregnancy AssociatedPregnancy Related

Page 37: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Health Promotion Initiatives

Page 38: Maternal Mortality in Georgia Through the Public Health Lens

Chronic Disease & Pregnancy Awareness

http://youtu.be/K02elLJotaU

Page 39: Maternal Mortality in Georgia Through the Public Health Lens

Cardiac Brochure

Chronic Disease Poster

Page 40: Maternal Mortality in Georgia Through the Public Health Lens

SCD Brochure

Diabetes Brochure

Page 41: Maternal Mortality in Georgia Through the Public Health Lens

Georgia Maternal Mortality Gap

Page 42: Maternal Mortality in Georgia Through the Public Health Lens

October: Domestic Violence Month

Page 43: Maternal Mortality in Georgia Through the Public Health Lens

Prevent

Page 44: Maternal Mortality in Georgia Through the Public Health Lens

Prevention Strategies

• Expansion of midwives• Increase family planning• Risk screening through prenatal care

• Early detection of problems can lead to better preparation at birth

• If no risks are found could provide a false sense of security

Page 45: Maternal Mortality in Georgia Through the Public Health Lens

MMRC current action item

AMCHP Grant• Every Mother’s Initiative grant ($30,000: 1

year)

Focused on risk factors• Chronic diseases

Two arms• Provider education• Patient education

Page 46: Maternal Mortality in Georgia Through the Public Health Lens

Protect

Page 47: Maternal Mortality in Georgia Through the Public Health Lens

Maternal Mortality Law

SB 273 – Senator Burke• Requires public health to establish a

maternal mortality review committee• Provide legislative findings • Provide data• Provide confidentiality and limited

liability of reviews

Page 48: Maternal Mortality in Georgia Through the Public Health Lens

Collective Impact

Page 49: Maternal Mortality in Georgia Through the Public Health Lens

Collective Impact

• The risk factors associated with whether a woman lives or dies as a result of pregnancy are the same risk factors that are associated with if a baby lives or dies.

• Understand and address the role of social determinants on maternal death• Housing?• Education?• Finances?

Page 50: Maternal Mortality in Georgia Through the Public Health Lens

How you can help?

Providers:• Report maternal deaths• Join our perinatal quality collaborative• Every woman, every time

Public:• Encourage healthy behaviors and lifestyles• Encourage early and regular prenatal care• End domestic violence• Address mental health concerns• Advocate for paid maternity leave

Page 51: Maternal Mortality in Georgia Through the Public Health Lens

Food for thought

• What role does the father play in preventing maternal death?

• Social support decreases infant death, what about maternal death?

• What about the mom after the baby is born? – Program support is usually focused on baby– Family support is usually focused on baby

• How can we better focus on women who were recently pregnant, and not just mothers?

Page 52: Maternal Mortality in Georgia Through the Public Health Lens

Pregnancy is SPECIAL, Let’s make it SAFE

~Safe Motherhood