Morbidity and Mortality in Pregnancy: Laying the Groundwork for Safe Motherhood

1. Morbidity and Mortality in Pregnancy: Laying the Groundwork for Safe Motherhood Stacie E. Geller, PhDDepartment of Obstetrics and Gynecology, University of Illinois, Chicago Suzanne Cox, MPHSchool of Public Health, University of Illinois, Chicago William Callaghan MDMaternal and Infant Health Branch, CDC Cynthia J. Berg, MDMaternal and Infant Health Branch, CDC

2. Safe Motherhood InitiativeNairobi 1987 Raise awareness Develop program priorities Stimulate research Mobilize resources Share information

3. Safe Motherhood Multifaceted Model Safe and healthy women throughout pregnancy & childbirth High quality maternal health services Economic and social conditions

4. Maternal MortalityThe Tip of the Iceberg Outcome indicator traditionally used in Safe Motherhood

5. Maternal Mortality The Tip of the Iceberg • Most devastating outcome • Huge burden of disease on the woman’s family and society • Death is a discrete outcome

6. Maternal Mortality The Tip of the Iceberg • Actual numbers of maternal deaths may be small in developed countries • By looking only at maternal deaths, other major problems in obstetric care may be overlooked

7. A Continuum of Maternal Health NORMAL PREGNANCY MORBIDITYSEVERE MORBIDITY NEAR MISS DEATH

8. A Continuum of Maternal HealthNORMAL PREGNANCY MORBIDITY NEAR MISS DEATH • Morbidity is an important outcome • Morbidity affects many women • Morbidity provides more cases for clinical review/monitoring of care • Knowledge gained can improve treatment & prevent progression to more severe morbidity

9. Mortality Definitions Ideal All deaths caused by the adverse effects of pregnancy Pragmatic Consistent classification Ability to make comparisons

10. Mortality Definitions Maternal Death (WHO) 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.

11. Mortality Definitions Maternal death – WHO/NCHS Pregnancy-related death – CDC/ACOG

12. Mortality Definitions Maternal death – WHO/NCHS < 42 days ICD code for underlying cause of death Pregnancy-related death – CDC/ACOG < 365 days All available information

13. Maternal Mortality in the 20th Century

14. Maternal Mortality Has Not Changed Since 1982

15. Pregnancy-Related Mortality Rates Overall pregnancy-related mortality ratio for the U.S. in 1999 13.2 pregnancy-related deaths per 100,000 livebirths

16. Pregnancy-Related Mortality Ratios by Race and Ethnicity, US, 1991-97

17. Pregnancy-Related Mortality Ratios by Country of Birth, U.S. 1991-97. PRMR

18. Pregnancy-Related Mortality Ratios by Age and Race, US, 1991-97

19. Trends in Cause of Pregnancy-Related Deaths emb inf anes other

20. Preventability of Mortality • Some believe that the U.S. has reached an irreducible level of maternal mortality

21. Preventability of Mortality Disparities exist in the world US ranks 30th, behind: Austria, Australia, Belgium, Canada, Croatia, Czech Republic, Denmark, Finland, Germany. Greece, Hungary, Ireland, Iceland, Italy, Japan, Kuwait, Lithuania, Netherlands, New Zealand, Norway, Poland, Portugal, Qatar, Serbia, Slovakia, Spain, Sweden, Switzerland, UK.

22. Preventability of Mortality • Disparities exist within the U.S.

23. Preventability of Mortality Disparities exist within the U.S. • By age • Women 35 years and older

24. Preventability of Mortality Disparities exist within the U.S. • By race • Black & American Indian/Alaskan Native

25. Preventability of Mortality Disparities exist within the U.S. • By place of birth • Hispanic and Asian/Pacific Islanders

26. Preventability of Mortality • Multiple studies from US and Europe show that 30-60% of maternal deaths are preventable

27. Preventability of Mortality • Most important contributing factor to preventable deaths is “substandard” quality of care.

28. Pregnancy-Related Mortality • Deaths caused by pregnancy complications have decreased from a century ago but still occur too frequently. • Many of these are preventable today by applying the knowledge that we have to all women to make their lives healthier before, during and after pregnancy.

29. Maternal Morbidity

30. The Importance of Studying Maternal Morbidity • Represents a huge burden of disease on the woman and her family • Can strengthen the study of maternal death • Focuses research on the nature of how a morbid condition can lead to death, recognizing that death is the last stop on a continuum of adverse events

31. The ContinuumNORMAL PREGNANCY MORBIDITY NEAR MISS DEATH • Continuum can be partitioned into meaningful clinical & epidemiologic ranges to differentiate deaths, near misses, & severe morbidities • Death is easily identified and labeled • Defining a normal pregnancy & locating intermediate points is far more complex

32. Definitions of Morbidity • Various definitions of morbidity, beginning with less severe complications of pregnancy & extending to near-miss morbidity • A general state of morbidity during L&D as conditions that adversely affects a woman’s physical health beyond what is expected in a normal delivery (Danel et al 2003) • In the US the prevalence of any specific morbidity was low, but the burden of total morbidity was high

33. Definitions of Morbidity • Historically, maternal hospitalization has served as a proxy for complications of pregnancy • Between 8-27% of women are hospitalized at least once during pregnancy • Most common reasons for hospitalizations during pregnancy include: • preterm labor, vomiting, genitourinary complications, & hypertensive disorders (Bacak etal. 2005)

34. Definitions of Morbidity • Use of hospitalization without measures of clinical and non-clinical status will not allow precise identification of maternal morbidity & is certainly an overestimate of the incidence of near miss morbidity

35. Other Measures to Assess Severe/Near Miss Morbidity • Admission to critical care or ICU • Organ system failure/dysfunction • Severe obstetrical complications • Maternal diseases • Single measures can under- or over-identify cases of near miss/severe morbidity • ICU admissions may identify the most critically ill patients, but dependent upon a # of factors (hospital structure or level of care available) • May still fail to capture some cases of critically ill women

36. Multiple Variable Model • Using multiple factors may improve the ability to report life-threatening morbidity • Near miss morbidity defined by life-threatening conditions • hemorrhage, PIH, pulmonary embolus, & uterine rupture (Stones et al 1991) • Study in South Africa proposed a broader clinical definition for near miss • organ system based, or management based (emergency hysterectomy) (Mantel etal. 1998) • Case-control approach to identify predictors of severe obstetric morbidity • advanced maternal age, social factors, and previous obstetric complications (Waterstone etal. 2001)

37. Near Miss Morbidity • Many health conditions & morbid events may put women at increased risk for death, but may not be near death • To precisely define near miss morbidity need to: • distinguish near miss from severe morbidity as a separate & distinct category • consider multiple measures since any one single criterion such as hospitalization, ICU admission, or organ system failure is imperfect proxy

38. A Scoring System to Define Near Miss/Severe Morbidity • Scoring system to identify women with near miss morbidity & differentiate them from severe but not life threatening conditions (Geller etal 2004) • Delineate a numeric scoring for identification of near miss events that other researchers and clinicians can replicate • Initially identified 11 factors

39. Initial 11 Factors: Sensitivity and Specificity

40. Scoring System • 5 clinical factors: OSD, intubation, ICU admission, surgical intervention, & transfusion • high sensitivity (100%) & specificity (93%) • constellation of factors related to women who are most severely ill • captured a wide range of morbidities • 4 factor system, eliminated OSF • high sensitivity (100%) & specificity (78%) but defined a category of near miss that was broader & more inclusive • 1-2 factor simpler system lost sensitivity & specificity depending on the variables chosen

41. Defining Morbidity • In choosing a model to define severe and/or near miss morbidity, the best one to be utilized would vary depending upon a number of factors: • Type of institution utilizing the system (is there an ICU and what is the rate of use?) • Availability of data and databases (can data on organ system failure be accessed without time consuming medical record review?) • Time & resources available to collect/analyze data • Intended use of the scoring system

42. Defining Morbidity • Use of a multifactor model for estimates of incidence of life-threatening conditions where more precise identification is important • Most comprehensive system • Captures a wide range of morbidities • Mirrors continuous nature of severity of morbidity • Reflects a constellation of factors related to women who are most severely ill • Most time intensive in terms of data collection & may require chart review

43. Defining Morbidity • Use of a simpler system for monitoring hospital or state-based obstetric care & identifying quality of care issues since a broader estimate of morbidity is acceptable • Simple & less time consuming • Easy to collect data & integrate into electronic record system • Loss of sensitivity & specificity depending on the variables chosen

44. Sensitivity & Specificity of Different Scoring Systems for Identifying Near-Miss Morbidity

45. Defining Morbidity • These models are important attempts to: • Facilitate the comparison of women with near miss or severe morbidity to women who die • Increase our understanding of the range of morbidity during pregnancy • Improve Attempts to objectively describe & identify extremely ill women • Develop interventions aimed at reducing both mortality & morbidity

46. Assessing the Magnitude of Maternal Morbidity • Maternal morbidity related to inpatient care during pregnancy • 1986-87, 22 pregnancy hospitalizations/100 deliveries (Franks etal. 1992) • 1991-92, updated definition including hosp for non-obstetric causes 18 hospitalizations/100 deliveries (Bennett etal. 1998) • Decline was attributable to the drop in hospitalizations for pregnancy loss (ectopic pregnancies & spontaneous abortions) • 1999-2000 there were 12.8 hospitalizations/100 deliveries (Bacak et al., 2005) • Decline likely due to increased use of outpatient management of conditions such as mild preeclampsia, preterm labor, & ectopic pregnancies.

47. The Magnitude of Maternal Morbidity • Population based study 1993-97 showed: • 43% of women (1.7 million women annually) experienced some form of maternal morbidity,much of which was preventable • 30.7% of women (1.2 million women annually) were reported to have either an obstetric complication excluding cesarean section, a preexisting medical condition, or both (Danel etal., 2003)

48. Causes of Morbidity • Of all the women giving birth during this time: • 3.6% had a hemorrhage • 3.0% had preeclampsia or eclampsia • 10.6% had an obstetric trauma such as a 3rd/4th degree laceration or a hematoma • 8.4% had an infection such as amnionitis • 2.8% had gestational diabetes • 4.1% had preexisting medical conditions (Danel et al., 2003) • Other conditions were also present in the population at much lower incidence rates • The more rare & severe conditions & complications occur in <0.1% of population (pulmonary & amniotic embolisms, hemorrhage) mirror the causes of death

49. Causes of Morbidity • Mothers Mortality and Severe Morbidity (MOMS) • A European population based survey to assess the incidence of three conditions of acute severe maternal morbidity (pre-eclampsia, postpartum hemorrhage, and sepsis) in 9 countries • Wide variations in the incidence of the 3 conditions, ranging from 14.7/ 1000 deliveries in Belgium to 6.0/ 1000 deliveries in Austria. • Severe hemorrhage was the most common followed by severe preeclampsia • Countries with the highest incidence of morbidity were not necessarily those with the highest maternal mortality (Zhang, etal. 2005)

50. Disparities in Morbidity • Morbidity is greatest among socio-economically disadvantaged groups • adolescents, unmarried women, &African-American women • African-American women at higher risk of morbidity compared to white women • 40% higher rate of hospitalization • a greater burden of disease or less access to preventive prenatal care or a combination of both (Bacak et al., 2005; Bennett et al., 1998; Franks et al., 1992; Scott et al., 1997) • Among socio-economically disadvantaged groups, racial & ethnic differences were sometimes greatly reduced • Among pregnant teens, the hospitalization ratios were 20.2 per 100 deliveries for blacks and 19.8 for whites • Unmarried black women had a hospitalization ratio of 22.7 versus 19.6 for unmarried white women