1. 1 Maternal Mortality Review Team Virginia Department of Health Office of the Chief Medical Examiner Victoria M. Kavanaugh, RN, PhD Coordinator

2. 2 Maternal death review dates to 1928 in Virginia. Collaboration between the Medical Society of Virginia and Virginia Department of Health. Early reviews focused on medical issues and natural deaths. Lack of funding and support: review activities declined in 1990s.

3. 3 Throughout the 1900’s, the maternal mortality rate declined significantly: Principles of asepsis were instituted Shift from home to hospital deliveries Institutional practice guidelines and guidelines defining physician qualifications for hospital delivery privileges Use of antibiotics Safer blood transfusions Better management of hypertensive disorders of pregnancy

4. 4 “Healthier Mothers and Babies” as measured by the decline in infant mortality and maternal mortality was considered to be one of the “Ten Great Public Health Achievements in the US, 1900-1999”* *MMWR, April 2, 1999/48(12);241-243.

5. 5 Since 1982, there has been no further decline in maternal mortality. Maternal mortality rates rose during 2003, 2004, 2005 (possibly due at least in part to improved identification of cases). 19999.9 20009.8 20019.9 20028.9 200312.1 200413.1 200515.1 200613.3 200712.7

6. 6 Reduce the US maternal mortality rate to 11.4 per 100,000 live births by 2020. US ranks 31 st among other developed countries in maternal mortality. ( Virginia ranks 17 th in the US. 1 ) US population has maternal mortality rates substantially lower in some racial/ethnic subgroups with no definable biologic reason to indicate an irreducible minimum has been reached. 1National Women’s Law Center Report Card, Maternal Mortality Rate, 1999-2004

7. 7  understand the causes of maternal death.  educate colleagues and policymakers about these deaths and the need for changes.  recommend improvements for prevention.

8. 8  Public health approach  Emphasis on interventions and preventability  Multidisciplinary review  Confidentiality – Team members receive no identifying information  Retrospective review  Consensus decision-making

9. 9 Virginia Chapters of … American College of Nurse Midwives American College of Obstetricians and Gynecologists National Association of Social Workers Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Medical Society of Virginia Regional Perinatal Councils Virginia Hospital and Healthcare Association Virginia Perinatal Association The Virginia Sexual and Domestic Violence Action Alliance Virginia Dietetic Association Virginia Department of Health … Family Health Services Local Health Department Office of Chief Medical Examiner Vital Records Women’s and Infant’s Health Virginia Department of Behavioral Health and Developmental Services Virginia Department of Social Services Virginia Department of Medical Assistance Services Psychiatry

10. 10 Pregnancy-Associated Maternal Death: All deaths of women occurring during pregnancy or within one year of termination of pregnancy. Regardless of cause of death. Regardless of outcome of pregnancy.

11. 11 1. Was this death pregnancy related? 2. Was this death preventable? 3. What factors contributed to the death and what reasonable changes could have been made to alter the outcome?

12. 12 Preventable death is broadly defined as a death that may have been averted by one or more changes in:  clinical care  facility infrastructure  community  systems response to patient factors These determinations were made with the benefit of retrospective review and current clinical practice guidelines.

13. 13 As each case was reviewed, the Team identified factors within those four categories that contributed to death in that case.

14. After review of the first 4 years of cases, the Team looked at the findings and identified a major risk factor for pregnancy-associated death in Virginia: Obesity The Team published, “Obesity and Maternal Death in Virginia, 1999-2002” in March of 2009. 14

15. 15

16.  Increased risk for hypertension  Increased risk for Type 2 diabetes  Increased risk for heart disease  Increased risk for certain cancers (Nearly ½ of all endometrial or uterine cancers are believed to be caused by excess body fat.)  Increased risk for pregnancy complications such as pre-eclampsia which are associated with morbidity later in life 16

17. BMI Category < 18.5Underweight 18.5 – 24.9Normal weight 25.0-29.9Overweight >30Obese 17

18. 137 women died from natural causes while pregnant or within one year of a pregnancy in Virginia during the review period, 1999-2004. 102 (74.4%) of those cases had both height and prepregnancy weights listed in the record from which prenatal BMI was calculated and are included in this report. 18

19.  Prepregnancy BMI ranged from 16.3 to 58.5  Average BMI was 29.96 (30.0 = Obese)  5 deaths were to underweight women  32 deaths were to normal weight women  24 deaths were to overweight women  41 deaths were to obese women 19

20. 20

21. 21 CDC Pediatric and Pregnancy Nutrition Surveillance System, 2003 Pregnancy Nutrition surveillance, Nation.

22. 22 All US Women A Closer Look:

23. 20-29 Years Old30-39 Years Old # %#% Underweight 12.346.8 Normal Weight 1534.91728.8 Overwt./obese 2762.83864.4 Total 4310059100 23

24. WhiteBlackAsianOther #%#%#%#% Underweight 24.124.4120.000 Normal wt. 1530.61328.9360.0133.3 Overwt./obese 3265.33066.7120.0266.6 Total 49100451005 3 24 Prepregnancy BMI Category by Race Among Women Who Died in Virginia

25. Total (Includes Asian and women of Other races) WhiteBlack No.RatioNo.RatioNo.Ratio Underweight 57.1 177.11522.5 Normal 3212.2 Overweight 2428.3 3219.23045.6 Obese 4124.6 25 Estimated Maternal Mortality Ratio by BMI Category and Race in Virginia, 1999-2004 Estimates of maternal mortality ratios for each BMI category were calculated using percentages of women in each BMI category in the national sample of prepregnancy BMI categories.

26. Underweight/Normal Weight Cardiovascular Disorders = 11 (28.9%) Infection = 5 (13.1%) Hemorrhage and Exacerbation of Chronic Conditions = 4 each (10.5% each) 26 Overweight/Obese Cardiovascular Disorders = 20 (30.8%) Cancer = 14 (21.5) Pulmonary Embolism = 10 (15.4%)

27. 27

28.  Two women classified as overweight were pregnant at the time of death and died from cardiac disorders. There was one stillbirth.  Among the obese women, there was one miscarriage, one ectopic pregnancy and five losses due to the mother’s death.  Fetal losses resulted from the mother’s death due to pulmonary embolism, cancer, cardiac arrest or arrhythmia. 28

29. 38.4% had at least one miscarriage prior to the most recent pregnancy 23.1% had a previous pregnancy complication such as gestational hypertension, preeclampsia, p0st partum hemorrhage, hyperemesis gravidarum, preterm labor. 10.8% had gestational diabetes in this or a prior pregnancy 29

30. 35.4% died within one week of delivery with an additional 9.3% dying before six weeks post partum. 64.0% of the deaths of overweight and obese women were determined by the Maternal Mortality Review Team to be directly related to the pregnancy. 31.2% were thought to be preventable with reasonable systems changes. 30

31. 31 All providers should educate patients about the adverse physical effects of being overweight and obese especially during pregnancy. Providers of pregnancy-related services should promote the use of WIC by disseminating a description of the program and eligibility requirements to all pregnant women and new mothers.

32. All healthcare providers should be informed about the specialized level of care needed for obese pregnant patients. Emphasis should be placed on: preconception counseling for all women on the risks associated with obesity and pregnancy; identification of obesity as a diagnosis in and of itself requiring supplemental testing or consult for care. 32

33. All schools in Virginia should participate in the Governor’s Nutrition and Physical Activity Scorecard which provides incentives to schools for implementing research based best practices supporting proper nutrition and increased physical activity. All employers should provide a health improvement program to employees which includes weight management strategies. Third party payers should provide coverage for dietary counseling, education, and nutrition therapy for individuals with BMIs greater than 30.0. 33

34. 34 Victoria Kavanaugh, RN, PhD Maternal Mortality Review Coordinator Office of the Chief Medical Examiner 737 North 5 th Street Richmond, VA 23219 (804) 205-3853 (804) 786-0391 fax Victoria.kavanaugh@vdh.virginia.gov http://vdhweb/medexam/index.asp