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Maternal Mortality Review in Maryland

Maternal Mortality Review in Maryland. Meena Abraham, M.P.H. MedChi, The Maryland State Medical Society. Maternal Mortality Ratio by Race Maryland and U.S., 1997-2001. Establishing MMR in Maryland. Legislation passed in 2000

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Maternal Mortality Review in Maryland

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  1. Maternal Mortality Review in Maryland Meena Abraham, M.P.H. MedChi, The Maryland State Medical Society

  2. Maternal Mortality Ratio by RaceMaryland and U.S., 1997-2001

  3. Establishing MMR in Maryland • Legislation passed in 2000 • MD State Health Department contracts with MedChi, The Maryland State Medical Society • Enhanced surveillance approach • not limited to traditional definition of maternal death (<42 days limit) • Identify all deaths up to 1 year postpartum • Determine deaths that are pregnancy-related

  4. MMR Process in Maryland • Identify pregnancy-associated deaths (1 yr) • Death certificate - cause of death or contributing factor related to pregnancy • Death certificate – pregnancy status and date of delivery items (revised in 2001) • Linkage of death certificates with fetal death certificates and birth certificates • Manual review of Medical Examiner files • Other notification

  5. MMR Process in Maryland, cont. • Abstract records from hospital of death, hospital of delivery, Office of CME • Classify by category to group cases and invite specialist to assist w/review • Suicide • Homicide • Substance abuse • Injury/accident • Cancer • Cardiovascular • Other

  6. MMR Process in Maryland, cont. • Review cases with MedChi’s Maternal and Child Health Committee plus invited specialist as needed • Pregnancy-relatedness • Preventability • Recommendations

  7. Method of Identification Pregnancy-associated Deaths 2000 n=32 (%) 2001 n=43 (%) Total N=75 (%) Death certificate cause of death 8 (25) 7 (16) 15 (20) Death certificate checkbox ------- 12 (28) 12 (16) Birth/fetal certificate linkage 21 (66) 31 (72) 52 (69) Medical examiner chart review 12 (38) 6 (14) 18 (24) Other (ME communication, newspaper) 1 (3) 1 (2) 2 (3) Cases by Method of Identification

  8. Year Deaths 2000 n (%) 2001 n (%) Total n (%) Pregnancy-associated 32 43 75 -Pregnancy-related 13 (41) 12 (28) 25 (33) -Pregnancy-relatedness undetermined 7 (22) 16 (37) 23 (31) -Not pregnancy-related 11 (34) 15 (35) 26 (35) -Unknown cause of death 1 (3) 0 1 (1) Pregnancy-associated Deaths in Maryland, 2000-01

  9. % Distribution by Maternal Race/Ethnicity

  10. % Distribution by Age Group

  11. % Distribution by Race, Age Group

  12. % Distribution by Marital Status, Education

  13. % Distribution by Gravida

  14. % Distribution by PNC

  15. Pregnancy-related Mortality Ratio

  16. % Distribution of Timing of Pregnancy-related Deaths, MD, U.S.

  17. Pregnancy Outcome in Pregnancy-related Deaths, MD and U.S. Maryland, 2000-2001 U.S., 1991-1999

  18. Classification Pregnancy-associated Deaths N=75 (%) Pregnancy-related Deaths n=25 (%) Preventable 37 (49) 4 (16) Not preventable 32 (43) 19 (76) Not Determinable 6 (8) 2 (8) Preventability of Deaths • Preventable – patient factor, provider practice, institutional systems • homicide, suicide, unintentional injury; others determined through discussion

  19. Summary of Key Findings • Enhanced surveillance increased identification of pregnancy-related deaths. • Cardiac disease leading cause of death • 44% of pregnancy-related deaths • 10% deaths in 15-44 yr old females • Obesity contributor to preg-related deaths • BMI <25: 24% • BMI 25-29: 24% • BMI>30: 52%

  20. Summary of Key Findings, cont. • Racial disparity—48% preg-related deaths compared to 33% births • Women >35 yrs disproportionate high rates of deaths compared to live births (#11) • Possible increased rates among Hispanic women—higher suicide rate • PNC initiation/utilization • No PNC in 12% preg-related deaths vs late/no PNC in 3.7% live births

  21. Special Focus: Maternal Suicides • Reviewed 10 cases occurring 1993-2001 • 3 pregnant • 7 postpartum: between 30-276 days • In-depth discussion with MCH Committee and psychiatrist consultant • Determined maternal depression is under-diagnosed and under-treated • Opportunity to decrease maternal and infant morbidity

  22. Maternal Depression Project • Formed Maternal Depression Team • Identified need to assess clinical practice and barriers to diagnosis/treatment • Developed survey and distributed to OB/Gyn, Pediatric and Family Practice departments at all hospitals in Md; separately mailed to certified nurse midwives • Identified differences by specialty and barriers • Identified need for patient educational materials and referral resources

  23. Maternal Depression Project • Directing efforts toward • Compiling resources in Maryland including referral list • Developing provider toolkit for educating, diagnosing, treating or referring women with depression • Educating clinicians about the prevalence and impact of maternal depression

  24. Acknowledgements • MedChi’s Maternal and Child Health Committee members and consultants • Preventive Medicine Resident— Sayeedha Uddin, MD, MPH • MCH Committee member and consultant— Cara Krulewitch, PhD, CNM • Center for Maternal and Child Health, DHMH—Maureen Edwards, MD, MPH, Diana Cheng, MD • MD Vital Statistics Administration— Isabelle Horon, DrPH

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