Maternal Mortality - US Resources

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 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: 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 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: The goal of this study was to examine whether sociodemographic, clinical, and other service-related factors, as well as preventability issues affect a woman's progression along the continuum of morbidity and mortality.
STUDY DESIGN: This was a case-control study of pregnancy-related deaths, women with near-miss morbidity, and those with other severe, but not life threatening, morbidity. Factors associated with maternal outcome were examined.
RESULTS: Provider factors (related to preventability) and clinical diagnosis were significantly associated with progression along the continuum after controlling for sociodemographic characteristics (P < .01 for both associations).
CONCLUSION: In order to improve mortality rates, we must understand maternal morbidity and how it may lead to death. This study shows that important initiatives include addressing preventability, in particular, provider factors, which may play a role in moving women along the continuum of morbidity and mortality.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.