1 Gina M. Brown, M.D., Katrina Manzano, M.P.H., Deborah Kaplan, R-PA, M.P.H. Bureau of Maternal, Infant, and Reproductive Health, NYC DOHMH Acknowledgements: NYC DOHMH Office of Vital Records NYS ACOG NYC DOHMH Maternal Mortality Review Committee Maternal Mortality in New York City: Increased Case ascertainment with enhanced surveillance

2 Pregnant Woman and Death - Austrian Espressionist, Egon Schiele 1911

3 Maternal Mortality Ratio Deaths/100,000 live births during pregnancy or within 1 year of termination. A ratio not a rate: cannot count total # pregnancies Pregnancy Related OB complications, management, or disease exacerbated by pregnancy Pregnancy Associated Not related to pregnancy Direct OB diseases or management Indirect Preexisting disease aggravated by pregnancy

4 Maternal Mortality Definitions WHO Deaths of women while pregnant or with in 42 days of the end of pregnancy Late maternal deaths — deaths 43 days to 1 year of the end of the pregnancy CDC Same as WHO NYC DOHMH Reports data up to 42 days Provides data to one year of end of pregnancy

5 Maternal Mortality Surveillance Background Mid 19 th century efforts National Board of Health complete state based reporting National Census Bureau 1946 National Office of Vital Statistics 1960 National Center for Health Statistics (NCHS)

6 US Maternal Mortality Surveillance History 1917 increased national attention first paid to MM 1931 Philadelphia County Medical Society organized reviews Results published 1934 Resulted in decline from 680  230 deaths/100, of 50 states conduct MM reviews 1956 AMA published Guide for Maternal Death Studies 1968 – 44 states + DC review deaths 1988 only 27 states have MM review committees 1986 ACOG formed the MM Study group

7 Current National Methods for Collecting MM Data State registration of deaths State reporting to NCHS Variety in data collection by state Variety in reporting by state/region MM reportable in some states- not all Most states/regions use death certificates

8 Limitations of death certificate data Improperly filled out – Pregnancy check box is not checked Not all states have a pregnancy check box on death certificates ICD death codes may not indicate pregnancy Pregnancy relationship to death may not be recognized

9 BMIRH MMR Enhanced Surveillance Methods Case ascertainment –Vital Statistics, Medical Examiner (ME), SPARCS (hospital discharge data) Case Review –Medical records, ME reports, maternal death certificates, infant birth certificates Data entry and analysis

10 NYC MMR Review BMIRH Enhanced Surveillance Year # Cases OVS * (Usual case ascertainment) # Cases BMIRH (enhanced surveillance including OVS*) Total *OVS- NYC Office of Vital Records

11 Data collected with enhanced surveillance OVS (Office of Vital Records) – Death certificate with pregnancy check box ME (medical examiner) – Collects detailed data – Define causality – Pick up uncertain associations SPARCS (hospital discharge data) – Adds additional cases missed Infant birth certificates – Prenatal and infant data  Increased # of cases improves the analysis of mortality trends

12 Maternal Death Cases by Referral Source and Classification BMIRH SourceDirectIndirectNot relatedTotal OVS OCME SPARCS Total * * Missing = (36%)(76%)

13 NYC MMR n = 169 MMR total47.63 / 100,000 live births Black83.56 Hispanic49.88 API19.42 White17.72 NYC OVS reported data 18.7 HP 2000 & 2010 goal3.3 US national data12-13

14 Percent of Live Births and Maternal Deaths By Race/Ethnicity BMIRH Live BirthsMaternal Deaths

15 Maternal Birthplace BMIRH (n=169) Birthplace NYC Live Births (% of Total) Maternal Deaths (% of Total) MMR US Puerto Rico Foreign Missing 19n/a

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17 Maternal Age BMIRH Age (years) NYC Live Births (% of Total) Maternal Deaths (% of Total) MMR < (OR 0.60, ns) (referent) > ( OR 1.98, p<.05) *

18 Location of Death BMIRH (n=169)

19 Comparing Leading Causes of Death (%) Cause International PRMR* National PRMR N=4200** NYC PRMR N=119*** EmbolismNegligible20%7% Hypertensive Disorders 12%16%10% Hemorrhage25%17%32% Infection/ Sepsis 15%13%7% Other Obstructed Labor 8% Unsafe Ab 13% Cardiomyopathy 8% CVA 5.0% Anesthesia 2% Cardiomyopathy 8% Anesthesia 7% *International WHO 1993, JAMWA 2002 **National MMWR 2003 ***NYC BMIRH

20 Pregnancy Outcome % All Deaths vs. Hemorrhage Pregnancy Outcome All NYC Maternal Deaths (n=169) NYC Hemorrhage Deaths ( n=39) US Hemorrhage Deaths (n=470) Live Birth Stillbirth Induced Abortion/ miscarriage 13188* Ectopic 1547 Molar Undelivered 2338 Unknown 8310 *US data combines abortion and miscarriage

21 Conclusions: Enhanced Surveillance of Maternal Mortality in NYC BMIRH NYC MMR is among the highest in the US Death certificate data may undercount maternal mortality Enhanced surveillance increases case ascertainment – pregnancy related and associated deaths Data analysis is improved with improved case ascertainment

22 Suggested Methods to Improve MM Case Ascertainment Required reporting Required ME evaluation Increased public awareness Increased medical community awareness Systemized reporting Expanded death certificates

23 Working with the Healthcare Community Maternal Mortality Review Committee Hemorrhage alert letter Point of care tools to prevent hemorrhage mortality Hemorrhage poster Educational slide sets Institutional Systemic Approaches to Hemorrhage Hemorrhage drills Organized response team for unanticipated blood loss Ob, Anesthesiology, Blood Bank, Nursing, other staff

24 Poster for Labor and Delivery and Operating Rooms

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