Maternal Mortality Resources

Objectives: We examined trends and racial disparities (White, African American) in trimester of prenatal care initiation and adequacy of prenatal care utilization for US women and specific high-risk subgroups, e.g., unmarried, young, or less-educated mothers. Methods: Data from 1981-1998 US natality files on singleton live births to US resident mothers were examined. Results: Overall, early and adequate use of care improved for both racial groups, and racial disparities in prenatal care use have been markedly reduced, except for some young mothers. Conclusions: While improvements are evident, it is doubtful that the Healthy People 2000 objective for prenatal care will soon be attained for African Americans or Whites. Further efforts are needed to understand influences on and to address barriers to prenatal care.

Despite marked improvements in lowering infant and maternal mortality rates, certain racial and ethnic groups have benefited less. The reasons for these inequalities are many and complex. This article reviews the literature to assess the extent and reasons for the disparate outcomes in infant and maternal mortality rates among different racial and ethnic groups in the United States. Some strategies aimed at reducing these disparities are also highlighted. A systematic search of OVID-MEDLINE (1970–2005) electronic databases was conducted. This review, which contains data mostly on Black/White disparities, suggests that infant and maternal mortality rates differ among racial and ethnic groups. Potential strategies to ameliorate these differences include continued funding for community health centers, equitable and timely access to health care, and training of more minority physicians. In addition, continued research on the role of stress in preterm delivery among some minority women is important in any effort to lower these disparities.

Objective: The purpose of this study was to examine nondelivery, pregnancy-associated hospitalizations in the United States and the factors associated with them. Study design: Population-based nondelivery hospitalizations during pregnancy were obtained from the 1999 and 2000 National Hospital Discharge Survey. Ratios of hospitalizations per 100 deliveries were calculated and analyzed by age, race, and payment source. Results: The pregnancy-associated hospitalization ratio for 1999 through 2000 was 12.8 per 100 deliveries (95% CI, 11.8-13.8). Hospitalizations were highest among young women, African American women, and women without private insurance. Preterm labor, nausea and/or vomiting, and genitourinary complications accounted for one half of antenatal hospitalizations. Conclusion: Pregnancy-associated hospitalizations declined during the 1990s. This may represent a decline in maternal morbidity or a change in management of pregnancy complications. Future research should be expanded to assess trends in morbidity treated in settings outside of hospitals

Objectives. This study examined the associations between prepregnancy weight and the risk of pregnancy complications and adverse outcomes among nulliparous women. Methods. We conducted a population-based cohort study with 96 801 Washington State birth certificates from 1992 to 1996. Women were categorized by body mass index. Multivariate logistic regression was performed. Results. The rate of occurrence of most of the outcomes increased with increasing body mass index category. Compared with lean women, both overweight and obese women had a significantly increased risk for gestational diabetes, preeclampsia, eclampsia, cesarean delivery, and delivery of a macrosomic infant. Conclusions. Among nulliparous women, not only prepregnancy obesity but also overweight increases the risk of pregnancy complications and adverse pregnancy outcomes.

OBJECTIVE: To use data from the Centers for Disease Control and Prevention's (CDC) Pregnancy-Related Mortality Surveillance System to examine trends in pregnancy-related mortality and risk factors for pregnancy-related death.
METHODS: In collaboration with ACOG and state health departments, the Pregnancy-Related Mortality Surveillance System has collected information on all deaths caused by pregnancy since 1979. Multiple data sources were used, including national death files, state health departments, maternal mortality review committees, individuals, and the media. As part of the initiation of the Pregnancy-Related Mortality Surveillance System in 1987, CDC staff contacted state health department personnel and encouraged them to identify and report pregnancy-related deaths. Data were reviewed and coded by experienced clinicians. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated.
RESULTS: After decreasing annually after 1979, the reported pregnancy-related mortality ratio increased from 7.2 in 1987 to 10.0 in 1990. This increase occurred among women of all races. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live-birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy-related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. During the periods 1979-1986 and 1987-1990, the cause-specific pregnancy-related mortality ratios decreased for deaths due to hemorrhage and anesthesia, whereas pregnancy-related mortality ratios due to cardiomyopathy and infection increased. The leading causes of death varied according to the outcome of the pregnancy.
CONCLUSION: Increased efforts to identify pregnancy-related deaths have contributed to an increase in the reported pregnancy-related mortality ratio. More than half of such deaths, however, are probably still unreported. Adequate surveillance of pregnancy-related mortality and morbidity is necessary for interpreting trends, identifying high-risk groups, and developing effective interventions.

OBJECTIVE: To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes of these deaths. METHODS: De-identified copies of death certificates for women who died during or within 1 year of pregnancy and matching birth or fetal death certificates for 1998 through 2005 were received by the Pregnancy Mortality Surveillance System from the 50 states, New York City, and Washington, DC. Causes of death and factors associated with them were identified, and pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated. RESULTS: The aggregate pregnancy-related mortality ratio for the 8-year period was 14.5 per 100,000 live births, which is higher than any period in the previous 20 years of the Pregnancy Mortality Surveillance System. African- American women continued to have a three- to four-fold higher risk of pregnancy-related death. The proportion of deaths attributable to hemorrhage and hypertensive disorders declined from previous years, whereas the proportion from medical conditions, particularly cardiovascular, increased. Seven causes of death—hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions— each contributed 10% to 13% of deaths. CONCLUSION: The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10th Revision, and the addition by states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality collaboratives have the potential to identify deaths, review the factors associated with them, and take action on the findings. (Obstet Gynecol 2010;116:1302–9) LEVEL OF EVIDENCE: III

OBJECTIVE: To describe trends in pregnancy-related mortality and risk factors for pregnancy-related deaths in the United States for the years 1991 through 1997.
METHODS: In collaboration with the American College of Obstetricians and Gynecologists and state health departments, the Pregnancy Mortality Surveillance System, part of the Division of Reproductive Health at the Centers for Disease Control and Prevention, has collected information on all reported pregnancy-related deaths occurring since 1979. Data include those present on death certificates and, when available, matching birth or fetal death certificates. Data are reviewed and coded by clinically experienced epidemiologists. The pregnancy-related mortality ratio was defined as pregnancy-related deaths per 100,000 live births.
RESULTS: The reported pregnancy-related mortality ratio increased from 10.3 in 1991 to 12.9 in 1997. An increased risk of pregnancy-related death was found for black women, older women, and women with no prenatal care. The leading causes of death were embolism, hemorrhage, and other medical conditions, although the percent of all pregnancy-related deaths caused by hemorrhage declined from 28% in the early 1980s to 18% in the current study period.
CONCLUSION: The reported pregnancy-related mortality ratio has increased, probably because of improved identification of pregnancy-related deaths. Black women continue to have an almost four-fold increased risk of pregnancy-related death, the greatest disparity among the maternal and child health indicators. Although review of pregnancy-related deaths by states remains an important public health function, such work must be expanded to identify factors that influence the survival of women with serious pregnancy complications.

OBJECTIVE: Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced.
METHODS: The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented.
RESULTS: Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women.
CONCLUSION: Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.

OBJECTIVE: To assess progress toward meeting the U.S. Healthy People 2010 objective of reducing the rate of maternal morbidity at delivery hospitalization by comparing National Hospital Discharge Survey data from two time periods. METHODS: Using data from the National Hospital Discharge Survey, we estimated rates of intrapartum morbidity defined by obstetric complications, preexisting medical conditions, and cesarean delivery during 2001–2005 and compared them with rates published for 1993–1997. We calculated and compared the rates for categories of morbidity as well as rates for the summary groups of morbidity. RESULTS: Between the two time periods, the rate of obstetric complications remained unchanged at 28.6%; the prevalence of preexisting medical conditions at delivery increased from 4.1% to 4.9%. Rates of chronic hypertension and preeclampsia, gestational and preexisting diabetes, asthma, and postpartum hemorrhage increased, whereas rates of third- and fourth-degree lacerations and various types of infection decreased. The cesarean delivery rate increased from 21.8% to 28.3%. CONCLUSION: Between 1993–1997 and 2001–2005, the rate of intrapartum morbidity associated with obstetric complications was unchanged and the rate of pregnancies complicated by preexisting medical conditions increased.

Peripartum cardiomyopathy (PPCM) is a relatively rare idiopathic form of heart failure that affects women during the last months of pregnancy or the first months after delivery. The aetiology and pathophysiological mechanisms of this disease are poorly characterised and incompletely understood. Diagnosis remains a challenge, as PPCM symptoms vary and may mimic those commonly experienced by women during pregnancy and postpartum due to normal physiological changes that occur during this period. The clinical course varies between complete recovery to rapid progression to end stage heart failure and even death. Standard heart failure treatment, with adjustments for women who are pregnant or lactating, is the treatment of choice. Disease specific therapeutic strategies, including prolactin blockade, show promise. National and international registries and collaborative research efforts are warranted to characterise this disease better and to develop novel treatments that can improve outcomes.

Objective: To study mortality after appendectomy. Summary Background Data: The management of patients with suspected appendicitis remains controversial, with advocates of early surgery as well as of expectant management. Mortality is not known. Methods: The authors conducted a complete follow-up of deaths within 30 days after all appendectomies in Sweden (population 8.9 million) during the years 1987 to 1996 (n 5 117,424) by register linkage. The case fatality rate (CFR) and the standardized mortality ratio (SMR) were analyzed by discharge diagnosis. Results: The CFR was 2.44 per 1,000 appendectomies. It was strongly related to age (0.31 per 1,000 appendectomies at 0–9 years of age, decreasing to 0.07 at 20–29 years, and reaching 164 among nonagenarians) and diagnosis at surgery (0.8 per 1,000 appendectomies after nonperforated appendicitis, 5.1 after perforated appendicitis, 1.9 after appendectomies for nonsurgical abdominal pain, and 10.0 for those with other diagnoses). The SMR showed a sevenfold excess rate of deaths after appendectomy compared with the general population. The relation to age was less marked (SMR of 44.4 at 0–9 years, decreasing to 2.4 in patients aged 20–29 years. and reaching 8.1 in nonagenarians). The SMR was doubled after perforation compared with nonperforated appendicitis (6.5 and 3.5, respectively). Nonsurgical abdominal pain and other diagnoses were associated with a high excess rate of deaths (9.1 and 14.9, respectively). The most common causes of deaths were appendicitis, ischemic heart diseases and tumors, followed by gastrointestinal diseases. Conclusions: The CFR after appendectomy is high in elderly patients. The excess rate of death for patients with nonperforated appendicitis and nonsurgical abdominal pain suggests that the deaths may partly be caused by the surgical trauma. Increased diagnostic efforts rather than urgent appendectomy are therefore warranted among frail patients with an equivocal diagnosis of appendicitis.

Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. Mortality from PE in pregnancy might be related to challenges in targeting the right population for prevention, ensuring that diagnosis is suspected and adequately investigated, and initiating timely and best possible treatment of this disease. Pregnancy is an example of Virchow’s triad: hypercoagulability, venous stasis, and vascular damage; together these factors lead to an increased incidence of venous thromboembolism. This disorder is often suspected in pregnant women because some of the physiological changes of pregnancy mimic its signs and symptoms. Despite concerns for fetal teratogenicity and oncogenicity associated with diagnostic testing, and potential adverse eff ects of pharmacological treatment, an accurate diagnosis of PE and a timely therapeutic intervention are crucial. Appropriate prophylaxis should be weighed against the risk of complications and off ered according to risk stratifi cation.

Management of massive, life-threatening primary postpartum hemorrhage in the labor and delivery service is a challenge for the clinical team and hospital transfusion service. Because severe postpartum obstetrical hemorrhage is uncommon, its occurrence can result in emergent but variable and nonstandard requests for blood products. The implementation of a standardized massive transfusion protocol for the labor and delivery department at our institution after a maternal death caused by amniotic fluid embolism is described. This guideline was modeled on a existing protocol used by the trauma service mandating emergency release of 6 units of group O D- red cells (RBCs), 4 units of fresh frozen or liquid plasma, and 1 apheresis unit of platelets (PLTs). The 6:4:1 fixed ratio of uncrossmatched RBCs, plasma, and PLTs allows the transfusion service to quickly provide blood products during the acute phase of resuscitation and allows the clinical team to anticipate and prevent dilutional coagulopathy. The successful management of three cases of massive primary postpartum hemorrhage after the implementation of our new massive transfusion protocol in the maternal and fetal medicine service is described.

The concept of knowing what works in terms of reducing maternal mortality is complicated by a huge diversity of country contexts and of determinants of maternal health. Here we aim to show that, despite this complexity, only a few strategic choices need to be made to reduce maternal mortality. We begin by presenting the logic that informs our strategic choices. This logic suggests that implementation of an effective intrapartum-care strategy is an overwhelming priority. We also discuss the alternative configurations of such a strategy and, using the best available evidence, prioritise one strategy based on delivery in primary-level institutions (health centres), backed up by access to referral-level facilities. We then go on to discuss strategies that complement intrapartum care. We conclude by discussing the inexplicable hesitation in decision-making after nearly 20 years of safe motherhood programming: if the fifth Millennium Development Goal is to be achieved, then what needs to be prioritised is obvious. Further delays in getting on with what works begs questions about the commitment of decision-makers to this goal.

OBJECTIVE: To evaluate whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcomes. METHODS: In a prospective population-based cohort study, 3,480 women with morbid obesity, defined as a body mass index (BMI) more than 40, and 12,698 women with a BMI between 35.1 and 40 were compared with normal-weight women (BMI 19.8 –26). The perinatal outcome of singletons born to women without insulin-dependent diabetes mellitus was evaluated after suitable adjustments. RESULTS: In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal-weight mothers, there was an increased risk of the following outcomes (adjusted odds ratio; 95% confidence interval): preeclampsia (4.82; 4.04, 5.74), antepartum stillbirth (2.79; 1.94, 4.02), cesarean delivery (2.69; 2.49, 2.90), instrumental delivery (1.34; 1.16, 1.56), shoulder dystocia (3.14; 1.86, 5.31), meconium aspiration (2.85; 1.60, 5.07), fetal distress (2.52; 2.12, 2.99), early neonatal death (3.41; 2.07, 5.63), and large-for-gestational age (3.82; 3.50, 4.16). The associations were similar for women with BMIs between 35.1 and 40 but to a lesser degree. CONCLUSION: Maternal morbid obesity in early pregnancy is strongly associated with a number of pregnancy complications and perinatal conditions.

Florida is one of several states that have sought to protect newborns by requiring that mothers known to have used alcohol or illicit drugs during pregnancy be reported to health authorities. To estimate the prevalence of substance abuse by pregnant women, we collected urine samples from all pregnant women who enrolled for prenatal care at any of the five public health clinics in Pinellas County, Florida (n=380), or at any of 12 private obstetrical offices in the county (n= 335); each center was studies for a one-month period during the first half of 1989. Toxicologic screening for alcohol, opiates, cocaine and its metabolites, and cannabinoids was performed blindly with the use of an enzyme-multiplied immunoassay technique. all positive results were confirmed. Among the 715 pregnant women we screened, the overall prevalence of a positive result on the toxicologic tests of urine was 14.8 percent; there was little difference in prevalence between the women seen at the public clinics (16.3 percent) and those seen at the private offices (13.1 percent). The frequency of a positive result was also similar among white women (15.4 percent) and black women (14.1 percent). Black women more frequently had evidence of cocaine use (7.5 percent vs. 1.8 percent for white women), whereas white women more frequently had evidence of the use of cannabinoids (14.4 percent vs. 6.0 percent for black women). During the six-month period in which we collected the urine samples, 133 women in Pinellas County were reported to health authorities after delivery for substance abuse during pregnancy. Despite the similar rates of substance abuse among black and white women in our study, black women were reported at approximately 10 times the rate for white women (P<0.0001), and poor women were more likely than others to be reported. We conclude that the use of illicit drugs is common among pregnant women regardless of race and socio-economic status. If legally mandated reporting is to be free of racial or economic bias, it must be based on objective medical criteria.

OBJECTIVE: We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006.
STUDY DESIGN: This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined.
RESULTS: Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.
CONCLUSION: Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.

INTRODUCTION: The 2000-2002 triennial UK Report on Confidential Enquiries into Maternal Deaths concluded that over 50% of maternal deaths involved substandard care and that many could have been prevented. Catastrophic events leading to cardio-respiratory arrest may necessitate the resuscitation of pregnant women in various hospital locations. This study was designed to evaluate knowledge about resuscitation of parturients among anesthesiologists, obstetricians and emergency physicians.
METHODS: A 12-question survey was distributed anonymously to residents and faculty in the anesthesia (ANES), obstetrics (OB), and emergency medicine (EM) departments at Stanford University Medical Center/Lucile Packard Children's Hospital, Stanford, California. Questions were designed to elicit knowledge deficiencies in four critical areas: need for left uterine displacement (LUD), advanced cardiac life support algorithms (ACLS), physiologic changes of pregnancy (PHYS), and the recommendation to perform cesarean delivery in parturients (>20 weeks gestation) after 4-5 min of unsuccessful resuscitation for cardiac arrest (5CD).
RESULTS: In total, 74/75 physicians (43% ANES, 37% OB, and 20% EM) completed the test. ANES scored highest in overall test scores, and in knowledge of PHYS (P<0.05). Scores for LUD and 5CD were similar among groups, but 25-40% of these questions were answered incorrectly. In the ACLS category, the EM group scored highest (93%).
CONCLUSION: We conclude that knowledge of important basic concepts, including the need for LUD and the potential benefit of early cesarean delivery during cardiac arrest, is inadequate among all three specialties. All three departments should provide ACLS physician training with emphasis on the special considerations for parturients.

This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers' Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003-05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000-02 triennium. Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death. Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications.

BACKGROUND: The Countdown to 2015 for Maternal, Newborn, and Child Survival initiative monitors coverage of priority interventions to achieve the Millennium Development Goals (MDG) for reduction of maternal and child mortality. We aimed to report on 68 countries which have 97% of maternal and child deaths worldwide, and on 22 interventions that have been proven to improve maternal, newborn, and child survival.
METHODS: We selected countries with high rates of maternal and child deaths, and interventions with the most potential to avert such deaths. We analysed country-specific data for maternal and child mortality and coverage of selected interventions. We also tracked cause-of-death profiles; indicators of nutritional status; the presence of supportive policies; financial flows to maternal, newborn, and child health; and equity in coverage of interventions.
FINDINGS: Of the 68 priority countries, 16 were on track to meet MDG 4. Of these, seven had been on track in 2005 when the Countdown initiative was launched, three (including China) moved into the on-track category in 2008, and six were included in the Countdown process for the first time in 2008. Trends in maternal mortality that would indicate progress towards MDG 5 were not available, but in most (56 of 68) countries, maternal mortality was high or very high. Coverage of different interventions varied widely both between and within countries. Interventions that can be routinely scheduled, such as immunisation and antenatal care, had much higher coverage than those that rely on functional health systems and 24-hour availability of clinical services, such as skilled or emergency care at birth and care of ill newborn babies and children. Data for postnatal care were either unavailable or showed poor coverage in almost all 68 countries. The most rapid increases in coverage were seen for immunisation, which also received significant investment during this period.
INTERPRETATION: Rapid progress is possible, but much more can and must be done. Focused efforts will be needed to improve coverage, especially for priorities such as contraceptive services, care in childbirth, postnatal care, and clinical case management of illnesses in newborn babies and children.

The maternal mortality rate in the United States has stagnated for the past 2 decades. To further lower morbidity and mortality, we must take a broader perspective. When a pregnant woman is treated in a nonobstetric part of the hospital, care must adapt quickly to her special needs. Excessive concern as to medication, radiation, and litigation may render her care neither safe, timely, efficient, effective, nor patient-centered. Anesthesiologists can significantly improve the care of the pregnant patient by applying their uniquely broad-based skills, experience, and knowledge outside the labor unit.

Objectives: This study sought to determine the prevalence of maternal morbidity during labor and delivery in the United States. Methods: Analyses focused on National Hospital Discharge Survey data available for women giving birth between 1993 and 1997. Results: The prevalence of specific types of maternal morbidity was low, but the burden of overall morbidity was high. Forty-three percent of women experienced some type of morbidity during their delivery hospitalization. Thirty-one percent (1.2 million women) had at least 1 obstetric complication or at least 1 preexisting medical condition. Conclusions: Maternal morbidity during delivery is frequent and often preventable. Reducing maternal morbidity is a national health objective, and its monitoring is key to improving maternal health.

OBJECTIVE: Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality.
METHODS: We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999-2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts.
RESULTS: Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France.
CONCLUSION: This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies.

The low maternal mortality rates in well-resourced countries are not an automatic consequence of prosperity. Morbidity cannot be avoided and preventing mortality requires good medical care. Now that deaths are infrequent in these countries, people expect investigation of every case and action to make pregnancy even safer. Confidential enquiries do this, and are appropriate when mortality rates are low enough for scrutiny of individual cases. Confidential enquiries have major advantages over other methods of investigation such as public enquiry or hospital audit. The function of confidential enquiries is to improve care, not apportion blame, and they receive frank comments as well as full facts. Analysis is by practising clinicians from many specialties and recommendations are disseminated to clinicians, managers, politicians and the public. The confidential enquiry method has now been adopted by other specialties and by many countries. In countries without confidential enquiries there is under-reporting of maternal mortality, particularly among the poor.

The United States has a higher ratio of maternal deaths than at least 40 other countries, even though it spends more money per capita for maternity care than any other. The lack of a comprehensive, confidential system of ascertainment of maternal death designed to record and analyze every maternal death continues to subject U.S. women to unnecessary risk of preventable mortality. Maternal deaths must be reviewed to make motherhood safer. The United Kingdom’s Confidential Enquiry into Maternal and Child Health is considered the ‘‘gold standard’’ of national professional self-evaluation. The aim of the Safe Motherhood Quilt Project is to raise public awareness of the rising U.S. maternal death rate and necessary steps to a solution.

OBJECTIVE: To describe the prevalence of hospitalizations during pregnancy, the reason for hospitalization, the length of stay, and the associated costs. METHODS: We analyzed data from a national managed care organization and determined the occurrence of hospitalizations for 46,179 women who had a live birth or a pregnancy loss in 1997. RESULTS: Overall, 8.7% of women were hospitalized during their pregnancy. Of these, 5.7% were hospitalized and discharged while pregnant, 0.8% experienced extended stays before a live birth or pregnancy loss, and 2.1% experienced pregnancy loss. Hospitalizations were more common among younger women, women with multiple gestations, and women in the northeastern United States. Women who had a live birth were primarily hospitalized for preterm labor (24%), hyperemesis (9%), hypertension (9%), kidney disorders (6%), and prolonged premature rupture of membranes (6%). Charges totaled over $36 million. CONCLUSION: Antenatal hospitalizations are common.

OBJECTIVE: The purpose of this study was to measure the reliability of a model that defines preventability in maternal morbidity and death.
STUDY DESIGN: One hundred cases of serious morbidity and death among peripartum women were reviewed by 2 independent groups of medical experts to identify potentially preventable provider or system events that may have led to the progression of illness.
RESULTS: Seventy-seven percent of the cases had concordant findings in both groups regarding the identification of any preventable events. Interrater agreement, which was measured by Cohen's Kappa, was 0.49, which suggests moderate to good reliability. Cases with multiple comorbidities, poor documentation, or preventable patient factors tended to have higher levels of disagreement.
CONCLUSION: There was high agreement between the 2 groups regarding the identification of preventable events that impact maternal morbidity and death. The reliability of this model for the assessment of preventability is an important step for improvement in obstetric and medical care.

Objectives: The purpose of this study was to assess whether African-American women are at increased risk of having peripartum cardiomyopathy. Background: Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions. Methods: A case-control study was performed at a regional center that provides medical care to a racially heterogeneous population. For each case, 3 healthy control patients were randomly selected who delivered babies within the same month. Results: African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non–African Americans (odds ratio [OR]: 15.7, 95% confidence interval [CI]: 3.5 to 70.6). Other significant univariate risk factors were hypertension (
OR: 10.8, 95%
CI: 2.6 to 44.4), being unmarried (
OR: 4.2, 95%
CI: 1.4 to 12.3), and having had >2 previous pregnancies (
OR: 2.9, 95%
CI: 1.1 to 7.4). African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable (
OR: 31.5, 95%
CI: 3.6 to 277.6) and stratified analyses (
OR: 12.9 to 29.1, p <0.001). Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.

Preeclampsia/eclampsia is one of the 3 leading causes of maternal morbidity and mortality worldwide. During the past 50 years, there has been a significant reduction in the rates of eclampsia, maternal mortality, and maternal morbidity in the developed countries. In contrast, the rates of eclampsia, maternal complications, and maternal mortality remain high in the developing countries. These differences are mainly due to universal access to prenatal care, access to timely care, and proper management of patients with preeclampsia–eclampsia in the developed countries. In contrast, most of maternal deaths and complications are due to lack of prenatal care, lack of access to hospital care, lack of resources, and inappropriate diagnosis and management of patients with preeclampsia–eclampsia in the developing countries. Preeclampsia/eclampsia is associated with substantial maternal complications, both acute and long-term. Clear protocols for early detection and management of hypertension in pregnancy at all levels of health care are required for better maternal as well as perinatal outcome. This is especially important in the developing countries.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes.
STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression.
RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status.
CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

OBJECTIVES: To estimate the incidence, describe the mortality, and identify independent predictors of peripartum cardiomyopathy, a very serious cardiovascular complication of pregnancy associated with maternal morbidity and mortality among otherwise healthy women without prior heart disease. METHODS: We identified all cases of diagnosed heart failure that occurred among women within 1 month before to 5 months after delivery of a liveborn neonate in Kaiser Permanente Northern California delivery hospitals between 1995 and 2004. Incident peripartum cardiomyopathy was confirmed from medical records documenting dilated cardiomyopathy with reduced left ventricular systolic function after excluding women with prior heart failure or valvular disease. Data sources included medical records, electronic clinical databases, and state birth and death files. RESULTS: Among 227,224 eligible women, we confirmed 110 recognized peripartum cardiomyopathy cases (incidence: 4.84 per 10,000 live births, 95% confidence interval 3.98 –5.83). Independent predictors included maternal age of 25 years or older, non-Hispanic African American and Filipino groups, parity of 4 or greater, multiple gestation, severe anemia, pre-existing and pregnancyrelated hypertensive disorders, and hemolysis, elevated liver enzymes, low platelets syndrome. Maternal death rate (per 1,000 person-years) was higher among cases (6.12) than noncases (0.23; P<.001). Neonates whose mothers developed peripartum cardiomyopathy experienced poorer clinical outcomes. CONCLUSION: Within a large, diverse northern California population, 1 of every 2,066 women delivering a liveborn neonate had recognized, confirmed peripartum cardiomyopathy, which was associated with higher maternal and neonatal death rates and worse neonatal outcomes. Several readily available patient characteristics can be used to identify women at risk for this severe pregnancy complication.

Purpose: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. Data Sources: The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Study Selection: Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. Data Extraction: Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. Data Synthesis: The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume–outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume–outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. Conclusions: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

PURPOSE: African-American women have a 2- to 4-fold increased risk of pregnancy-related death compared with Caucasian women. We conducted this study to determine if differences in a combination of socioeconomic and medical risk factors may explain this racial disparity in pregnancy-related death.
METHODS: Pregnancy-related deaths of African-American (N=60) and Caucasian (N=47) women were identified from review of pregnancy-associated deaths (N=400) ascertained through cause of death on death certificates, electronic linkage of birth and death files, and review of the hospital discharge database for the State of North Carolina, during the period between 1992 and 1998. Controls (N=3404) were randomly selected from all live births for the same 7-year period. Logistic regression was used to model the association between race and pregnancy-related death.
RESULTS: The unadjusted odds ratio (OR) for pregnancy-related death for African-Americans compared with Caucasians was 3.07 (95% confidence interval [CI], 2.08, 4.54). After controlling for gestational age at delivery, maternal age, income, hypertension, and receipt of prenatal care, African-American race remained a significant predictor variable (OR 2.65 [95% CI 1.73, 4.07]).
CONCLUSIONS: Our analysis confirms that there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.

PURPOSE: Our study aim was to identify factors that may contribute to the racial disparity in pregnancy-related mortality.
METHODS: We examined differences in severity of disease, comorbidities, and receipt of care among 608 (304 African-American and 304 white) consecutive patients of non-Hispanic ethnicity with one of three pregnancy-related morbidities (pregnancy-related hypertension, puerperal infection, and hemorrhage) from hospitals selected at random from a statewide region.
RESULTS: African-American women had more severe hypertension, lower hemoglobin concentrations preceding hemorrhage, more antepartum hospital admissions, and a higher rate of obesity. The rate of surgical intervention for hemorrhage was lower among African-Americans, although the severity of hemorrhage did not differ between the two racial groups. More African-American women received eclampsia prophylaxis. After stratifying by severity of hypertension, we found that more African-Americans received antihypertensive therapy. The rate of enrollment for prenatal care was lower in the African-American group. Among women receiving prenatal care, African-American women enrolled significantly later in their pregnancies.
CONCLUSIONS: We have identified racial differences in severity of disease, comorbidities, and care status among women with pregnancy-related complications that would place African-Americans at disadvantage to survive pregnancy. These differences are potentially modifiable.

Background: Maternal mortality, as a largely avoidable cause of death, is an important focus of international development eff orts, and a target for Millennium Development Goal (MDG) 5. However, data weaknesses have made monitoring progress problematic. In 2006, a new maternal mortality working group was established to develop improved estimation methods and make new estimates of maternal mortality for 2005, and to analyse trends in maternal mortality since 1990. Methods: We developed and used a range of methods, depending on the type of data available, to produce comparable country, regional, and global estimates of maternal mortality ratios for 2005 and to assess trends between 1990 and 2005. Findings: We estimate that there were 535 900 maternal deaths in 2005, corresponding to a maternal mortality ratio of 402 (uncertainty bounds 216–654) deaths per 100 000 livebirths. Most maternal deaths in 2005 were concentrated in sub-Saharan Africa (270 500, 50%) and Asia (240 600, 45%). For all countries with data, there was a decrease of 2·5% per year in the maternal mortality ratio between 1990 and 2005 (p<0·0001); however, there was no evidence of a signifi cant reduction in maternal mortality ratios in sub-Saharan Africa in the same period. Interpretation: Although some regions have shown some progress since 1990 in reducing maternal deaths, maternal mortality ratios in sub-Saharan Africa have remained very high, with little evidence of improvement in the past 15 years. To achieve MDG5 targets by 2015 will require sustained and urgent emphasis on improved pregnancy and delivery care throughout the developing world.

BACKGROUND: Maternal mortality, as a largely avoidable cause of death, is an important focus of international development efforts, and a target for Millennium Development Goal (MDG) 5. However, data weaknesses have made monitoring progress problematic. In 2006, a new maternal mortality working group was established to develop improved estimation methods and make new estimates of maternal mortality for 2005, and to analyse trends in maternal mortality since 1990.
METHODS: We developed and used a range of methods, depending on the type of data available, to produce comparable country, regional, and global estimates of maternal mortality ratios for 2005 and to assess trends between 1990 and 2005.
FINDINGS: We estimate that there were 535,900 maternal deaths in 2005, corresponding to a maternal mortality ratio of 402 (uncertainty bounds 216-654) deaths per 100,000 livebirths. Most maternal deaths in 2005 were concentrated in sub-Saharan Africa (270,500, 50%) and Asia (240,600, 45%). For all countries with data, there was a decrease of 2.5% per year in the maternal mortality ratio between 1990 and 2005 (p<0.0001); however, there was no evidence of a significant reduction in maternal mortality ratios in sub-Saharan Africa in the same period.
INTERPRETATION: Although some regions have shown some progress since 1990 in reducing maternal deaths, maternal mortality ratios in sub-Saharan Africa have remained very high, with little evidence of improvement in the past 15 years. To achieve MDG5 targets by 2015 will require sustained and urgent emphasis on improved pregnancy and delivery care throughout the developing world.

OBJECTIVES: I studied the extent to which maternal deaths are underreported on death certificates.
METHODS: We collected data on maternal deaths from death certificates, linkage of death certificates with birth and fetal death records, and review of medical examiner records.
RESULTS: Thirty-eight percent of maternal deaths were unreported on death certificates. Half or more deaths were unreported for women who were undelivered at the time of death, experienced a fetal death or therapeutic abortion, died more than a week after delivery, or died as a result of a cardiovascular disorder.
CONCLUSIONS: The number of maternal deaths is substantially underestimated when death certificates alone are used to identify deaths, and it is unlikely that the Healthy People 2010 objective of reducing the maternal mortality rate to no more than 3.3 deaths per 100000 live births by 2010 can be achieved. Increasing numbers of births to older women and multiple-gestation pregnancies are likely to complicate efforts to reduce maternal mortality.

Objectives—This report presents final 2003 data on U.S. deaths; death rates; life expectancy; infant and maternal mortality; and trends by selected characteristics such as age, sex, Hispanic origin, race, marital status, educational attainment, injury at work, State of residence, and cause of death. A previous report presented preliminary mortality data for 2003 and summarized key findings in the final data for 2003. Methods—This report presents descriptive tabulations of information reported on death certificates, which are completed by funeral directors, attending physicians, medical examiners, and coroners. The original records are filed in the State registration offices. Statistical information is compiled into a national database through the Vital Statistics Cooperative Program of the Centers for Disease Control and Prevention’s, National Center for Health Statistics (NCHS). Causes of death are processed in accordance with the International Classification of Diseases, Tenth Revision (ICD–10). Results—In 2003, a total of 2,448,288 deaths were reported in the United States. The age-adjusted death rate was 832.7 deaths per 100,000 standard population, representing a decrease of 1.5 percent from the 2002 rate and a record low historical figure. Life expectancy at birth rose by 0.2 years to a record high of 77.5 years. Considering all deaths, age-specific death rates rose only for those 45–54 years and declined for the age groups 55–64 years, 65–74 years, 75–84 years, and 85 years and over. For the most part, the 15 leading causes of death in 2003 remained the same as in 2002. Heart disease and cancer continued to be the leading and second leading causes of death, together accounting for over half of all deaths. Homicide became the 15th leading cause in 2003, dropping from the 14th leading cause in 2002. Pneumonitis dropped out of the top 15 altogether, and Parkinson’s disease entered the list as the 14th leading cause of death. The infant mortality rate in 2003 was 6.85 per 1,000 births. Conclusions—Generally, mortality patterns in 2003 were consistent with long-term trends. Life expectancy in 2003 increased again to a new record level. The age-adjusted death rate declined to a record low historical figure. The infant mortality rate decreased significantly in 2003; except for 2002, it either decreased or remained level each successive year from 1958 to 2003.

OBJECTIVE: This report presents data on U.S. deaths to pregnant or recently pregnant women, summarizes long-term processing issues, and examines recent changes affecting the data and the impact of the changes on the statistics for these women.
METHODS: This report presents descriptive tabulations of information reported on death certificates that are completed by funeral directors, attending physicians, medical examiners, and coroners. The original records are filed in the state registration offices. Statistical information is compiled into a national database through the Vital Statistics Cooperative Program of the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS). Causes of death are processed in accordance with the International Classification of Diseases (ICD).
RESULTS: Maternal mortality fluctuates from year to year but was 12.1 deaths per 100,000 live births in 2003. The implementation of the International Classification of Diseases, Tenth Revision (ICD-10) in 1999 resulted in about a 13 percent increase in the number of deaths identified as maternal deaths between 1998 and 1999. The rate increased again between 2002 and 2003 after a separate pregnancy question became a standard item on the U.S. Standard Certificate of Death. The adoption of a standard separate question on pregnancy facilitates the identification of late maternal deaths.
CONCLUSION: Maternal deaths increased with the introduction of the ICD-10 and with changes associated with the addition of a separate pregnancy status question on the U.S. Standard Certificate of Death. These changes may result in better identification of maternal deaths.

BACKGROUND: The 1998 public awareness campaign on Safe Motherhood called attention to the issue of maternal mortality worldwide. This paper focuses upon maternal mortality trends in the United States and Canada, and examines differentials in maternal mortality in the United States by maternal characteristics.
METHODS: Data from the vital statistics systems of the United States and Canada were used in the analysis. Both systems identify maternal deaths using the definition of the World Health Organization's International Classification of Diseases. Numbers of deaths, maternal mortality rates, and confidence intervals for the rates are shown in the paper.
RESULTS: Maternal mortality declined for much of the century in both countries, but the rates have not changed substantially between 1982 and 1997. In this period the maternal mortality levels were lower in Canada than in the United States. Maternal mortality rates vary by maternal characteristics, especially maternal age and race.
CONCLUSIONS: Maternal mortality continues to be an issue in developed countries, such as the United States and Canada. Maternal mortality rates have been stable recently, despite evidence that many maternal deaths continue to be preventable. Additional investment is needed to realize further improvements in maternal mortality.

Reports by the Institute of Medicine (IOM) recommend that gestational weight gain goals should be modified according to prepregnancy body mass index (BMI), which could result in better maternal and infant outcomes. The authors assessed whether the risk of the pregnancy outcomes such as rate of cesarean section to primiparous and multiparous women, macrosomia, and breastfeeding at 10 weeks postpartum can be modified by following the IOM guidelines for gestational weight gain irrespective of prepregnancy BMI. Staff from the New Jersey Pregnancy Risk Assessment Monitoring System interviewed a sample of women who delivered live births in New Jersey during 2002 through 2005 (n¼7661). In New Jersey, 18% of mothers were obese, 13% were overweight, and 16% were underweight. In logistic regression analyses, after controlling for maternal characteristics, the effect of prepregnancy obesity and weight gain more than 34 lb independently and significantly increased the risk of all four adverse outcomes. For no outcomes was the 25- to 34-pound weight gain category significantly distinguishable from the 16- to 24-pound reference category. These results strongly support the idea that the IOM weight gain recommendation (education during preconception regarding the importance of optimal BMI at the start of pregnancy) will help to achieve better pregnancy outcomes in obese and overweight women.

Pregnancies following in-vitro fertilization (IVF) are known to be at increased risk of a number of pregnancy- and delivery-related complications when compared with non-IVF pregnancies. Most of these complications seem to be due to underlying fertility problems. Ovarian stimulation carries a marked risk for two serious conditions - ovarian torsion and ovarian hyperstimulation syndrome - both of which are relatively rare. Although some common pregnancy complications show an up to five times increased risk over non-IVF pregnancies, the absolute frequencies are still low for most of these conditions. However, an increased risk of placenta praevia might be to some extent due to the IVF procedure. No long-terms effects on cancer risk or mortality can be linked to the IVF procedure, although follow-up time is still relatively short

Australia is one of the safest countries in the world to birth. Because maternal deaths are rare, often the focus during pregnancy is on the well-being of the fetus. The relative safety of birth has fostered a shift in the focus of maternal health, from survival, to the model of care or the birth experience. Yet women still die in Australia as a result of child bearing and many of these deaths are associated with avoidable factors. The purpose of this paper is to outline the maternal death monitoring and review process in Australia and to present to clinicians the salient features of the most recently published Australian maternal death report. The notion of preventability and the potential for practice to have an effect on reducing maternal mortality are also discussed.

OBJECTIVE: To examine the effect of gestational weight change on pregnancy outcomes in obese women. METHODS: A population-based cohort study of 120,251 pregnant, obese women delivering full-term, liveborn, singleton infants was examined to assess the risk of four pregnancy outcomes (preeclampsia, cesarean delivery, small for gestational age births, and large for gestational age births) by obesity class and total gestational weight gain. RESULTS: Gestational weight gain incidence for overweight or obese pregnant women, less than the currently recommended 15 lb, was associated with a significantly lower risk of preeclampsia, cesarean delivery, and large for gestational age birth and higher risk of small for gestational age birth. These results were similar for each National Institutes of Health obesity class (30 –34.9, 35–35.9, and 40.0 kg/m2), but at different amounts of gestational weight gain. CONCLUSION: Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes

OBJECTIVE: To estimate the national incidence of peripartum hysterectomy and quantify the risk associated with cesarean deliveries and other factors. METHODS: A population-based, matched case-control study using the United Kingdom Obstetric Surveillance System, including 318 women in the United Kingdom who underwent peripartum hysterectomy between February 2005 and February 2006 and 614 matched control women. RESULTS: The incidence of peripartum hysterectomy was 4.1 cases per 10,000 births (95% confidence interval [CI] 3.6–4.5). Maternal mortality was 0.6% (95% CI 0–1.5%). Previous cesarean delivery (odds ratio [OR] 3.52, 95% CI 2.35–5.26), maternal age over 35 years (OR 2.42, 95% CI 1.66 –3.58), parity of three or greater (OR 2.30, 95% CI 1.26–4.18), previous manual placental removal (OR 12.5, 95% CI 1.17–133.0), previous myomectomy (OR 14.0, 95% CI 1.31–149.3), and twin pregnancy (OR 6.30, 95% CI 1.73–23.0) were all risk factors for peripartum hysterectomy. The risk associated with previous cesarean delivery was higher with increasing numbers of previous cesarean deliveries (OR 2.14 with one previous delivery [95% CI 1.37–3.33], 18.6 with two or more [95% CI 7.67– 45.4]). Women undergoing a first cesarean delivery in the current pregnancy were also at increased risk (OR 7.13, 95% CI 3.71–13.7). CONCLUSION: Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity greater than 3.

Objective: To describe on a national basis ethnic differences in severe maternal morbidity in the United Kingdom. Design: National cohort study using the UK Obstetric Surveillance System (UKOSS). Setting: All hospitals with consultant led maternity units in the UK. Participants: 686 women with severe maternal morbidity between February 2005 and February 2006. Main outcome measures: Rates, risk ratios, and odds ratios of severe maternal morbidity in different ethnic groups. Results: 686 cases of severe maternal morbidity were reported in an estimated 775 186 maternities, representing an estimated incidence of 89 (95% confidence interval 82 to 95) cases per 100 000 maternities. 74% of women were white, and 26% were non-white. The estimated risk of severe maternal morbidity in white women was 80 cases per 100 000 maternities, and that in non-white women was 126 cases per 100 000 (risk difference 46 (27 to 66) cases per 100 000; risk ratio 1.58, 95% confidence interval 1.33 to 1.87). Black African women (risk difference 108 (18 to 197) cases per 100 000 maternities; risk ratio 2.35, 1.45 to 3.81) and black Caribbean women (risk difference 116 (59 to 172) cases per 100 000 maternities; risk ratio 2.45, 1.81 to 3.31) had the highest risk compared with white women. The risk in non-white women remained high after adjustment for differences in age, socioeconomic and smoking status, body mass index, and parity (odds ratio 1.50, 1.15 to 1.96). Conclusions: Severe maternal morbidity is significantly more common among non-white women than among white women in the UK, particularly in black African and Caribbean ethnic groups. This pattern is very similar to reported ethnic differences in maternal death rates. These differences may be due to the presence of pre-existing maternal medical factors or to factors related to care during pregnancy, labour, and birth; they are unlikely to be due to differences in age, socioeconomic or smoking status, body mass index, or parity. This highlights to clinicians and policy makers the importance of tailored maternity services and improved access to care for women from ethnic minorities. National information on the ethnicity of women giving birth in the UK is needed to enable ongoing accurate study of these inequalities.

Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that - essentially - no progress has been made in most US States since 1982. Additionally, the US Centers for Disease Control and Prevention has stated that most cases are probably preventable. Two disheartening issues within this topic include a gross underestimation of the magnitude of maternal mortality - particularly before 1987, but which likely persists to a lesser degree today - and the continued significant racial disparity in maternal mortality. Explanations for the plateau in maternal mortality include the recent trend of delayed childbearing, with the potential accompanying complications associated with older reproductive age (particularly over 35 years) and multiparity. The impressive increase in multifetal pregnancies related to delayed childbearing and assisted reproductive technology also plays a role. Finally, peripartum cardiomyopathy has become an increasingly recognized source of maternal mortality. Pregnancy-related mortality is largely accounted for by thromboembolic disease, hemorrhage, hypertension and its associated complications, and infection. However, since the inclusion of maternal deaths occurring after 42 days post-delivery as pregnancy related, traumatic injuries - including homicides and suicides - are an alarming source of maternal mortality. An especially important contemporary issue to consider within this topic is cesarean delivery "on maternal request", opponents of which cite concerns not only for immediate morbidity and mortality increased over that associated with a vaginal birth, but also for potential morbidity and mortality associated with future pregnancies. One particularly appealing opportunity to reduce maternal mortality is to recognize, examine, and learn from so-called "near-miss" cases.

Every year, some eight million women around the world suffer pregnancy-related complications; over half a million of these women die. Although most of these deaths could be averted at little or no extra cost, even where resources are limited, if we are to take action and develop and implement changes to maternity services to save the lives of mothers and newborns, we need the right kind of information. This more in-depth information might not be available through national statistics on maternal mortality rates or death certificate data; what is required is a detailed understanding of the clinical, social, cultural and other underlying factors that result in a mother's death. The World Health Organization's programme and philosophy for such maternal death or disability reviews is called Beyond the numbers. It outlines the five key methodologies for reviewing maternal deaths or disabilities that are now being introduced in a number of countries around the world.

BACKGROUND: The rate of elective primary cesarean delivery continues to rise, owing in part to the widespread perception that the procedure is of little or no risk to healthy women.
METHODS: Using the Canadian Institute for Health Information's Discharge Abstract Database, we carried out a retrospective population-based cohort study of all women in Canada (excluding Quebec and Manitoba) who delivered from April 1991 through March 2005. Healthy women who underwent a primary cesarean delivery for breech presentation constituted a surrogate "planned cesarean group" considered to have undergone low-risk elective cesarean delivery, for comparison with an otherwise similar group of women who had planned to deliver vaginally.
RESULTS: The planned cesarean group comprised 46,766 women v. 2,292,420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1-6.3), wound hematoma (OR 5.1, 95% CI 4.6-5.5), hysterectomy (OR 3.2, 95% CI 2.2-4.8), major puerperal infection (OR 3.0, 95% CI 2.7-3.4), anesthetic complications (OR 2.3, 95% CI 2.0-2.6), venous thromboembolism (OR 2.2, 95% CI 1.5-3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2-3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46-1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2-0.8). Absolute risk increases in severe maternal morbidity rates were low (e.g., for postpartum cardiac arrest, the increase with planned cesarean delivery was 1.6 per 1000 deliveries, 95% CI 1.2-2.1). The difference in the rate of in-hospital maternal death between the 2 groups was nonsignificant (p = 0.87).
INTERPRETATION: Although the absolute difference is small, the risks of severe maternal morbidity associated with planned cesarean delivery are higher than those associated with planned vaginal delivery. These risks should be considered by women contemplating an elective cesarean delivery and by their physicians.

Background Like previous epidemic and pandemic diseases, 2009 pandemic influenza A (H1N1) may pose an increased risk of severe illness in pregnant women. Methods Statewide surveillance for patients who were hospitalized with or died from 2009 H1N1 influenza was initiated by the California Department of Public Health. We reviewed demographic and clinical data reported from April 23 through August 11, 2009, for all H1N1-infected, reproductive-age women who were hospitalized or died — nonpregnant women, pregnant women, and postpartum women (those who had delivered ≤2 weeks previously). Results Data were reported for 94 pregnant women, 8 postpartum women, and 137 nonpregnant women of reproductive age who were hospitalized with 2009 H1N1 influenza. Rapid antigen tests were falsely negative in 38% of the patients tested (58 of 153). Most pregnant patients (89 of 94 [95%]) were in the second or third trimester, and approximately one third (32 of 93 [34%]) had established risk factors for complications from influenza other than pregnancy. As compared with early antiviral treatment (administered ≤2 days after symptom onset) in pregnant women, later treatment was associated with admission to an intensive care unit (ICU) or death (relative risk, 4.3). In all, 18 pregnant women and 4 postpartum women (total, 22 of 102 [22%]) required intensive care, and 8 (8%) died. Six deliveries occurred in the ICU, including four emergency cesarean deliveries. The 2009 H1N1 influenza–specific maternal mortality ratio (the number of maternal deaths per 100,000 live births) was 4.3. Conclusions 2009 H1N1 influenza can cause severe illness and death in pregnant and postpartum women; regardless of the results of rapid antigen testing, prompt evaluation and antiviral treatment of influenza-like illness should be considered in such women. The high cause-specific maternal mortality rate suggests that 2009 H1N1 influenza may increase the 2009 maternal mortality ratio in the United States.

OBJECTIVE: To estimate mortality ratios for all reported pregnancy deaths in the United States, 1999–2005, and to estimate the effect of the 1999 implementation of International Classification of Diseases, Tenth Revision (ICD- 10) and adoption of the U.S. Standard Certificate of Death, 2003 Revision, on the ascertainment of deaths resulting from pregnancy. METHODS: We combined information on pregnancy deaths from the National Vital Statistics System and the Pregnancy Mortality Surveillance System to estimate maternal (during or within 42 days of pregnancy) and pregnancyrelated (during or within 1 year of pregnancy) mortality ratios (deaths per 100,000 live births). Data for 1995–1997, 1999–2002, and 2003–2005 were compared in order to estimate the effects of the change to ICD-10 and the inclusion of a pregnancy checkbox on the death certificate. RESULTS: The maternal mortality ratio increased significantly from 11.6 in 1995–1997 to 13.1 for 1999–2002 and 15.3 in 2003–2005; the pregnancy-related mortality ratio increased significantly from 12.6 to 14.7 and 18.1 during the same periods. Vital statistics identified significantly more indirect maternal deaths in 2002–2005 than in 1999–2002. Between 2002 and 2005, mortality ratios increased significantly among 19 states using the revised death certificate with a pregnancy checkbox; ratios did not increase in states without a checkbox. CONCLUSION: Changes in ICD-10 and the 2003 revision of the death certificate increased ascertainment of pregnancy deaths. The changes may also have contributed to misclassification of some deaths as maternal in the vital statistics system. Combining data from both systems estimates higher pregnancy mortality ratios than from either system individually. (Obstet Gynecol 2011;118:104–10) DOI: 10.1097/AOG.0b013e31821fd49d LEVEL OF EVIDENCE: II

BACKGROUND: Although the risk of dying during childbirth or from complications afterward has been greatly reduced during the past 100 years, the current rate of approximately 1 death in 10,000 live births is still too high. The goal of the US Department of Health and Human Services is to reduce this rate by more than half by the year 2010.
OBJECTIVE: To present Wisconsin data regarding pregnancy-associated deaths and pregnancy-related deaths.
METHODS: Cases in which a woman had died during pregnancy or within 1 year of the end of her pregnancy were identified, and case-specific data were collected. The Wisconsin Maternal Mortality Review Team then conducted systematic reviews of the information, summarized issues related to maternal mortality, considered the relationship to pregnancy and factors of avoidability, and made recommendations to improve maternal health and survival. Finally, pregnancy-associated and pregnancy-related mortality ratios were calculated.
RESULTS: From 1998 through 2001, 23 Wisconsin women died as a result of their pregnancy or from complications up to a year later. This gives a Wisconsin pregnancy-related mortality ratio of 8.4 per 100,000 live births. This ratio was higher in African American women and in women who smoked. The primary cause of death was embolic disease. Almost half of the pregnancy-related deaths (48%) occurred during the postpartum period, and nearly one-quarter (22%) were avoidable.
CONCLUSIONS: The disparity in pregnancy-related mortality ratios among ethnic groups and the finding of avoidable deaths are areas that should be targeted by health care providers and public health workers. Six areas on which to focus include the following: addressing racial disparities, assuring the performance of autopsies, lifestyle changes related to obesity and smoking, and management of embolic and cardiovascular disease, as well as postpartum hemorrhage.

Major obstetric hemorrhage remains the leading cause of maternal mortality and morbidity worldwide, and is associated with a high rate of substandard care. A well-defined and multidisciplinary approach that aims to act quickly and avoid omissions or conflicting strategies is key. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta, uterine atony, and genital-tract trauma in the postpartum period. Basic treatment of postpartum hemorrhage relies on manual removal of the placenta or manual exploration of the uterus plus bladder emptying and oxytocin administration. If this does not arrest bleeding, or if there is any suspicion of genital-tract trauma, examination of the vagina and cervix with appropriate valves and analgesia/anesthesia must follow quickly. Postpartum uterine atony resistant to oxytocin must be treated with prostaglandin within 15 to 30 minutes; uterine balloon tamponade can be also useful at this stage. Aggressive transfusion therapy and resuscitation are mandatory in major obstetric hemorrhage. Specific invasive treatment must be considered within no more than 30 to 60 minutes, if previous measures have failed-and even earlier in some particular etiologies. The two main options are radiologic embolization and surgical artery ligations. Recombinant factor VIIa may also be considered, but should not delay the performance of a life-saving procedure such as embolization or surgery. Hysterectomy must be implemented when all other interventions have failed.

BACKGROUND: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984.
METHODS: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death.
RESULTS: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n=6) and African-American race (n=6).
CONCLUSIONS: The 8 anesthesia-related and seven anesthesia-contributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

PURPOSE OF REVIEW: Although there have been few recent publications about obstetric deaths due to anaesthesia, it is timely to review their occurrence and put them into context. Health services are under constant review and a recent Department of Health publication highlights the need for safer care. Changes, including those related to training and permitted hours of work, may impact on safety. Without knowing where we are now, we cannot know whether these changes are an improvement or not.
RECENT FINDINGS: The UK Confidential Enquiry reports have tracked anaesthetic-related deaths since 1952. During the 1990 s, the numbers became almost irreducible: the last report gave six deaths caused by anaesthesia. This review puts these into a global perspective.
SUMMARY: Medical intervention undoubtedly saves many lives. Concerns about a possible increase in anaesthetic maternal mortality must be kept in perspective with the overall benefits. The growing complexity of problems such as maternal disease, obesity, and the increasing age of motherhood, nevertheless, increases the challenges presented. Multidisciplinary working is all-important.

OBJECTIVE: To estimate the association between changes in Illinois professional liability premiums for obstetrician–gynecologists and singleton primary cesarean delivery rates. METHODS: Data from the National Center for Health Statistics were used to identify all singleton births between 37 weeks and 44 weeks of gestation occurring in Illinois from 1998 through 2003. Primary cesarean delivery rates for women delivered between 37 weeks and 44 weeks of gestation per 1,000 gravid women eligible to have a primary cesarean delivery were calculated for each Illinois county. The annual medical professional liability premium for each county in Illinois was represented by the reported professional liability insurance rate charges (adjusted to 2004 dollars) from the ISMIE Mutual Insurance Company. Separate analyses were conducted for nulliparous and multiparous women. The independent association between county-level primary cesarean delivery rates and the previous year’s insurance premiums was evaluated using linear regression models. RESULTS: During the study period, 817,521 women were eligible for inclusion in the analysis. The county-level mean primary cesarean delivery rate increased from 126 to 163 per 1,000 (P<.001) eligible women, whereas the mean annual medical professional liability insurance premiums also rose significantly (from $60,766 in 1997 to $83,167 in 2002, P<.001). Multivariable analyses demonstrated that for each annual $10,000 insurance premium increase, the primary cesarean delivery rate increased by 15.7 per 1,000 for nulliparous women. This association also was evident for multiparous women, who had an increase in cesarean deliveries of 4.7 per 1,000 for every $10,000 increase. CONCLUSION: Higher rates of primary cesarean delivery are associated with increased medical professional liability premiums for obstetrician– gynecologists in Illinois.

Background: There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants. Methods: We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000. Results: Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birthweight deliveries occurred in urban areas with more than 100 such deliveries. Conclusions: Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.

Objective.To examine the effects of neonatal intensive care unit (NICU) patient volume and the level of NICU care available at the hospital of birth on neonatal mortality. Design. Birth certificate data linked to infant death certificates and to infant discharge abstracts were used in a logistic regression model to control for differences in each patient's clinical and demographic risks. Hospitals were classified by the level of NICU care available (no
NICU: level I; intermediate
NICU: level II; expanded intermediate
NICU: level II+: tertiary
NICU: level III) and by the average patient census in the NICU. Setting. All nonfederal hospitals in California with maternity services. Patients. All births in nonfederal hospitals in California in 1990 (N=594 104), 473 209 (singletons only) of which were successfully linked with discharge abstracts. Of these infants, 53 229 were classified as likely NICU admissions. Main Outcome Measures. Death within the first 28 days of life, or within the first year of life, if continuously hospitalized. Results.Patient volume and level of NICU care at the hospital of birth both had significant effects on mortality. Compared with hospitals without an NICU, infants born in a hospital with a level III NICU with an average NICU census of at least 15 patients per day had significantly lower risk-adjusted neonatal mortality (odds ratio, 0.62; 95% confidence interval, 0.47-0.82; P=.002). Risk-adjusted neonatal mortality for infants born in smaller level III NICUs, and in level II+ and level II NICUs, regardless of size, was not significantly different from hospitals without an NICU, and was significantly higher than hospitals with large level III NICUs. Conclusions. Risk-adjusted neonatal mortality was significantly lower for births that occurred in hospitals with large (average census, >15 patients per day) level III NICUs. Despite the differences in outcomes, costs for the birth of infants born at hospitals with large level III NICUs were not more than those for infants born at other hospitals with NICUs. Concentration of high-risk deliveries in urban areas in a smaller number of hospitals that could provide level III NICU care has the potential to decrease neonatal mortality without increasing costs.

Objective To assess the most commonly employed diagnostic indicators of severe maternal morbidity (obstetric near-miss). Methods Review of the literature from January 1989 to August 2008. Results Fifty-one manuscripts met the eligibility criteria, and 96 indicators were utilized at least once. Admission to intensive care unit (n = 28 studies) was the indicator most frequently utilized, followed by eclampsia and hemorrhage (n = 27), blood transfusion (n = 26) and emergent hysterectomy (n = 24). Conclusion Considering these Wndings, a trial version of a 13-item instrument for diagnosing obstetric near-miss is proposed. It includes the indicators eclampsia, severe hypertension, pulmonary edema, cardiac arrest, obstetrical hemorrhage, uterine rupture, admission to intensive care unit, emergent hysterectomy, blood transfusion, anesthetic accidents, urea >15 mmol/l or creatinine >400 mmol/l, oliguria (<400 ml/24 h) and coma. Further studies should focus on consensual deWnitions for these indicators and evaluate the psychometric proprieties of this trial version.

As anaesthetic-related maternal mortality reduces in the developed world, alternative indicators of obstetric anaesthetic quality are required. Serious morbidity is difficult to define and quantify, but can be reduced by the provision of effective critical care. Regional anaesthesia, although safer than general anaesthesia, is not without risks. Evidence-based strategies exist to reduce the risks.

The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable--rural populations and poor people--is essential if substantial progress is to be achieved by 2015.

BACKGROUND: Maternal mortality ratio (more commonly cited as maternal mortality rate) is the number of maternal deaths that result from the reproductive process per 100,000 live births. Unfortunately, it is estimated that more than half of maternal deaths are not recorded as such. Worldwide data are probably based upon pregnancy-associated or pregnancy-related deaths only. Persistent efforts are made to assess true mortality rates, though these are considered at most educated guesses.
OBJECTIVE: This editorial was aimed to discuss the lately shared opinions regarding global reduction of maternal mortality rates, an unaccomplished goal during the past 20 years.
CONCLUSIONS: Reassessment of resources and means of intervention will hopefully result in narrowing the gap between nations, and perhaps further reducing global maternal mortality subsequently creating a safer world for mothers.

OBJECTIVE: To assess the association between pre-gestational obesity and weight gain with cesarean delivery and labor complications. METHODS: A total of 4,486 women 20-28 weeks pregnant attending general prenatal care clinics of the national health system in Brazil from 1991 to 1995 were enrolled and followed up through birth. Body mass index categories based on prepregnancy weight and total weight gain were calculated. Associations between body mass index categories and labor complications were adjusted through logistic regression analysis. RESULTS: Obesity was present in 308 (6.9%) patients. Cesarean delivery was performed in 164 (53.2%) obese, 407 (43.1%) pre-obese, 1,045 (35.1%) normal weight and 64 (24.5%) underweight women. The relative risk for cesarean delivery in obese women was 1.8 (95%
CI: 1.5-2.0) compared to normal weight women. Greater weight gain was particularly associated with cesarean among the obese (RR 4th vs 2nd weight gain quartile 2.2; 95%
CI: 1.4-3.2). Increased weight at the beginning of pregnancy was associated with a significantly higher adjusted risk of meconium with vaginal delivery and perinatal death and infection in women submitted to cesarean section. Similarly, greater weight gain during pregnancy increased the risk for meconium and hemorrhage in women submitted to vaginal delivery and for prematurity with cesarean. CONCLUSIONS: Pre-gestational obesity and greater weight gain independently increase the risk of cesarean delivery, as well as of several adverse outcomes with vaginal delivery. These findings provide further evidence of the negative effects of prepregnancy obesity and greater gestational weight gain on pregnancy outcomes.

Objective To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. Methods In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter’s association with maternal characteristics and perinatal outcomes. Findings Of the 97 095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. Conclusion Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories.

OBJECTIVE: Current information on the risk of uterine rupture after cesarean delivery has generally compared the risk after trial of labor to that occurring with an elective cesarean delivery without labor. Because antepartum counseling cannot account for whether a woman will develop an indication requiring a repeat cesarean delivery or whether labor will occur before scheduled cesarean delivery, the purpose of this analysis was to provide clinically useful information regarding the risks of uterine rupture and adverse perinatal outcome for women at term with a history of prior cesarean delivery. METHODS: Women with a term singleton gestation and prior cesarean delivery were studied over 4 years at 19 centers. For this analysis, outcomes from five groups were studied: trial of labor, elective repeat with no labor, elective repeat with labor (women presenting in earl labor who subsequently underwent cesarean delivery), indicated repeat with labor, and indicated repeat without labor. All cases of uterine rupture were reviewed centrally to assure accuracy of diagnosis. RESULTS: A total of 39,117 women were studied. In term pregnant women with a prior cesarean delivery, the overall risk for uterine rupture was 0.32% (125 of 39,117), and the overall risk for serious adverse perinatal outcome (stillbirth, hypoxic ischemic encephalopathy, neonatal death) was 106 of 39,049 (0.27%). The uterine rupture risk for indicated repeat cesarean delivery (labor or without labor) was 7 of 6,080 (0.12%); the risk for elective (no indication) repeat cesarean delivery (labor or without labor) was 4 of 17,714 (0.02%). Indicated repeat cesarean delivery increased the risk of uterine rupture by a factor of 5 (odds ratio 5.1, 95% confidence interval 1.49 –17.44). In the absence of an indication, the presence of labor also increased the risk of uterine rupture (4 of 2,721 [0.15%] compared with 0 of 14,993, P<.01). The highest rate of uterine rupture occurred in women undergoing trial of labor (0.74%, 114 of 15,323).

OBJECTIVE: Our study's objective was to determine the relationship between state-specific maternal mortality ratios and the density of maternal-fetal medicine specialists.
STUDY DESIGN: State maternal mortality ratios from 1994 to 2001 were calculated from the Centers for Disease Control and Prevention WONDER database. Practitioner distribution data were obtained from professional associations. Demographic information regarding states was gathered from the 2000 US census data. Bivariable and multivariable analyses were conducted with the use of Spearman correlations and Poisson regression, respectively.
RESULTS: The median state maternal-mortality ratio was 7.5/100,000 live births. Our study showed that an increase of 5 maternal-fetal specialists per 10,000 live births results in a 27% reduction in the risk of maternal death (relative risk [RR] = 0.73, 95% CI = 0.58-0.93, P = 0.012). This risk reduction was based on a multivariable Poisson regression model that included the following variables and their significant interactions: state-specific percentages of mothers in poverty, mothers without a high school diploma, minority mothers, and teenage mothers.
CONCLUSION: The density of maternal-fetal medicine specialists is significantly and inversely associated with maternal mortality ratios, even after controlling for state-level measures of maternal poverty, education, race, age, and their significant interactions.

Maternal deaths in developed countries continue to decline and are rare. Maternal mortality statistics are essentially similar in the United States and United Kingdom. However, the situation is completely different in developing countries, where maternal mortality exceeds 0.5 million every year. This article not only assesses morbidity risks in some of the leading causes of maternal death but also highlights strategies to minimize the risks and to prevent maternal morbidity and mortality.

Objective: This study was undertaken to assess the safety of trial of labor after previous cesarean delivery. Study design: Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section. Results: Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (!500) than in high volume (R500 births per year) obstetric units. Conclusion: Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.

OBJECTIVE: This analysis considers the usefulness of maternal mortality ratio (MMR) as an indicator of obstetric care in the context of low overall maternal mortality. We explore whether variation in the level of MMR among European countries reflects differences in obstetric care.
DESIGN: The data presented in this article were collected as part of the European Concerted Action on Mothers' Mortality and Severe morbidity (MOMS). In this study, a panel of experts followed a protocol to determine cause of death and whether it was pregnancy-related. This analysis uses the expert panel's confirmation of cause of death and obstetric attribution.
SETTING: All maternal deaths within 11 European countries.
POPULATION: Two hundred and ninety obstetric deaths occuring between 1992 and 1995.
METHODS: We present the results of a multivariable analysis that controls for cause of death, moment of death, place of death, pregnancy outcome, women's age and nationality.
MAIN OUTCOME MEASURES: We test the hypothesis that countries with higher MMR would have proportionally more cases of direct obstetric death due to thromboembolism, hypertension, haemorrhage or infection compared with other countries in the study. We examine timing of death and maternal age to measure whether there are differences between country groups for older mothers.
RESULTS: We find distinct patterns in cause and timing of death and age-specific mortality ratios between countries with different levels of MMR.
CONCLUSIONS: Despite low rates of maternal mortality in Europe, between-country differences follow patterns with respect to cause and timing of death and maternal age. In addition to representing an important indicator of health status in a country, differences in MMR among European countries provide insight to where obstetric care plays a role maternal deaths.

OBJECTIVE: To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality. METHODS: We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios. RESULTS: Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10–0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated atlow-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47– 0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34–0.83). CONCLUSION: Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings.

Objectives—This report presents final 2007 data on U.S. deaths, death rates, life expectancy, infant and maternal mortality, and trends by selected characteristics such as age, sex, Hispanic origin, race, marital status, educational attainment, injury at work, state of residence, and cause of death. Methods—Information reported on death certificates, which are completed by funeral directors, attending physicians, medical examiners, and coroners, is presented in descriptive tabulations. The original records are filed in state registration offices. Statistical information is compiled in a national database through the Vital Statistics Cooperative Program of the Centers for Disease Control and Prevention’s National Center for Health Statistics. Causes of death are processed in accordance with the International Classification of Diseases, Tenth Revision. Results—In 2007, a total of 2,423,712 deaths were reported in the United States. The age-adjusted death rate was 760.2 deaths per 100,000 standard population, a decrease of 2.1 percent from the 2006 rate and a record low historical figure. Life expectancy at birth rose 0.2 year, from a 2006 value of 77.7 years to a record 77.9 in 2007. Age-specific death rates decreased for most age groups—15–24, 35–44, 45–54, 55–64, 65–74, 75–84, and 85 and over—and remained unchanged for the age groups of under age 1, 1–4, 5–14, and 25–34. The 15 leading causes of death in 2007 remained the same as in 2006 with the exception of two causes that exchanged ranks. Alzheimer’s disease, the seventh leading cause of death in 2006, became the sixth leading cause in 2007, and Diabetes mellitus, the sixth leading cause in 2006, dropped to the seventh leading cause in 2007. Heart disease and cancer continued to be the leading and second-leading causes of death, respectively, together accounting for almost one-half of all deaths (48.6 percent). The infant mortality rate in 2007 was 6.75 deaths per 1,000 live births. Conclusions—Mortality patterns in 2007, such as the decline in the age-adjusted death rate to a record historical low, were generally consistent with long-term trends. Life expectancy reached a record high in 2007, increasing 0.2 year from 2006.

WHO on-line site for ICD-10 codes. This link is to the pregnancy section which defines all the terms used to define conditions for maternal mortality reporting.

Examining health care disparities is an integral part of improving health care quality. Health care disparities are the differences or gaps in care experienced by one population compared with another population. As the National Healthcare Quality Report (NHQR) shows,Americans too often do not receive care that they need or they receive care that causes harm. The National Healthcare Disparities Report (NHDR) shows that moreover, someAmericans receive even worse care than otherAmericans. The quality of health care is different for different people. Within the scope of health care delivery, these disparities are due to differences in access to care, provider biases, poor provider-patient communication, poor health literacy, and other factors. The purpose of the NHDR, as mandated by Congress,i is to identify the differences or gaps where some populations receive poor or worse care than others and to track how these gaps are changing over time. Although the emphasis is on disparities related to race, ethnicity, and socioeconomic status, this directive also includes a charge to examine disparities in “priority populations.” These include groups with unique health care needs or issues that require special attention. Among the priority populations addressed in the NHDR are women, children, older adults, residents of rural areas, and individuals with disabilities or special health care needs.

Objectives—This report presents final 2002 data on the 10 leading causes of death in the United States by age, race, sex, and Hispanic origin. Leading causes of infant, neonatal, and postneonatal death are also presented. This report supplements the annual report of final mortality statistics. Methods—Data in this report are based on information from all death certificates filed in the 50 States and the District of Columbia in 2002. Causes of death classified by the International Classification of Diseases, Tenth Revision (ICD-10) are ranked according to the number of deaths assigned to rankable causes. Results—In 2002, the 10 leading causes of death were (in rank order) Diseases of heart; Malignant neoplasms; Cerebrovascular diseases; Chronic lower respiratory diseases; Accidents (unintentional injuries); Diabetes mellitus; Influenza and pneumonia; Alzheimer’s disease; Nephritis, nephrotic syndrome and nephrosis; and Septicemia and accounted for about 79 percent of all deaths occurring in the United States. Differences in the rankings are evident by age, sex, race, and Hispanic origin. Leading causes of infant death for 2002 were (in rank order) Congenital malformations, deformations and chromosomal abnormalities; Disorders related to short gestation and low birthweight, not elsewhere classified; Sudden infant death syndrome; Newborn affected by maternal complications of pregnancy; Newborn affected by complications of placenta, cord and membranes; Accidents (unintentional injuries); Respiratory distress of newborn; Bacterial sepsis of newborn; Diseases of the circulatory system; and Intrauterine hypoxia and birth asphyxia. Important variation in the leading causes of infant death is noted for the neonatal and postneonatal periods.

Objectives—This report presents final 2002 data on the 10 leading causes of death in the United States by age, race, sex, and Hispanic origin. Leading causes of infant, neonatal, and postneonatal death are also presented. This report supplements the annual report of final mortality statistics. Methods—Data in this report are based on information from all death certificates filed in the 50 States and the District of Columbia in 2002. Causes of death classified by the International Classification of Diseases, Tenth Revision (ICD-10) are ranked according to the number of deaths assigned to rankable causes. Results—In 2002, the 10 leading causes of death were (in rank order) Diseases of heart; Malignant neoplasms; Cerebrovascular diseases; Chronic lower respiratory diseases; Accidents (unintentional injuries); Diabetes mellitus; Influenza and pneumonia; Alzheimer’s disease; Nephritis, nephrotic syndrome and nephrosis; and Septicemia and accounted for about 79 percent of all deaths occurring in the United States. Differences in the rankings are evident by age, sex, race, and Hispanic origin. Leading causes of infant death for 2002 were (in rank order) Congenital malformations, deformations and chromosomal abnormalities; Disorders related to short gestation and low birthweight, not elsewhere classified; Sudden infant death syndrome; Newborn affected by maternal complications of pregnancy; Newborn affected by complications of placenta, cord and membranes; Accidents (unintentional injuries); Respiratory distress of newborn; Bacterial sepsis of newborn; Diseases of the circulatory system; and Intrauterine hypoxia and birth asphyxia. Important variation in the leading causes of infant death is noted for the neonatal and postneonatal periods.

Objectives—This report presents national estimates of the use of nonfederal short-stay hospitals in the United States during 2005 and selected trend data. Numbers and rates of discharges, diagnoses, and procedures are shown by age and sex. Average lengths of stay are presented for all discharges and for selected diagnostic categories by age and by sex. Methods—The estimates are based on data collected through the 2005 National Hospital Discharge Survey (NHDS). The survey has been conducted annually by NCHS since 1965. Diagnoses and procedures presented are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM). Results—Trends in the utilization of nonfederal short-stay hospitals show that the overall average length of a hospital stay has declined significantly. In 2005, the average length of stay for all inpatients was 4.8 days compared with 7.8 days in 1970. Stays for discharges aged 15–44, 45–64 and 65 years and over also declined, but the average lengths of stay for those under 15 years of age were the same in 1970 and 2005. In 2005, there were an estimated 34.7 million hospital discharges, excluding newborn infants. Persons aged 65 years and over comprised 38 percent of all inpatients. One notable trend for elderly people is that their rate of hospitalization for septicemia increased 47 percent from 2000 to 2005. There were 45 million procedures performed on inpatients during 2005. Obstetrical procedures (6.9 million) comprised 25 percent of all procedures performed on females. Cesarean section (18 percent), repair of current obstetric laceration (18 percent), and artificial rupture of membranes (14 percent) accounted for one-half of all obstetrical procedures. Males had more cardiovascular procedures than females (4.1 million compared with 2.9 million), whereas females had more operations on the digestive system than males (3.2 million compared with 2.4 million).

Two slides on Pregnancy-Related Mortality Rates by Nativity (US born or foreign born) for Latina California Residents: 1990-2004.

PURPOSE: Our study aim was to identify factors that may contribute to the racial disparity in pregnancyrelated mortality. METHODS: We examined differences in severity of disease, comorbidities, and receipt of care among 608 (304 African-American and 304 white) consecutive patients of non-Hispanic ethnicity with one of three pregnancy-related morbidities (pregnancy-related hypertension, puerperal infection, and hemorrhage) from hospitals selected at random from a statewide region. RESULTS: African-American women had more severe hypertension, lower hemoglobin concentrations preceding hemorrhage, more antepartum hospital admissions, and a higher rate of obesity. The rate of surgical intervention for hemorrhage was lower among African-Americans, although the severity of hemorrhage did not differ between the two racial groups. More African-American women received eclampsia prophylaxis. After stratifying by severity of hypertension, we found that more African-Americans received antihypertensive therapy. The rate of enrollment for prenatal care was lower in the African-American group. Among women receiving prenatal care, African-American women enrolled significantly later in their pregnancies. CONCLUSIONS: We have identified racial differences in severity of disease, comorbidities, and care status among women with pregnancy-related complications that would place African-Americans at disadvantage to survive pregnancy. These differences are potentially modifiable. Ann Epidemiol 2007;17:180–185.  2007 Elsevier Inc. All rights reserved. KEY WORDS: Racial Disparity, Pregnancy-Related Mortality, Pregnancy-Related Morbidity

The Seventh Report of the United Kingdom Confidential Enquires into Maternal Deaths (2003-2005). Slide set provided by Dr Gwyneth Lewis, CEMACH Clinical Director, Maternal Death Enquiry.

An overview of the role of the California Maternal Quality Care Collaborative (CMQCC) to reduce the rising rates of maternal mortality and the associated increase in maternal morbidity in the state of California. The innovative connection of a quality improvement collaborative with the California Pregnancy-Related and Pregnancy-Associated Mortality Review committee facilitates the more rapid diffusion of findings into action.

The goal of all labor and delivery units is a safe birth for both newborn and mother. A previous Alert(1) reviewed the causes of death and injury among newborns with normal birth weight and suggested risk reduction strategies. This Alert addresses the equally tragic loss of mothers. Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S., despite the rarity of the incidence of maternal death – deaths that occur within 42 days of birth or termination of pregnancy. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in 2004, 2005 and 2006. According to the National Center for Health Statistics of the Centers for Disease Control and Prevention, in 2006, the national maternal mortality rate was 13.3 deaths per 100,000 live births. (2) “Although the current maternal mortality rate may reflect increased identification of women who died during or shortly after pregnancy (3), there clearly has been no decrease in maternal mortality in recent years, and we are not moving toward the U.S. government’s Healthy People 2010 target of no more than 3.3 maternal deaths per 100,000 live births (4),” says William M. Callaghan, M.D., M.P.H., senior scientist, Division of Reproductive Health, Centers for Disease Control and Prevention.

The Safe Motherhood Initiative is a joint project of the American College of Obstetricians and Gynecologists District II/New York in collaboration with the Bureau of Women’s Health of the New York State Department of Health. Established in 2001, the mission of the Initiative is to help prevent pregnancy-related deaths through improved understanding of the causes and risk factors for maternal mortality. Utilizing the maternal death protocol and accompanying abstraction form developed in year one, the Safe Motherhood Initiative and the state’s Regional Perinatal Centers conduct quality assurance and quality improvement activities related to maternal mortality. The Initiative was inspired by the signifi cant racial disparities associated with maternal mortality. The key strategies for prevention of maternal deaths in New York State include the development of a standardized system to report and review pregnancy-related deaths along with the provision of recommendations and training that have the direct goal of improving maternity care.