Maternal Mortality/Pregnancy-Related Deaths is defined by the CDC as "the death of a woman while pregnant or within 1 year of the end of pregnancy - regardless of the outcome, duration or site of the pregnancy - from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes."(https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm)
Maternal Death is defined by the CDC and World Health Organization as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental/incidental causes." (World Health Organization. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Geneva, Switzerland: World Health Organization; 1992.)
Severe Maternal Morbidity is defined by the CDC as an index of 18 indicators of significant events (i.e blood transfusion, hysterectomy, heart failure, eclampsia, respiratory distress, and sepsis)
Challenges with Reporting of Maternal Deaths
There is a need to improve the quality and validity of the reporting of maternal mortality data.
In the past decade, the National Vital Statistics System (NVSS) has not been able to generate accurate estimates of the maternal mortality statistics because of problems with coding and reporting of the data.
There is evidence of both underreporting and overreporting, largely due to the implementation of a pregnancy related check box to the United States National Death Certificate
Because of the lack of accurate data to accurately measure the magnitude of the issue and thus the inability to identify at-risk populations --> the ability to design effective maternal mortality prevention efforts nationally have been affected
Resources/Articles:
Leading Causes
Overall - Heart disease and stroke are the leading causes of pregnancy-related deaths overall
During delivery - Obstetric emergencies (i.e severe bleeding and amniotic fluid embolism) are the leading cause of deaths during delivery
1 week after delivery - Leading cause is severe bleeding, high blood pressure and infection
1 week to 1 year after delivery - Cardiomyopathy is the leading cause of deaths after 1 week to 1 year after delivery
Other Causes
Unintentional injuries (overdose, car crashes), homicide and suicide
Over a 4 year period in Philadelphia, 49% of maternal deaths had nonmedical causes.
Overdoses were 40% of those nonmedical causes of maternal deaths
Mehta PK, Bachhuber MA, Hoffman R, Srinivas SK. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia. Am J Public Health. 2016;106(12):2208–2210 [PubMed: 27736205
Self-harm (majority occurring in the postpartum period)
Undiagnosed pulmonary edema --> sometimes a complication of preeclampsia (b/c of endothelial cell wall damage, decreased colloid osmotic pressure, LV dysfunction, etc)
Pre-existing Medical Conditions/Risk Factors that may increase the risk of Maternal Death or complicate pregnancy
Preeclamspia
Eclampsia
Gestational Diabetes
Depression
Obesity
Substance Use Disorder
Mental illness
Intimate Partner Violence
Resources
Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions
National Pregnancy-related mortality rate was 17.2 per 100,000 live births (https://www.cdc.gov/vitalsigns/maternal-deaths/)
About 700 women die from pregnancy-related complications each year in the U.S
About 3/5 of those pregnancy-related deaths could be prevented
31% of pregnancy-related deaths occurred during pregnancy
36% happened at delivery or in the week after delivery
33% happened 1 week to 1 year postpartum
The United States maternal mortality rate is much higher than in most industrialized countries
In 2014, pregnancy related deaths ranked as the 6th greatest cause of death among women 20-34 in the U.S
National Race-Related Disparities
Black women were about 3 times as likely to die from a pregnancy-related cause as a White Woman
Data from the Trends in Maternal Mortality: 2009 - 2013 by the New Jersey Maternal Mortality Case Review Team (https://www.nj.gov/health/fhs/maternalchild/documents/nj_maternal_mortality_trends_2009_2013.pdf)
From 2009 - 2013 there were 225 Maternal Mortality Cases in New Jersey
Of the 225 maternal deaths,
78 were deemed to be pregnancy-related
18 were undetermined
Of the 78 pregnancy-related deaths:
Race/Ethnicity
26.9% were non-Hispanic White women
46.2% were non-Hispanic Black women
15.4% were Hispanic women
7.7% were Asian women
Timing of Death
10.2 % occurred while pregnant
8.9% occurred less than one day postpartum
17.8% occurred 1-42 dayspostpartum
49.8% occurred 43+ days postpartum
Mode of Delivery
47.7% had a vaginal delivery
50.8% had a cesarean delivery
The leading pregnancy related causes of death from 2009-2013 were:
Cardiac (16.7%)
Pregnancy-related cardiomyopathy (10.3%)
Embolism (9.0%)
Septic shock/sepsis(9.0%)
Cerebral hemorrhage (7.7%)
Gravida (# of times pregnant)
1 pregnancy (26.4%)
2-3 pregnancies (40.3%)
4-5 pregnancies (19.4%)
6 or more (13.9%)
Recommendations by the New Jersey Maternal Mortality Case Review Team
Improve Case Identification of maternal deaths
Screening and intervention for:
Postpartum depression
Treatment for Drug Use
Universal screening for domestic violence
Improving clinical practice and education
Providers should increase reproductive life planning and treatment of women w/ chronic disease
Simulation training - this is a multidisciplinary approach that requires effective team work. Simulated training may help improve the team work and improve response to labor and delivery emergencies
Recognize and rapid response for postpartum hemorrhage (PPH)
Implement things like risk assessments for PPH on admission, prior to birth and after birth
Protocols for hemorrhage management
Pregnancy testing for all women of childbearing age in ER departments
Other statistics for New Jersey (https://www.njspotlight.com/2020/01/first-lady-spearheading-plan-to-reduce-njs-high-maternal-mortality-rate/)
New Jersey ranks 47th nationwide for maternal health outcomes
Their maternal mortality rate is 37 out of 100,000 (National avg is 16 out of 100,000)
Maternal mortality rate for white women in New Jersey is 12.8 for Black women it is 46.5
Non-Hispanic Blacks and Native Americans have 3-4x higher rates of pregnancy-related death than non-Hispanic white women
These disparities persisted even AFTER controlling for patient-level factors and hospital delivery
Non-Hispanic blacks, Hispanics, and Asian al had lower odds of labor induction than non-Hispanic whites
Grobman WA, Bailit JL, Rice MM, et al.; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic disparities in maternal morbidity and obstetric care. Obstet Gynecol. 2015;125(6):1460–1467 [PubMed: 26000518]
For non-Hispanic Black women, the most common underlying causes of deaths included preeclampsia, eclampsia and emoblism
For non-Hispanic white women, mental health conditions were the leading cause of death
Review to action, CDC Foundation. Capacity to review and prevent maternal deaths. report from nine maternal mortality review committees. 2018 http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed July 1, 2019.