california maternal mortality and pregnancy-associated mortality review elizabeth lawton mhs...

California Maternal Mortality and Pregnancy-Associated Mortality

Review

Elizabeth Lawton MHS

California Department of Public Health

Maternal, Child, Adolescent Health Division

Empowering Oklahoma’s Women Conference

November 13, 2015

The Problem: Maternal Mortality California Pregnancy-Associated Mortality Review

(CA-PAMR) What did we learn from CA-PAMR? What other resources were developed?

Strengthened public health programs Move upstream to preventive, life course model QI Activities for Maternity Care Providers

Status of Maternal Mortality since 2006 What contributed to the decline?

Next direction of PAMR

What This Talk Will Address

Maternal Mortality Rate, California and United States; 1999-2006

Ma

tern

al

De

ath

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er

10

0,0

00

Liv

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irth

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HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

http://wonder.cdc.govon/

Maternal Mortality Rates by Age Group, California Residents; 1999-2006

7.6

12.1

8.211.710.1

15.416.3

13.8

51.7

36.9

42.8

64.361.6

59.3

55.757.7

0

10

20

30

40

50

60

70

1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008

Three-Year Moving Average

20-24 Years 25-29 Years 30-34 Years 35-39 Years 40-54 Years

Ma

tern

al

De

ath

s p

er

10

0,0

00

Liv

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irth

s

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2006

7.1

12.4

27.729.0

32.2

35.3

45.7

41.5

51.0

46.1

9.1

12.8

9.37.6

0

10

20

30

40

50

60

1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008


White, Non-Hispanic African-American, Non-Hispanic

Hispanic Asian, Non-Hispanic

Mat

ern

al

Dea

ths

per

100

,000

Liv

e B

irth

s

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

Initiated in 2004-2006 in order to:

Investigate the rise in maternal mortality and the widening racial/ethnic disparity

Identify possible reasons for the rise

Direct policy and programmatic interventions

California Health and Safety Codes give CDPH the broad authority to investigate sources of morbidity and mortality.

California Pregnancy-Associated Mortality Review

CA-PAMR Project Partners

California Department of Public Health (CDPH),

Center for Family Health, Maternal Child and Adolescent Health Division (MCAH)

Public Health Institute (PHI); Sue Holtby MPH and Christy McCain, MPH

California Maternal Quality Care Collaborative (CMQCC); Elliott Main, MD, Christine Morton, PhD

CA-PAMR Committee

CA-PAMR Committee

CA-PAMR Status and Publications

Concluded review of deaths from 2002-2007 Initial CDPH report

‘Made the Case’ and describes methodology Findings from review of 2002-2003 maternal deaths

Follow-up report 2016

THE CALIFORNIA PREGNANCY-ASSOCIATED

MORTALITY REVIEW (CA-PAMR)

Report from 2002-2003 Maternal Death Reviews

April 2011

ARTICLE in MATERNAL AND CHILD HEALTH JOURNAL

California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings Connie Mitchell • Elizabeth Lawton • Christine Morton • Christy McCain • Sue Holtby • Elliott Main

CA-PAMR Status and Publications

Key Steps of CA-PAMR Methodology

STEP 1: Hospital discharge data linked to birth, death certificates Identifies women who died within one year postpartum from any cause

(Pregnancy-Associated Cohort)

STEP 2: Additional data gathered for each death Coroner Reports, Autopsy Results, and additional information from the Death Certificate (e.g., multiple causes of death, recent surgeries, etc) are obtained

STEP 3: Cases selected for CA-PAMR Committee review Documented (ICD-10 obstetric (“O”) code) and suspected pregnancy-related

deaths are prioritized for review

STEP 4: Medical records abstracted and summarized All available labor and delivery, prenatal, hospitalization, transport, and

outpatient and emergency department records are obtained and summarized

STEP 5: Cases reviewed by CA-PAMR Committee Committee determines whether the death was pregnancy-related, the

cause of death, contributing factors and quality improvement opportunities

Source: The California Pregnancy-Associated Mortality Review. Report from 2002-2003 Maternal Deaths. California Department of Public Health, April 2011.

CA-PAMR Pregnancy-Related Causes of Death, 2002-2005 (After CA-PAMR case review)

Cause of Pregnancy-Related Deaths N (%) Rate (95% CI)Cardiovascular disease 49 (23.7) 2.3 (1.6-2.9)

Cardiomyopathy 33 (15.9)

Other cardiovascular 16 (7.7)

Preeclampsia/eclampsia 36 (17.4) 1.7 (1.1-2.2)

Obstetric hemorrhage 20 (9.7) 0.9 (0.5-1.3)

Deep vein thrombosis/pulmonary embolism 20 (9.7) 0.9 (0.5-1.3)

Amniotic fluid embolism 18 (8.7) 0.8 (0.5-1.2)

All Other Causes (Sepsis, Cerebral vascular accident, Anesthesia complications, Acute fatty liver, etc)

64 (30.9) 3.0 (2.3-3.7)

TOTAL 207 9.7 (8.4-11.0)

Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015

Risk Factor: Obesity; CA-PAMR 2002-2005


Preventability – or – Chance to Alter Outcome; CA-PAMR 2002-2005

* Significantly more likely to have good-to-strong chance than CVD and AFE deaths

**Significantly less likely to have good-to-strong chance than all causes


Contributing Factors by Health Care Professionals CA-PAMR 2002-2005


In-Depth Review of Pregnancy-Related Cardiovascular Disease CA-PAMR 2002-2006 (N=64 CVD out of 257 P-R)

Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.

Key Findings (1): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006


Racial/Ethnic disparity even more pronounced

African-American women 5.5% of CA births

22% of all pregnancy-related deaths

40% of cardiovascular pregnancy-related deaths

Other risk factors

Obesity, Hypertensive disorders (20%), Substance use (38%), especially stimulants (11%) and alcohol (17%)



Time to death from birth or fetal demise

ALL CVD: 9d median, 56d mean, range (0,340d)

CMP: 67d median, 112d mean, range (0,340d)

Timing of CVD diagnosis

Preexisitng disease: 3%

Prenatal period: 8%

At labor and delivery: 65%

Postpartum period: 34%

Postmortem: 48%



Presented with Signs and Symptoms of CVD

Prenatal period: 43%

At labor and delivery: 51%

Postpartum period: 80%

Shortness of Breath (61%) and Edema (44%)

52% Identified as Pregnancy-Related on Death Certificate (before case review)

69% Autopsy performed (critical for diagnosis of cardiomyopathy)

Between 2006-2010, CDPH MCAH also:

Invested in Preconception Health Program

Funded local Maternal Health Programs to develop interventions for regional issues

Revamped Black Infant Health Program

Began mapping out more 1o and 2o prevention strategies to move MCAH activities upstream

Incorporated the Life Course Model throughout

Developed surveillance capacity to monitor maternal morbidity, including severe maternal morbidity and composite measures.

Maternal Public Health Programs and Surveillance Strengthened in California

QI Activities for Maternity Care Providers

Translation of CA-PAMR findings into Quality Improvement Activities

California Maternal Quality Care Collaborative

Volunteer Task Force, CA-PAMR Committee members

CDPH MCAH Title V funds

Series of Toolkits to Transform Maternity Care

Hospital Learning Collaboratives

Improve Response and Recognition to:

Obstetric Hemorrhage

Preeclampsia

Cardiovascular Disease

Available – at no cost – at www.CMQCC.org

Quality Improvement Toolkits

First Version released July 2010

Maternal Mortality Rate, California and United States; 1999-2013

11.1

7.7

10.0

14.6

11.8 11.7

14.0

7.47.3

10.9

9.7

11.6

9.2

6.2

16.9

8.9

15.1

13.1

12.19.99.9

9.8

13.3

12.7

15.5 16.916.6

19.3

19.9

22.0

0

3

6

9

12

15

18

21

24

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Ma

tern

al

De

ath

s p

er

10

0,0

00

Liv

e B

irth

s

HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

http://wonder.cdc.govon/

With this decline, California has achieved and surpassed the Healthy

People 2020 objective for maternal mortality of 11.4 deaths per

100,000 live births. The decline in maternal mortality even continued during 2009 and

2010 when pregnant women were disproportionally impacted by the

H1N1 influenza epidemic.

In 2013, the U.S. rates are projected to be nearly three times

California’s rates.

California’s maternal mortality rates declined while U.S. maternal

mortality rates increased, even though California accounts for one in

eight births nationally.

Maternal Mortality Decline

Maternal Mortality Rates by Age Group, California Residents; 1999-2013

39.9

34.8

5.37.6 4.38.2

6.910.1

10.213.8

22.424.4

51.7

41.8

36.9

42.8

64.361.6

59.355.757.7

0

10

20

30

40

50

60

70

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

2004-2006

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012

2011-2013


20-24 Years 25-29 Years 30-34 Years 35-39 Years 40-54 Years

Ma

tern

al

De

ath

s p

er

10

0,0

00

Liv

e B

irth

s

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

a

aa

b

b

b

c

cc

d

dd

Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2013

7.0

7.1

26.4

37.2

33.8

41.1

46.1

51.0

41.5

45.7

35.332.2

29.0 29.527.7

4.9

9.1 7.8

7.6

0

10

20

30

40

50

60

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

2004-2006

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012

2011-2013


White, Non-Hispanic African-American, Non-Hispanic

Hispanic Asian, Non-Hispanic

Mat

ern

al

Dea

ths

per

100

,000

Liv

e B

irth

s


a

a

a

b

b

b

c

cc

Disparities in Maternal Mortality by Race/Ethnicity, California Residents; 1999-2013

7.0

41.1

37.2

26.4

9.56.9

10.710.99.5

10.9 10.912.2 11.511.8

7.1

12.4

29.533.8

27.7

29.0

32.2

35.5

41.5

45.7

51.0

46.1

3.84.3

3.9

3.2

3.83.9

3.1 3.0 3.0

3.8 3.8

4.4

3.7

0

10

20

30

40

50

60

1999-2001

2000-2002

2001-2003

2002-2004

2003-2005

2004-2006

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012

2011-2013

Year

0

1

2

3

4

5

6

7

8

9

10White, Non-Hispanic

African-American, Non-Hispanic

Maternal Mortality Disparity Ratio

Mat

ern

al

Dea

ths

per

100

,000

Liv

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irth

sR

atio o

f Afric

an-A

merican

to W

hite

Matern

al M

ortality


Mortality rates for African-American women are the lowest they have

been since 1999.

In 2011-2013, 26.4 deaths among African-American women per

100,000 live births, half of the peak in 2005-2007.

African-American women continue to have a three- to four-fold higher

risk of maternal mortality compared to White women.

African-Americans are disproportionately impacted by negative

social determinants of health such as lower wages, access to

housing, unsafe environments and racism.

African-American women may have higher rates of underlying

health conditions such as hypertension, obesity, and

cardiovascular disease that complicate their pregnancies.

Maternal Mortality Decline: Racial Disparities Persist (1)

The disparities may also reflect a disparity in health care that can

be attributed to differences in health insurance, entry to prenatal

care, and access or quality of care.

Finally, the persistent disparity indicates that maternal mortality rates

are decreasing proportionally among both African-American and White

women. One group is not showing a greater increase or decline, thus

the ratio remains steady.

Maternal Mortality Decline: Racial Disparities Persist (2)

Maternal Mortality Rate (early and late deaths),

California Residents; 1999-2013

Ma

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10

0,0

00

Liv

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irth

s

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (Early maternal deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) and code O96 is also included when calculating Early and Late Maternal Deaths up to one year postpartum. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

Late maternal deaths did not decline as dramatically

15.2 deaths per 100,000 live births in 2013.

Decline from 2005 peak rate of 19.1 deaths per 100,000 live births

Not as strong as that observed among the early maternal deaths.

Maternal mortality may be shifting to late postpartum deaths as chronic

diseases, like cardiovascular disease, play a prominent role in maternal

deaths.

This is especially true for peripartum cardiomyopathy, a type of

cardiovascular disease unique to pregnancy which typically occurs in

the last month of pregnancy through the fifth month postpartum

Consistent with data published by the Centers for Disease Control.

Maternal Mortality Decline: Late Maternal Deaths

What Contributed to the Decline in Maternal Mortality in California? (1)

We do not fully know what caused the rise in maternal mortality and

cannot fully explain what has caused its decline. Some hypotheses

for the recent decline include: Improved attention to the issue of maternal mortality and morbidity by

public health officials and maternity care providers through the

following activities. California Pregnancy-Associated Mortality Review (CA-PAMR) Hospital quality improvement strategies have been developed by

Stanford University’s California Maternal Quality Care Collaborative

(CMQCC) with funding from CDPH MCAH. To date, CMQCC has

developed three quality improvement toolkits and sponsored learning

collaboratives for the maternity care community.

What Contributed to the Decline in Maternal Mortality in California? (2)

Maternal mortality may be shifting to late postpartum deaths as

chronic diseases, like cardiovascular disease, play a prominent role. The impact of the economic downturn in 2008.

Reduction of the overall California birth rate Women who gave birth in the last six years may have been

healthier and had lower risk pregnancies Emigration from California due to job loss, cost-of-living, or

housing issues Women may have delayed having children until more economically

certain times. Vital statistics data reporting may be contributing to the apparent

decline, either through improvements in identification of pregnancy

prior to death or in the coding for causes or timing of death.

Next Direction for California and CA-PAMR

Continued analysis of CA-PAMR 1.0 (2002-2007) case reviews Racial Ethnic Disparities Congential CVD and Genetic conditions related to CVD Preeclampsia deaths from stroke Validation of the death certificate’s ability to identify pregnancy-

related deaths Continued examination of the decline

CA-PAMR 2.0 – investigation of violent and accidental pregnancy-

related deaths Suicides, Homicides, Drug Overdoses

Strengthening Maternal Mental Health capacity at CDPH Collaboration with CDPH Office of Health Equity Changes to Vital Statistics forms Venous Thromboembolism Toolkit

Thank you and GOOD LUCK Oklahoma!!!

Questions, Comments, Request for Resources:

Elizabeth Lawton

916-650-0364; [email protected]

mailto:[email protected]

california maternal mortality and pregnancy-associated mortality review elizabeth lawton mhs...

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