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Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services

Classification of Pregnancy-Related Mortality based on Death Certificate versus Medical Chart Review Michigan, 1990-1998. Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services Community Public Health Agency Michigan Department of Community Health. Background.

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Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services

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  1. Classification of Pregnancy-Related Mortality based on Death Certificateversus Medical Chart Review Michigan, 1990-1998 Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services Community Public Health Agency Michigan Department of Community Health

  2. Background • U.S. maternal mortality among the highest in industrialized nations • No decline since 1982 • Statistics based on Death certificate • ICD-9 630 - 676 • World Health Organization Definition • Death within 42 days of end of pregnancy • Due to complications of pregnancy • Chain of events initiated by pregnancy • Aggravation by physiologic or pharmacological effects of pregnancy

  3. Goal of Study Improve Identification, Classification and Knowledge of Pregnancy-Related Deaths

  4. Methods Review medical charts and supporting documentation to compare classifications Death Certificate and Michigan Maternal Mortality Study Medical Review Committee

  5. Study Definition and Data Sources Maternal death: • Death matched to live birth in previous 365 days • Death of woman while pregnant Reporting sources for maternal deaths • Hospitals • Medical Examiners • Michigan Department of Community Health, Division of Vital Records

  6. Pregnancy-Associated and Related Mortality Ratio by Race, Death Certificate Number Mortality Ratio (/100,000 live births) Pregnancy-Associated 516 41.0 White 269 27.4 Black 228 92.8 Pregnancy-Related 90 7.1 (.ICD-9 630-376 on birth certificate-365 days) White 33 3.4 Black 53 21.6 Black/White Ratio 6.4

  7. Cases Reviewed Number Percent Selected for Review 232 44.9% Reviewed 217 93.5% No chart available 13 5.6% Awaiting review 2 0.1% Classified Pregnancy- 169 77.9% Related by MMMS Committee

  8. Death Certificate Pregnancy-Related Cause Committee Reclassification Pregnancy-Related - DC Total 90 Selected for Review 86 95.5% No chart/awaiting review 5 5.8% DC/Committee Agreement 77 89.5% Reclassified Unrelated 2 2.3% (1 Black, 1 Native American) Reclassified Undetermined 2 2.3% (2 Black)

  9. Characteristics of Reclassified CasesPregnancy-Related on Death Certificate Death Certificate Cause Committee Cause Abortion/spontaneous Ventricular fibrillation and induced (3) Cardiac arrest Bacteremia Obstetric air embolism (1) Pulmonary embolism

  10. Characteristics of Reclassified CasesPregnancy-Related on Death Certificate Number Number Time of Death No Live Birth 3 >42 days 1 Autopsy Yes 3 No 1 Place of Death DOA/ER 3 Inpatient 1 Prenatal Care Yes 1 No 3 (Native American 1) (Black 3)

  11. Reclassification of Death CertificateNon-pregnancy-Related Cause Number Percent Total cases reviewed 217 Classified Pregnancy-Related by Committee 169 77.9% Reclassified from Death Certificate by Committee as Pregnancy-Related 92 70.2%

  12. Reclassified Cases - CauseNon-Pregnancy-Related on Death Certificate No patterns for Race Prenatal care Place of Death Time to death Residence Birth attendant Education Birth place Birth outcome Payment source Medical risk factors Complications of pregnancy

  13. Characteristics of Reclassified CasesNon-Pregnancy-Related on Death Certificate Percent of Death certificates coded as underlying cause Reviewed Reclassified Circulatory System 56.5% 56.2% Respiratory System 12.3% 83.3% Reclassification of remaining reviewed causes evenly distributed

  14. Pregnancy-Related Mortality Ratio by RaceCommittee Review Number Mortality Ratio (/100,000 live births) Total 169 13.4 White 73 7.4 Black 91 37.0 Black/White Ratio 5.0

  15. Comparison of Black/White Ratio Committee Review and Death CertificatePregnancy-Related deaths, three-year running average

  16. Black/White Ratio by Age Group Committee Review and Death Certificate

  17. Time of Pregnancy-Related Death by RaceDeath Certificate

  18. Time of Pregnancy-Related Death by RaceCommittee Review

  19. Study Limitations Inability to identify all cases Small numbers of events for analysis

  20. Summary Reclassification as pregnancy -related • resulted in a decrease of the black/white discrepancy • Increased identification of black and white women with circulatory system complications • Decreased racial discrepancy for pregnancy-loss

  21. Public Health Recommendations Increase information to physicians about need to specify pregnancy on death certificate Increase information to physicians and women at risk about cardiovascular compromise in pregnancy-related mortality

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