2. Hank Weiss, Center for Injury Research & Control Injuries During Pregnancy Injuries During Pregnancy Tracking & Understanding the Hidden Epidemic Hank Weiss PhD, Associate Professor Center for Injury Research and Control University of Pittsburgh AMCHP 2005 Conference

3. Hank Weiss, Center for Injury Research & Control Pop Quiz The leading cause of pregnancy-related serious injury is: 1. Falls? 2. Violence? 3. Motor vehicle crashes? 4. Poisonings? 5. Parachute jumps?

4. Hank Weiss, Center for Injury Research & Control Parachute Jumps? 2005

5. Hank Weiss, Center for Injury Research & Control Headlines December 19, 2004

6. Hank Weiss, Center for Injury Research & Control 1. The Role of Place: Leading Causes of Death, 2002, All Races, Females 15-39 District of Columbia (n=121,798) 1 HIV27 2Homicide19* 3 Unintentional Injury13* 4Malignant Neoplasms 6 5 Heart Disease 5 Utah (n=462,282) Unintentional Injury61* Malignant Neoplasms31 Suicide 28 Heart Disease10 Homicide10* US Unintentional Injury9,015* Malignant Neoplasms5,702 Heart Disease2,770 Suicide 2,146 Homicide2,011* 4.5 X 6 X 0.7 X Ratio = Unintentional/ Homicide

7. Hank Weiss, Center for Injury Research & Control 2. The Role of Autopsy Bias

8. Hank Weiss, Center for Injury Research & Control Pop Quiz Answer The leading cause of pregnancy-related serious injury is: 1. Motor vehicle crashes 2. Falls 3. Poisonings 4. Violence 5. Parachute jumps

9. Hank Weiss, Center for Injury Research & Control 3 days of Google News [US crash|pregnant] Man, Pregnant Woman Seriously Injured In Crash - Turn to 10.com, RI - 4 hours ago. TAUNTON, Mass. -- A man and a pregnant woman were seriously injured in a car crash in Taunton Sunday night. The car went off the... Man, Pregnant Woman Seriously Injured In Crash Mother Of Unborn Baby Killed In Crash Clings For Her Life - [WCPO, OH - 11 hours ago.... Overnight, Tameka's aunts say doctors tried to induce Tameka's pregnancy without success -- and throughout the day, tameka's health began to fail.... Mother Of Unborn Baby Killed In Crash Clings For Her Life Woman forced to have C-section after car accident - Longview Daily News, WA - Feb 12, 2005. An eight-month pregnant Auburn, Wash., woman was thrown from a pickup in a Thursday morning freeway crash, leading doctors to deliver her baby in an emergency... Woman forced to have C-section after car accident RAPOZA JURY SELECTION DELAYED UNTIL FEB. 22 - KPIX-TV 5, CA - Feb 11, 2005.... plunge near Moss Beach on Oct. 6, 2002. The crash killed Rapoza's seven-months-pregnant wife, Raye, 34, and daughter Tehani, 4.... RAPOZA JURY SELECTION DELAYED UNTIL FEB. 22 SCC Freshman Died In Crash of Pickup - Nebraska StatePaper.com, NE-Feb 11, 2005.... Benham was ejected from the truck. Her body was found in the bed of the pickup. Benham was approximately one month into a pregnancy.... SCC Freshman Died In Crash of Pickup Neurologist: Toss lawsuit in blackout driver case - Beaver County Times, PA - Feb 11, 2005.... sentenced to three to six years in prison for an October 2000 crash that killed Patricia Schick, 54, and Sherri Zeis, 27, who was nine weeks pregnant with her... Neurologist: Toss lawsuit in blackout driver case Feb 11-13, 2005

10. Hank Weiss, Center for Injury Research & Control Objectives 1. Overview of Epidemiology of Maternal injury. 2. Nature and importance of maternal injuries to the Fetus and Infant. 3. Deficiencies of existing data systems. 4. Focus on motor vehicle injuries. 5. Discuss ways to better understand and address the problem.

11. Hank Weiss, Center for Injury Research & Control Maternal Injury The Basis of the Threat to Fetuses

12. Hank Weiss, Center for Injury Research & Control Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits Injury Severity Pyramid

13. Hank Weiss, Center for Injury Research & Control Level of Injury Pyramid Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits

14. Hank Weiss, Center for Injury Research & Control Lack of data New Item on Death Certificate Geographical Bias of Reports Autopsy Bias of Reports

15. Hank Weiss, Center for Injury Research & Control 1.Unintentional Injury = 6,908  MV Traffic = 4,979 2. Malignant Neoplasms = 2,718 3. Homicide = 1,565 4.Suicide = 1,489 5.Heart Disease = 1,370 Total Reproductive Age Deaths = 21,267 Total Reproductive Age Injury Deaths = 10,341 Leading Causes of Death U.S. All Women Ages 15-34, 2002 Year: 2002, Source CDC, WISQARS, PRMS National Vital Statistics Reports Volume 53, Number 5 (October 12, 2004)

16. Hank Weiss, Center for Injury Research & Control “About one-half of all female reproductive age deaths are due to injury and half of those are due to MV crashes” Therefore:

17. Hank Weiss, Center for Injury Research & Control Maternal deaths Defined by the World Health Organization as ‘‘the death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes’’

18. Hank Weiss, Center for Injury Research & Control Maternal Mortality Ratio, U.S. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00054602.htm

19. Hank Weiss, Center for Injury Research & Control U.S. Maternal Mortality (2002) =357

20. Hank Weiss, Center for Injury Research & Control U.S. Birth Rate 7.8% pregnant X 10341 injury deaths = 806 X 9/12 = 605 X=7.8%

21. Hank Weiss, Center for Injury Research & Control More pregnant women die from intentional & unintentional injury than all “maternal mortality” related conditions combined and motor vehicles are probably the leading cause of pregnancy- associated maternal injury death (assuming little pregnancy effect on injury risk). Therefore:

22. Hank Weiss, Center for Injury Research & Control Next Level of Injury Pyramid Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits

23. Hank Weiss, Center for Injury Research & Control Pregnancy-associated Injury Hospital Discharges 19 States, ‘97 19 State Data, Weiss HB, Lawrence BA and Miller TR. "Pregnancy associated assault hospitalizations," Obstet Gynecol, 2002; 100(3): 773-780.Pregnancy associated assault hospitalizations

24. Hank Weiss, Center for Injury Research & Control Pregnancy Assocaited Rate versus Rate Ratio

25. Hank Weiss, Center for Injury Research & Control Next Level of Injury Pyramid Maternal Injury Deaths Maternal Injury Hospitalizations Maternal Injury ED Visits

26. Hank Weiss, Center for Injury Research & Control Leading Causes of ED Injury Visits – Pregnant Women, Utah (Source: Weiss, Cook, Unpublished)

27. Hank Weiss, Center for Injury Research & Control Intent of ED Injury Visits – Pregnant Women, Utah (Source: Weiss, Cook, Unpublished)

28. Hank Weiss, Center for Injury Research & Control U.S. Births vs. ED Treated Female MV Occupant, Falls & Assault Injuries Injury Data: 2002 CDC WISQARS (non-fatal)

29. Hank Weiss, Center for Injury Research & Control U.S. Births vs. ED Treated Female MV Occupant, Overexertion and Unintentional Struck-by/Against Injuries Injury Data: 2002 CDC WISQARS (non-fatal)

30. Hank Weiss, Center for Injury Research & Control Leading Cause of Maternal Injury Maternal and Fetal Deaths = MV Hospitalizations = MV ED Visits = MV

31. Hank Weiss, Center for Injury Research & Control Total Miles (in billions) Driven by Women of Reproductive Age, 1969 to 1990 Bureau of Transportation Statistics, Omnibus Survey – US Department of Transportation

32. Hank Weiss, Center for Injury Research & Control Impact on the Fetus

33. Hank Weiss, Center for Injury Research & Control Fetal & Birth Related Threats Fetal death Prematurity Low birth weight Obstetric complications Placental injury Uterine rupture Amniotic rupture Trauma-related elective and therapeutic abortion

34. Hank Weiss, Center for Injury Research & Control Threats to the Baby Neonatal death Direct and indirect neural and other organ and structural damage Mental retardation? ADHD? Autism? Cerebral palsy? Epilepsy? ???

35. Hank Weiss, Center for Injury Research & Control Fetal Injury Mortality

36. Hank Weiss, Center for Injury Research & Control ICD-9 Classification 760.5 = Fetus or newborn affected by maternal conditions classifiable to 800-995 “…E code should be used as the primary code if, and only if, the morbid condition is classifiable to Chapter XVII (injury) (Injury and Poisoning)” (WHO, 1977)

37. Hank Weiss, Center for Injury Research & Control ICD-10 Classification P00.5 = Newborn (suspected to be) affected by maternal injury P01.6 = Newborn (suspected to be) affected by maternal death (all types)

38. Hank Weiss, Center for Injury Research & Control Out of Sight Out of Mind?

39. Hank Weiss, Center for Injury Research & Control “What Gets Measured Gets Done” James Marks MD, MPH (Commentary on Safe Motherhood)

40. Hank Weiss, Center for Injury Research & Control Fetal Death Registries Most but not all states Only 20 weeks are greater included ICD limitations (no mechanism codes) Reliance on written cause narratives

41. Hank Weiss, Center for Injury Research & Control Traumatic Fetal Deaths By Mechanism Selected States, 1995-1997 Weiss et al, JAMA, 2001, October 17;286(15):1862-1868

42. Hank Weiss, Center for Injury Research & Control Fetal Crash Death Comparisons, 1998

43. Hank Weiss, Center for Injury Research & Control Morbidity: Primary and Secondary Impacts on the Baby

44. Hank Weiss, Center for Injury Research & Control Population Based Fetal Trauma Outcome Studies January/2002 Trauma during pregnancy; outcomes at birth: Schiff et al (J Trauma, 2002) (89-97): Birth outcome after hospitalized injury in Wash. State Outcomes one or more years after birth None

45. Hank Weiss, Center for Injury Research & Control Maternal Outcomes (Schiff) Hospitalized Injury/Birth Linkage Adjusted RR* (95% Confidence Interval) Preterm labor3.4 (3.0-3.9) Placental abruption4.0 (3.0-5.4) Labor induction1.1 (0.9-1.2) Cesarean delivery1.3 (1.1-1.5) *Adjusted for smoking, education, PNC initiation –Schiff et al (J Trauma, 2002) (89-97): Birth outcome after hospitalized injury in Wash. State

46. Hank Weiss, Center for Injury Research & Control Infant Outcomes (Schiff) Adjusted RR* (95% Confidence Interval) Preterm delivery1.5 (1.2-1.8) Low birth weight1.4 (1.1-1.8) Fetal distress1.4 (1.2-1.7) Fetal death2.9 (1.2-6.9) *Adjusted for smoking, education, PNC initiation

47. Hank Weiss, Center for Injury Research & Control Biomechanical Considerations Virginia Tech Simulations Moorcraft, Duma, et al Driver, no restraint, 16 & 22 MPH1622 Driver with seatbelt, 8 & 34 MPH834 Driver with seatbelt & airbag, 28 MPH28 Front passenger improper belt use, 22 MPH22 Front passenger proper belt use + airbag, 22 MPH22

48. Hank Weiss, Center for Injury Research & Control Modeled Effect of Crash Factors on Risk of Fetal Loss Moorcraft et al, Am J Obstet Gynecol, 2003 RestraintSpeed KPH (MPH) Risk of Adverse Outcome* None13 (8)36% None20 (12)54% None25 (16)70% None35 (22)86% 3-pt belt13 (8)9% 3-pt belt25 (16)26% 3-pt belt35 (22)51% 3-pt belt45 (28)76% 3-pt belt55 (34)90% Airbag + 3-pt belt25 (16)26% Airbag + 3-pt belt35 (22)51% Airbag + 3-pt belt45 (28)76% *Includes placental abruption, uterine rupture, direct fetal injury, maternal death or fetal Loss

49. Hank Weiss, Center for Injury Research & Control Population Based Fetal MV Trauma Outcome Studies Crashes during pregnancy and outcomes at birth: Wolf (J Trauma, 1993): Non-seat-belt risk in Wash. State. Hyde et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah Child outcomes one or more years after birth None

50. Hank Weiss, Center for Injury Research & Control Pregnancy-Related Crashes ~3% of births linked to driver MV police reported crash during pregnancy (Hyde et. al., Utah crash linkage, 2003) Extrapolations to 4 million annual births: ≅ 160,000 pregnant crashes per year ≅ 7 times # of infants in crashes Hyde et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah

51. Hank Weiss, Center for Injury Research & Control Utah Crash Linkage Birth Outcome Summary Pregnant women not wearing a seatbelt during an MVC were more likely to: 1.3 times more likely to have low birth weight babies compared to pregnant women not involved in a MVC nearly three times more likely to experience fetal death compared to pregnant women with seatbelts Hyde et al (ObGyn, 2003): Effect of motor vehicle crashes on birth & fetal outcomes in Utah

52. Hank Weiss, Center for Injury Research & Control Comparison to Infants in Crashes Weiss & Cook, 2005, Preliminary Extrapolations to US and Infant Comparisons Pregnancy related MVC incidents by Level Pregnancy Extrapolation to US based on 4 million live births Infant Comparison 3/100 pregnancies in crashes 120,77824,000 (95-99 NASS data) 1/100 pregnancies with ED MV 40,2597,713 1/1000 pregnancies hospitalized with MV (from 19 state study) 4000400 (95-99 NASS data) Fetal Deaths ~700120(2002)

53. Hank Weiss, Center for Injury Research & Control Summary Injury and motor vehicle injury is a surprisingly common occurrence during pregnancy MV trauma to pregnant women has probably increased substantially over last 20 years Critical gaps in reporting and surveillance of pregnancy related injury hide the problem Fetal injury mortality represents a large proportion of childhood injury mortality We are just beginning to understand and measure adverse birth outcomes due to trauma

54. Hank Weiss, Center for Injury Research & Control General Recommendations 1. Maternal/fetal injury issues should be incorporated in national prevention and research objectives. 2. ICD coding guidelines need to be changed to allow coding external cause of maternal injury in vital stats. 3. Maternal injuries should be included an expanded definition of maternal mortality. 4. Pregnancy status & fetal outcomes need to be added to injury surveillance systems.

55. Hank Weiss, Center for Injury Research & Control General Recommendations 5. States should continuously link birth to hospital discharge and ED data to create a pregnancy morbidity surveillance system. 6. CDC should incorporate better injury experience in pregnancy risk assessment (PRAMS). 7. CDC should improve maternal injury details in their birth defects surveillance system. 8. NICHD should examine ways to study developmental outcomes in children exposed to in utero trauma.

56. Hank Weiss, Center for Injury Research & Control Motor Vehicle Recommendations 9.States should continuously link birth and crash data. 10.The FHA should add pregnancy status to driver behavior surveys. 11.NHTSA should mandate pregnant crash dummies tests to understand crash dynamics on women & fetuses. 12.States should enhance education & belt laws to improve the use & proper use of seat belts by pregnant women. 13.Research should explore ways to reduce pregnant: Driving Motor vehicle travel Crash risk Occupant protection

57. Hank Weiss, Center for Injury Research & Control The Hidden Epidemic

58. Hank Weiss, Center for Injury Research & Control Conclusion Questions ? Injury Prevention Begins at Conception!

59. Hank Weiss, Center for Injury Research & Control Hank Weiss, MPH, PhD Associate Professor Phone: (412) 648-9290 Email: hw@injurycontrol.com University of Pittsburghhw@injurycontrol.com Center for Injury Research and Control (CIRCL) Links: http://www.circl.pitt.edu/home/ Contact Information