1. Maternal Death and Severe Morbidity Review
William M. Callaghan, MD, MPH
Chief, Maternal and Infant Health Branch
Division of Reproductive Health
Centers for Disease Control and Prevention
Oklahoma Every Mother Counts Initiative
April 24, 2015
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health

2. I have no conflicts of interest to disclose.

3. Overview How do we account for maternal deaths in the United States?
What is the difference between state and national review?
Ideas for severe morbidity. Is state-level review the answer?
Can we do it better?

4. 11 8 28
460
850

6. Maternal Mortality:

7. Factors Contributing to the Decline of Maternal Mortality in the 20th Century
Improved standard of living
Improved obstetric training and delivery practices
Hospital deliveries
Use of aseptic techniques
Contraception
Medical advances
Antibiotics
Blood transfusion
Oxytocin
Better management of hypertensive disorders

8. Role of Maternal Mortality Review
1930: Maternal Welfare Committee, Philadelphia County Medical Society
1933: Maternal Mortality in New York City: A study of all Puerperal Deaths,
AMA Committee on Maternal and Child Care
“Guide for Maternal Death Studies”

11. Terminology and definitions Classification of causes
Organization and operation of maternal mortality review committees
Locations
Composition
Case finding
Analysis
Findings for action
Future expansion to maternal morbidity

12. Colonial period births, deaths and marriages recorded by local clergy
Nineteenth century births and deaths accounted for by census
1880 Census Bureau accepts vital registrations from states and cities
1933 complete state-based reports to Census Bureau
1946 National Office of Vital Statistics in the Public Health Service
1960 National Center for Health Statistics
1987 NCHS incorporated into CDC
Hetzel AM. History and Organization of the Vital Statistics System. Hyattsville, Md: National
Center for Health Statistics; Appendix II

13. Definitions
WHO ICD-9
Maternal Death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes
Cause of Death in pregnancy chapter ( )
Maternal mortality rate (MMR)

14. Definitions WHO ICD-10 Used for mortality beginning 1999
Maternal Death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes
Late Maternal Death - New
Used for mortality beginning 1999
Pregnancy chapter O00-O99

17. 2003 and beyond: Pregnancy checkbox
2002: 21 states with checkbox or prompt
2005: 35 states with checkbox or prompt
2010:41 states and DC with checkbox or prompt (5 different question formats)

18. Recent Trend
CDC WONDER

19. Xu , JQ, et al. Deaths: Final data for 2007. NVSR 58 (19). NCHS 2010
In 2012 there were 787 deaths from maternal causes with no increases (in fact decreases in some instances) for hemorrhage, hypertensive disorders, embolisms and ectopics. This 40% increase was largely attributed to the category O99 – “other maternal diseases classifiable elsewhere but complicating pregnancy.” Perhaps the checkbox is finding true disease or perhaps disease unrelated to pregnancy but at this point it is not known.
Xu , JQ, et al. Deaths: Final data for NVSR 58 (19). NCHS 2010

21. Pregnancy-Mortality Surveillance System
ACOG/CDC Maternal Mortality Study Group (1986)
Pregnancy-associated
All deaths during pregnancy and within the 1 year following the end of pregnancy
Pregnancy-related (subset of pregnancy-associated)
Complication of pregnancy
Aggravation of a unrelated condition by the physiology of pregnancy
Chain of events initiated by the pregnancy
Pregnancy Mortality Surveillance System (PMSS)
Pregnancy-related mortality ratio (PRMR)

22. Deaths per 100,000 live births

23. MMR, United States, 1999-2013 CDC WONDER Quintile 1:<10
Suppressed

26. Obstet Gynecol 1996;88:161-7
Obstet Gynecol 2003;101:289–96
Obstet Gynecol 2010;116(6):1302-9
Obstet Gynecol 2015;125:5–12

27. “PMSS Team” <3 FTEs Carol Bruce, Team Lead
Bill Callaghan, Branch Chief
Andreea Creanga, Senior Scientist
Kristi Seed, Contractor (full time)
Carla Syverson, Contractor
Danielle Suchdev, Epidemiologist
<3 FTEs

28. Yearly Operations
PMSS DATA REQUEST & RECEIPT
PMSS CODING & DATA ENTRY
ON-GOING ABORTION DATA REQUEST & RECEIPT STARTING W/ 2011 DATA
PMSS & ABORTION DATA REVIEW
ANALYSIS

30. Pregnancy-related mortality by year and race-ethnicity: United States, 2006-2010
* Number of pregnancy-related deaths per 100,000 live births.

31. Pregnancy-related mortality ratios by age, race and ethnicity: United States, 2006–2010.
* Number of pregnancy-related deaths per 100,000 live births.

32. Cause-specific proportionate pregnancy-related mortality: United States, 1987–2010.

33. Hemorrhage Mortality Proportionate=percent of all deaths
Cause specific=deaths from hemorrhage per 100,000 live births

34. Hemorrhage and decrease in ectopic deaths
Creanga et al., Obstet Gynecol 2011;117:

37. Pregnancy-Associated Mortality in Oklahoma, 2007-2013
Mortality per 100,000 Live Births
Year N
Pregnancy Associated
Pregnancy Related
Not Pregnancy Related
2007 37
67.34
20.02
47.32
2008 21
38.35
18.26
20.09
2009 40
73.34
27.50
45.84
2010 30
56.39
34.48
21.91
2011 23
44.02
32.53
11.48
2012
43.61
24.65
18.96
2013 28
52.48
28.12
24.37
TOTAL
202
53.65
26.51
27.14

38. The surveillance cycle
Identify cases
Review cases
Evaluate and refine
Analyse the results
Act

39. Maternal Morbidity

40. Morbidity: The Problem
Maternal morbidity is difficult to define
Broad range of complications and conditions
Broad range of severity
Maternal morbidity cannot be captured by a defined set of metrics
We need to start somewhere
Healthy mom
Death

41. Severe Maternal Morbidity: Near Miss
Life-threatening events at delivery hospitalization
‘‘a very ill pregnant or recently delivered woman who would have died had it not been but luck and good quality care was on her side’’ (Mantel et al. Br J Obstet Gynecol, 105:985-90, 1998)
“a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” (Say et al. Best Pract Res Clin Obstet Gynaecol 2009; 23: doi: /j.bpobgyn )
Variety of data sources to identify cases based on indicators
Near miss by expert opinion
Geller et al., JAMWA, 2002

42. Severe Maternal Morbidity: Near Miss
5 factor scoring system identified women with “near miss” morbidity
Organ system failure
Extended intubation
ICU admission
Surgical intervention
Transfusion ≥4 units blood
Geller et al., J Clin Epidemiol, 2004

43. Severe Maternal Morbidity: Near Miss
Overcomes the issue of severity
Requires multiple sources or a dedicated perinatal database for identification
Most scoring system factors not available in administrative databases
Less useful in smaller institutions
Cumbersome for state-level and national surveillance
Organ system failure performs well by itself (Se 95%; Sp 88%)
Indicators of such in administrative data are attractive candidates
Transfusion ≥4 units and/or ICU admission is nearly as sensitive as the 5-factor system (Se 100%; Sp 78%)
Geller et al. construct has been validated (You et al., Am J Perinatol 2013;30:21-4)

44. Nationwide Inpatient Sample database
Aim to capture indicators of organ system failure
Use mortality hospitalizations to identify morbidity not previously considered
Length of stay >90th percentile for diagnosis-identified cases by mode of delivery
>2 days vaginal
>3 days repeat cesarean
>4 days primary cesarean
Include postpartum admissions
Callaghan et al. Obstet Gynecol 2012;120:

45. Maternal morbidity Codes
ICD-9-CM
Codes
Diagnosis code
Procedure
code
Acute renal failure
584, 669.3 x
Cardiac arrest/ventricular fibrillation
427.41, , 427.5
Heart failure during procedure or surgery
669.4x, 997.1
Shock
669.1, 785.5x, 995.0, 995.4, 998.0
Sepsis
, ,
Disseminated intravascular coagulation
286.6, 286.9, 666.3
Amniotic fluid embolism
673.1
Thrombotic embolism
415.1x, 673.0, 673.2, 673.3, 673.8
Puerperal cerebrovascular disorders
430, 431, 432.x, 433.x, 434.x, 436, 437.x, 671.5, 674.0, 997.2, 999.2
Severe anesthesia complications
668.0, 668.1, 668.2
Pulmonary edema
428.1, 518.4
Adult respiratory distress syndrome
518.5, , , ,799.1
Acute myocardial infarction
410.xx
Eclampsia
642.6x
Blood transfusion
Hysterectomy
Ventilation
93.90, , 96.7x
Sickle cell anemia with crisis
282.62, ,
Intracranial injuries
800.xx, 801.xx, 803.xx, 804.xx, 851.xx-854.xx
Internal injuries of thorax, abdomen, and pelvis
860.xx—869.xx
Aneurysm
441.x
Operations on heart and pericardium
35.xx, 36.xx, 37.xx, 39.xx
Cardio monitoring
89.6x
Temporary tracheostomy
31.1
Conversion of cardiac rhythm
99.6x

46. Callaghan et al. Obstet Gynecol 2012;120:1029-36

47. Severe Morbidity
Between and severe morbidity during delivery hospitalization increased ~75% ( per 1,000 deliveries).
blood transfusions, acute renal failure, and aneurysms all more than doubled
Severe morbidity at postpartum hospitalizations more than doubled ( per 1000 deliveries).
13 of 25 indicators of severe morbidity at least doubled.
Large proportions of women who died in hospital had indicators for severe morbidity
e.g. 1/3 had transfusion; nearly 2/3 had ventilation
Severe morbidity 100 times more common than mortality

48. Facility surveillance AND REVIEW:
Transfusion ≥4 units
ICU admission
Obstet Gynecol 2014;123:978-81

52. Alignment The “M” in MFM Every Mother Initiative (AMCHP)
Alliance for Innovation in Maternal Health (AIM)

56. Alignment

58. Alignment

59. Alignment

60. Alignment

61. Alignment

63. Alignment

65. Frieden TR. Am J Public Health 2010;100:590-95

66. Thank You
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health