maternal mortality review update - university at albany, sunymarch 23, 2017 maternal mortality...

March 23, 2017

Maternal Mortality Review Update

Preliminary Findings from the Review of 2012-2013 Maternal DeathsVictoria Lazariu, PhDDivision of Family Health, New York State Department of Health

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MMR TeamDr. Marilyn Kacica, MD MPH

Dr. Chris Kus, MD, MPH SPH:Sava Svirskiy Eva Williford, MSTim Eager, MS Kate Mishkin, MPHBrandi Wells, MPH

IPRO:Marilyn Zumbo and Deborah Phaff

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Our PartnersMark Sharp, Vital Statistics

Lenny Kluz, Assistant Director Vital Records

Colleen Kewley, NYPORTS Coordinator

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Outline• Background

• Recent Trends in Maternal Mortality Trends As Reported in Vital Records

• Findings from the Review of 2012-2013 Maternal Deaths

• What Did We Learn from Maternal Mortality Reviews?– Differences in Two Cohorts: 2006-2008 vs 2012-2013

• Next Steps

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Background

Maternal Mortality

• Measured as maternal deaths per 100,000 live births

• Maternal deaths are identified by ICD 10 Codes indicating obstetric deaths within 42 days postpartum

A34, O00-O95, O98-O99

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Background

Maternal Mortality

• US ranks 60th in the world behind all other developed nations in maternal mortality*

• 2010: NY ranks 46th among 50 states with a rate of 18.9

Center, N.W.s.L., Health Care Making the Grade on Women's Health: A National and State by State Report Card. 2010. Available from: http://hrc.nwlc.org/status-indicators/maternal-mortality-rate-100000

• 2016: NY ranks 30th with a rate of 20.9Explore Maternal Mortality in New York | 2016 Health of Women and Children Report. 2017; Available from: http://www.americashealthrankings.org/explore/2016-health-of-women-and-children-report/measure/maternal_mortality/state/NY.

*Kassebaum NJ, Bertozzi-Villa A, Coqqeshall MS et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 Sep 13;384(9947):980-1004. doi: 10.1016/S0140-6736(14)60696-6. Epub 2014 May 2.

http://hrc.nwlc.org/status-indicators/maternal-mortality-rate-100000

http://www.americashealthrankings.org/explore/2016-health-of-women-and-children-report/measure/maternal_mortality/state/NY

http://www.ncbi.nlm.nih.gov/pubmed/24797575

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Trends in Maternal Mortality as Reported in Vital Records*

*Causes of death from death records A34, O00-O95,O98-O99. 2000-2014 data from NY Vital Records. 2015 NY and national data from CDC Wonder database.

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*Causes of death from death records A34, O00-O95,O98-O99.

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*Causes of death from death records A34, O00-O95,O98-O99.

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Maternal MortalityReviews, 2012-2013

• Case identification

• Pregnancy-related deaths

• Pregnancy-associated, not related deaths

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Pregnancy-related death is the death of a woman while pregnant or within a year from termination of pregnancy, occurring as result of a pregnancy-related illness (i.e. preeclampsia) or as a result of an underlying illness exacerbated by the physiology of pregnancy (i.e. mitral stenosis.) • A pregnancy-related death that occurred within 42 days

of the termination of the pregnancy is a maternal death.

Pregnancy-associated, not related death is the death of a woman while pregnant or within one year of termination of pregnancy from any cause, not as a cause of pregnancy or illness exacerbated by pregnancy (i.e. motor vehicle accident.)

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Identified 216 women of reproductive age who died within a year of the end of a pregnancy

• 99 deaths linked to a live birth record• 117 deaths not linked to a live birth records but

• With an obstetric cause of death or• With pregnancy indicated on death record or• Linked to hospital records with an indication of pregnancy


Case Identification

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99% of reviews completed• 164 pregnancy-associated deaths

• 60 pregnancy-related– 50 maternal deaths (within 42 days of

end of pregnancy)• 16 unknown if related• 88 not related


Case Identification

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99% of reviews completed• 46 ‘false’ pregnancies

• 29 obstetric causes of death on death record (17 of them had pregnancy checked on death record)

• 2 pregnancy checked but no obstetric cause of death

• 15 indication of pregnancy on hospital record


Case Identification

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Maternal deaths: MMR vs Vital Statistics2012

MMR Vital Statistics

Maternal Mortality Rate comparison

Black to Whiteratios

Total27

Unknown: 445 11.3 vs 18.8

Black mothers11

Unknown: 222 25.9 vs 51.8

3.2 vs 4.0White mothers

12Unknown: 2

19 8.2 vs 13.0

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Maternal deaths: MMR vs Vital Statistics2013

MMR Vital Statistics

Maternal Mortality Rate comparison

Black to Whiteratios

Total23

Unknown: 642 9.8 vs 17.9

Black mothers8

Unknown: 419 19.6 vs 46.6

2.6 vs 3.4White mothers

11Unknown: 2

20 7.6 vs 13.9

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Pregnancy-Related Deaths, n=60

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Maternal Demographics


• Average age: 33 years old

• Primary language : English (63%)

• Marital status: even distribution between single and married

• Ethnicity: – Hispanic or Latino 17%, 10– Not Hispanic 73%, 44– Unknown 10%, 6

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Demographics: Mother’s Race


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Maternal Demographics


• Almost a half of the women in the cohort were employed during the index pregnancy

• Health insurance:– Medicaid 67%, 40– Private insurance 23%, 14

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Maternal Demographics: Education


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Prenatal history

Parity: • 32% no previous births • 13% had one previous birth• 28% 2 or more• 27% unknown

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Prenatal history

Prenatal care records: • 50% (n=30) prenatal care records• 12% (n=7) prenatal care summary

High risk or MFM care• 10% (n=6)

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Prenatal history

Prenatal care received: • Intensive care 3%, 2• Adequate care 28%, 17• Intermediate care 13%, 8• No prenatal care 3%, 2• Missing information 45%, 27

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Prenatally-Identified Risk Factors

Majority of women (85%) had at least one risk factor.

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Risk Factor Percent, number of cases

ObstetricPrevious TOP

Previous cesareanUterine abnormality or incompetent cervix

Hx of premature birth

62%, 37251261

HematologicAnemia

Sickle cellCoagulation disorder

25%,15951

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CardiacCardiomyopathy

Mitral valve prolapseMurmur

CHFCongenital heart defect

Dilated aortic rootIntraarterial septal aneurysm

Tachycardia arrthythmia

18%, 1122211111

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PulmonaryAsthma

Tuberculosis+PPD

18%, 11722

EndocrineDiabetes

Type 2 (4), type 1(1), gestational (1)Thyroid disorder

Hypothyroidism (2), Hx of abnormal thyroid test (1)

17%,106

4

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Hypertension 17%, 10

Psychiatric disordersDepression

AnxietyBipolar

Schizoaffective

12%,74311

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Risk factorRace Ethnicity

Black White Asian Other Hispanic Not Hispanic Unknown

Obstetric 19 13 4 1 6 29 2

Hematologic 11 3 0 1 1 13 1

Cardiac 5 4 0 2 2 5 4

Pulmonary 6 4 1 0 4 7 0

Endocrine 6 4 0 0 0 6 4

Hypertension 8 2 0 0 0 7 3

Psychiatric disorder 2 5 0 0 3 4 0

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Unhealthy pre-pregnancy weight status 47%, 28• Obesity, BMI>=30 21• Overweight, BMI between 25 and 30 7

Smoking prior to pregnancy: 12% Alcohol use prior to pregnancy: 12%Drug use prior to pregnancy: 13%



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Intrapartum Medical HistoryHospital of delivery or termination of pregnancy

• Regional Perinatal Center (35%, n=21)• Level 3 hospital (25%, n=15) • Level 2 hospital (17%, n=10)• Level 1 hospital (12%, n=7)

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Intrapartum Medical HistoryType of delivery• C- sections 68%, n=41

• Emergent 33%, n=20• Unscheduled non-emergent 17%, n=10• Elective scheduled 12%, n=7• Peri or postmortem 7%, n=4

• Normal spontaneous vaginal deliveries 20%, n=12• VBAC (n=1)

• Undelivered 10%, n=6• Unknown (n=1, death record only) 2%

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• Embolism (not cerebral) 30% (n=18)• Hemorrhage 18% (n=11)• Infection 15% (n=9)• Cardiomyopathy 10% (n=6)• Hypertensive disorders 10% (n=6)• Cardiovascular problems 5% (n=3)• Cardiac arrest/failure 3% (n=2)• Hematopoietic (sickle cell, thalassemia, ITP) 3% (n=2)• Intracerebral hemorrhage (not associated with PIH) 3% (n=2)• Pulmonary problems 2% (n=1)


Causes of Death Among Pregnancy-Related Deaths (n=60)

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Problems/deficiencies in care• Physician, midwife or resident• Nursing• Support services (laboratory, x-ray)• System• Hospital• Family• Patient• Access to care

Assessment of Care

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Failure to recognize and treat 9 cases• ‘failure to recognize maternal hemorrhage and to treat timely and

aggressively’

Delay in treatment 5 cases• ‘Delay in proceeding with D&C hysterectomy’

Lack of supervision 2 cases• ‘attending - lack of supervision’

Break in communication 2 cases• ‘Unrecognized hypovolemic shock/ unsupervised PACU patient/poor

communication’

Deficiency: Physician, midwife or resident (n=10)

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Not following protocols 4 cases• ‘ escalation policy which was in place was not adhered to’

Break in communication 4 cases• ‘Nursing should have reached out to on call attending if provider not

able to be contacted. Escalation policy which was in place was not adhere to.’

Failure to recognize severity 3 cases• ‘failure to recognize post operative infection’

Delay in administering treatment 1 case• ‘ delay in administering antibiotics’

Deficiency: Nursing (n=7)

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Timeliness of services• ‘delay in obtaining x-rays’• ‘availability and timely replacement of blood products’

Deficiency: Support services (n=4)

Deficiency: Hospital (n=4)

Communication• poor communication between servicesInterpreter not available • ‘Availability of an interpreter’

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Protocols not in place or not followed 7 cases• ‘no availability of a comprehensive protocol for management of

post partum hemorrhage’

Inadequate resources (ICU beds, supplies) 3 cases• ‘unavailability of ICU beds, unavailability of thrombolytic agents in

a timely manner’

Inadequate staff (level and education) 2 cases• ‘provider not informed of patient’s relevant medical history’

Deficiency: System (n=10)

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Patient not following treatment/recommendations

• ‘termination of pregnancy was recommended, patient refused ‘

• ‘patient did not seek prenatal care, smoked, drunk and used illicit drugs’

• ‘patient discontinued anti seizure medication – thought would harm the baby’

• ‘mental illness may have played a role in patient seeking care - not clear but unlikely’

Deficiency: Patient (n=15)

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Lack of support to follow medical recommendations • ‘did the family tried to help patient quit smoking?’• ‘did not bring her for post operative care’ • ‘Patient has 6 children, unknown if failure to keep appointment is due

to lack of home help’

Domestic violence • ‘FOB assaulted the patient’

Deficiency: Family (n=6)

Deficiency: Access to care (n=2)• No health insurance

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Pregnancy-Associated Deaths, n=104

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• Race– White 59%, 61– Black 25%, 26– Asian 5%, 5– American Indian or Alaska Native 2%, 2– Other 10%, 10

• Ethnicity– Hispanic or Latino 18%, 19– Not Hispanic 49%, 51– Unknown 33%, 34


Maternal Demographics (n=104)

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• Race– White 59%, 61– Black 25%, 26– Asian 5%, 5– American Indian or Alaska Native 2%, 2– Other 10%, 10

• Ethnicity– Hispanic or Latino 18%, 19– Not Hispanic 49%, 51– Unknown 33%, 34


Maternal Demographics (n=104)

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Type of delivery• NVSD 28%, 29

• VBAC 3

• Cesarean delivery 23%, 24• Unscheduled not emergent 9• Elective/scheduled 8• Emergent 6• Peri or post-mortem 1

• Undelivered 18%, 19• Other 3%, 3• Unknown 28%, 29


Intrapartum Medical History (n=104)

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Place of delivery• Regional perinatal center 24%, 25• Level 3 hospital 15%, 16• Level 2 hospital 7%, 7• Level 1 hospital 5%, 5• Non-birthing facility 4%, 4• Home 1%, 1• Jail 1%, 1• Unknown 43%,45


Intrapartum Medical History (n=104)

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• Injury 52% (n=54)• Cancer 9% (n=9)• Infection 6% (n=6)• Cardiac arrhythmia 5% (n=5)• Unknown 5% (n=5)• Pulmonary problems 4% (n=4)• Cardiomyopathy 3% (n=3)• Cardiovascular problems 3% (n=3)• Other 14% (n=15)


Causes of Death Among Pregnancy-Associated Deaths (n=104)

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• Injury (n=54)– Substance abuse 26% (n=14)– Suicide 22% (n=12)– MVA 19% (n=10)– Homicide 17% (n=9)– Undetermined injury 2% (n=1)– Unintentional 2% (n=1)


Pregnancy-Associated Deaths - Injury

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What did we learn from Maternal Mortality Reviews

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Characteristic 2006-2008 (N=125) 2012-2013 (N=60)AgeMothers in MMR cohort are older (on average) than mothers with live births

2 years older 2009 births

3 years older2012 births

Most women in cohort are less than 35 70% (n=88) 62% (n=37)

Women at highest risk are 30 and older 30% more likely to die than younger women

35 and older 85% more likely to die than younger women

Maternal Characteristics

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Characteristic 2006-2008 (N=125) 2012-2013 (N=60)Race

BlackWhiteAsianOther

Native HawaiianUnknown

46%18%10%8%1%18%

42%43%10%5%0%0%


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Characteristic 2006-2008 (N=125)

2012-2013 (N=60)

Pre-pregnancy weight statusOverweight (BMI between 25 and 30) 15% (n=19) 12% (n=7)

Obese (BMI of 30 or more) 30% (n=38) 35% (n=21)

Substance use prior to pregnancySmoking 12% (n=15) 12% (n=7)Alcohol 2% (n=3) 12% (n=7)

Drug use 6% (n=7) 13% (n=8)


March 23, 2017 53Prenatally-Identified Risk Factors

Number of risk factors identifiedNumber of cases

2006-2008 2012-20130 45 (36%) 9 (15%)1 40 (32%) 18 (30%)2 23 (18%) 14 (23%)3 8 (6%) 8 (13%)4 6 (5%) 8 (7%)5 1 (1%) 2 (3%)6 1 (1%) 3 (5%)7 1 (1%)8 1 (2%)

10 1 (2%)

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2006-2008 (n=125) 2012-2013 (n=60)At least one risk factor identified

64% 85%

Hematologic 19% (n=29) 25% (n=15)Hypertension 17% (n=26) 17% (n=10)Cardiac 13% (n=20) 18% (n=11)Pulmonary 9% (n=13) 18% (n=11)Endocrine 8% (n=12) 17% (n=10)Psychiatric disorders 5% (n=8) 12% (n=7)

Provider-Identified Risk Factors

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2006-2008 (n=125) 2012-2013 (n=60)

Regional perinatal centerLevel 3Level 2Level 1

30%, 3046%, 5710%, 1310%, 12

35%, 2125%, 1517%, 1012%, 7

Place of delivery

Intrapartum Medical History

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2006-2008 (n=125) 2012-2013 (n=60)Type of delivery

Cesarean birth 63% 68%

Outcome of pregnancyUndelivered 10% (n=13) 7% (n=4)

Stillborn 6% (n=8) 8% (n=5)Singleton 70% (n=89) 75% (n=45)

Multifetal, live births 2% (n=3) 3% (n=2)

Intrapartum Medical History

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Pregnancy-Related Deaths

Cause of death 2006-2008 (n=125) 2012-2013 (n=60)Hemorrhage 23% (n=29) 18% (n=11)Hypertensive disorders 23% (n=29) 10% (n=6)Embolism 17% (n=21) 30% (n=18)Cardiovascular problems 10% (n=12) 5% (n=3)Infection 3% (n=4) 15% (n=9)Cardiomyopathy 2% (n=2) 10% (n=6)

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Pregnancy-Associated Deaths

Top four causes of death2006-2008 (n=215) 2012-2013 (n=104)

Cancer 25%, 54 Injury 52%, 54

External causes of accidental injury 12%, 26 Cancer 9%, 9Auto accidents 11%, 24 Infection 6%, 6Assault 9%, 20 Cardiac arrhythmia 5%, 5

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Next Steps• Report summarizing our findings

• Review the 2014 maternal deaths

• Early reviews of 2015 and 2016 death records

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Questions:

[email protected]

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