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Maternal Deaths in the United StatesWhy Is It So Hard to Account for Them?

William M. Callaghan, MD, MPHChief, Maternal and Infant Health Branch

Division of Reproductive Health

Centers for Disease Control and Prevention

New York Academy of Medicine

Maternal Mortality Summit

February 14, 2018

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Presenter Disclosures

➢No financial disclosures

➢The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

3

4

Maternal Mortality Rate, United States

0

100

200

300

400

500

600

700

800

900

1000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

Death

s p

er

100,0

00 liv

e b

irth

s

JAMA “proclamation”

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CDC, Morbidity and Mortality Weekly Report, October 1 1999

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7

8

9

5

7

9

11

13

15

17

19

21

23

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Death

s p

er

100,0

00 b

irth

s

21.5

Maternal Mortality Rate, 1999-2014

National Vital Statistics System (NVSS); CDC WONDER

9.8

1010

Maternal Mortality: Vital Statistics

Maternal death is 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 the pregnancy or its management but not from accidental or incidental causes.

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Vital Statistics: The Basis for Identification

➢Based on death certificates sent from the states

➢Coded by ICD-10 coding rules

➢Information based on COD and checkbox indicating recent or current pregnancy status• Checkbox introduced in 2003 with incremental uptake over time

• Not all maternal deaths have a clinically meaningful code

➢Historically, maternal deaths were under-counted

➢Pilot studies of checkbox suggest misclassification• No recent pregnancy

• Cause of death not related to pregnancy

➢Death certificates may paint an incomplete picture

COD: cause of death

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13

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Am J Prev Med 2000;19:35-

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Vital statistics, 1991-1992

Checkbox is a simple and effective way of identifying maternal deaths

Regular use by all states would enhance surveillance

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2003 and beyond: Pregnancy checkbox

2003: 21 states with checkbox; 2 states with prompt

2005: 35 states with checkbox or prompt

2014:45 states and DC with standard checkbox; 4 states non-standard checkbox

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0

5

10

15

20

25

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Death

s p

er

100,0

00 b

irth

s

Maternal Mortality Rate, 1999-2014

35

50

23

National Vital Statistics System; CDC WONDER

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Pregnancy Checkbox QA Pilot

➢ Total number of potential pregnancy-related deaths

identified*: 221

➢ Checkbox is only indication of pregnancy: 84 (38%)

➢ Pending confirmation: 41

➢ Confirmed: 43

▪ False positives**: 24 (56%)

▪ True positives***: 19

* Identified through linkage and/or checkbox

** No evidence of pregnancy is preceding year

*** Pregnancy in preceding year confirmed

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19

20

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Death

s p

er

100,0

00 b

irth

s

MMR Due to Hemorrhage, Hypertension and Embolisms, 1999-2014

National Vital Statistics System; CDC WONDER

21

0

1

2

3

4

5

6

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Death

s p

er

100,0

00 b

irth

s

MMR due to other specified pregnancy relatedconditions (O26.8), 1999-2014

National Vital Statistics System; CDC WONDER

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0

0.5

1

1.5

2

2.5

3

3.5

4

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Death

s p

er

100,0

00 b

irth

s

MMR due to other specified diseases and conditions complicating pregnancy, childbirth and the puerperium (O99.8), 1999-2014

National Vital Statistics System; CDC WONDER

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Distribution of ICD-10 O chapter codes recorded as

underlying cause-of-death, 2000-2014

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Perc

ent

All maternal deaths except O26.8 and O99.8 O26.8 O99.8

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Pregnancy Mortality Surveillance System (PMSS)

ACOG: American College of Obstetricians and Gynecologists

➢ACOG/CDC Maternal Mortality Study Group (1986)

➢Pregnancy-associated (temporal relationship)● All deaths during pregnancy and within the year following the end of pregnancy

➢Pregnancy-related (subset of pregnancy-associated; causal relationship)● Complication of pregnancy

● Aggravation of a unrelated condition by the physiology of pregnancy

● Chain of events initiated by the pregnancy

➢Pregnancy-related mortality ratio (PRMR; deaths per 100,000 births)

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PMSS: Enhanced Surveillance

COD: cause of death

➢Based on death and linked birth or fetal death certificates when death occurred following birth or stillbirth

➢Independent of ICD-10

➢Information includes COD and checkbox indicating recent or current pregnancy status and all other details concerning pregnancy• COD descriptions often unclear

• If checkbox only and unclear COD, difficult to include or exclude

➢Clinical relevance instead of rule-based designation of COD

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Comparison: MMR and PRMR

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7

9

11

13

15

17

19

21

23

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

De

ath

s p

er

10

0,0

00

bir

ths

PRMR

MMR

13.2

17.3

9.8

21.5

Pregnancy Mortality Surveillance System https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

PRMR: Pregnancy-related mortality ratio

MMR: Maternal Mortality rate

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Comparison: MMR and PRMR

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5

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25

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Dea

ths p

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0,0

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irth

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PRMR MMR PRMR <=42 days

PRMR: Pregnancy-related mortality ratio MMR: maternal mortality rate

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Cause-specific proportionate pregnancy-related mortality,

PMSS, 1987-2013

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25.0

30.0

Pe

rce

nt

of

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ath

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1987-1990 1991-1997 1998-2005 2006-2010 2011-2013

Creanga AA, et al. Obstet Gynecol 2015;125:5-12.

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Pregnancy-related Mortality Ratios by State, PMSS, 2006-2013

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35

Death

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States + DC

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Pregnancy-related Mortality by Race and Hispanic Ethnicity, 2006-2013

NHW: Non-Hispanic white NHB: Non-Hispanic black AI/AN: American Indian/Alaska Native

API: Asian/Pacific Islander

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5

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15

20

25

30

35

40

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NHW NHB AI/AN API HISP

Death

s p

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irth

s

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R² = 0.5165

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35

0 10 20 30 40 50 60

Perc

ent

NH

B B

irth

s

PRMR

State PRMR by Percent Non-Hispanic Black Births

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0

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20

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40

50

60

<12 12 13-15 16+

PR

MR

(D

eath

s p

er

100,0

00 b

irth

s)

Years of Education

NHW NHB Hispanic

PRMR by Race/Ethnicity and Education

3333

What Are the Real Trends in Maternal Mortality?

➢The measured maternal mortality rate is increasing

➢The pregnancy-related mortality rate has increased but is now relatively stable

➢Disparities are persistent, and some causes of death may be increasing

➢There are hints that efforts to improve identification have resulted in misclassification● What is the extent of the false positives?

● What is the extent of the false negatives?

● Why are mistakes being made?

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Beyond Better Data

➢We need to aspire to something greater● Information needed for prevention will not be found on death certificates

➢There is no acceptable rate of maternal mortality

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Where Can We Go?

➢Surveillance of maternal mortality is driven by information from state-and city-based reviews which● Goes beyond vital statistics

● Informs and evaluates local quality improvement initiatives

● Provides an accurate national picture for trends and causes of death

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➢NYS received an award from CDC to support their Perinatal Quality Collaborative

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Building U.S. Capacity to Review and Prevent Maternal Deaths

➢Technical assistance to support jurisdiction-level maternal mortality review

➢Promotes opportunities to identify interventions with the greatest potential to end preventable maternal mortality

➢Partnership of CDC Division of Reproductive Health, the Association of Maternal and Child Health Programs, and the CDC Foundation (funded through an award agreement with Merck on behalf of its Merck for Mothers program)

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Building U.S. Capacity to Review and Prevent Maternal Deaths

REPORT FROM MATERNAL MORTALITY REVIEW COMMITTEES, 2018

➢Was the death pregnancy-related?

➢What was the underlying cause of death?

➢Was the death preventable?

➢What were the factors that contributed to the death?

➢What are the recommendations and actions that address those contributing factors?

➢What is the anticipated impact of those actions if implemented?

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Resources: MMRIA

➢Addresses barrier identified by MMRCs (2012)

➢Built with expert input

➢Lessons learned from precursor (2014-2016)

➢One stop shop

➢Comprehensive, but standardized

➢Common language for reviews to work together

➢13 jurisdictions using MMRIA, 12 preparing to use (and 2 on the wait list)

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Report from Maternal Mortality Review Committees

➢Included data from 9 state-based MMRCs

➢35% of pregnancy-associated deaths were pregnancy-related

➢Nearly 50% of all pregnancy-related deaths were caused by hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, or infections.

➢Over 60% of pregnancy-related deaths estimated to be preventable

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Report from Maternal Mortality Review Committees

➢Select examples of factors that contributed to the death included: lack of patient knowledge on warning signs, provider misdiagnosis, and lack of coordination between providers

➢Recommendations for action were identified and grouped into themes

➢Anticipated magnitude of impact of each recommendation if implemented was grouped into categories based on best informed opinions.

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Report from Maternal Mortality Review

Committees: Suggestions for Action

CARDIOVASCULAR AND CORONARY CONDITIONS HEMORRHAGE

Improve training Improve training

Adopt maternal levels of care/Ensure appropriate level of care determination

Adopt maternal levels of care/Ensure appropriate level of care determination

Improve procedures related to communication and coordination between providers

Improve procedures related to communication and coordination between providers

Improve standards regarding assessment, diagnosis, and treatment decisions

Improve standards regarding assessment, diagnosis, and treatment decisions

Improve policies related to patient management, communication and coordination between providers, and language translation

Improve policies related to patient management, communication and coordination between providers, and language translation

Improve access to care Improve patient/provider communication

Improve policies regarding prevention initiatives Enforce policies/procedures

Mandate autopsies

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Review to Action

Reviewtoaction.org

➢Goals:● Assist states to establish maternal mortality review committees for states which

lack one

● Improve processes of existing committees through standardization

● Connect states with committees to share best practices

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Thank You

wgc0@cdc.gov