# Presentation: 539851

## 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

**Maternal Mortality Ratio by Race****Maryland and U.S., 1997-2001**

## 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

## 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

## 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

## MMR Process in Maryland, cont.

- Review cases with MedChi’s Maternal and Child Health Committee plus invited specialist as needed
- Pregnancy-relatedness
- Preventability
- Recommendations

## Cases by Method of Identification

## Pregnancy-associated Deaths in Maryland, 2000-01

## % Distribution by Maternal Race/Ethnicity

| 
Race/ Ethnicity | 2001 MD Live Births
72,987 | Pregnancy-related Deaths |  |
| --- | --- | --- | --- |
|  |  | MD 2000-01
N=25 | U.S. 1991-99
N=4,200 |
| White | 55 | 36 | 55 |
| Black | 33 | 48 | 40 |
| Hispanic  | 7 | 12 | ------- |
| Asian | 5 | 4 | ------- |

## % Distribution by Age Group

| Age Group | 2001 MD Live Births | MD Deaths
2000-01 | U.S. Deaths
1991-99 |
| --- | --- | --- | --- |
| <20 years | 9 | 8 | 9 |
| 20-24 | 20 | 12 | 21 |
| 25-29 | 24 | 24 | 22 |
| 30-34 | 28 | 16 | 23 |
| 35-39 | 15 | 28 | 18 |
| 40 yrs+ | 3 | 12 | 7 |

## % Distribution by Race, Age Group

|  | Preg-related Deaths |  |  | 2001 MD Live Births |  |
| --- | --- | --- | --- | --- | --- |
| Age Group | White | Black | Other | White | Black |
| <20 yrs | 11 | 8 | 0 | 6 | 16 |
| 20-24 | 22 | 8 | 0 | 41 | 26 |
| 25-29 | 22 | 8 | 75 | 24 | 23 |
| 30-34 | 0 | 33 | 0 | 50 | 21 |
| 35-39 | 22 | 33 | 25 | 18 | 14 |
| 40 yrs+ | 22 | 8 | 0 | 4 | 2 |

## % Distribution by Marital Status, Education

|  | Preg-related Deaths |  |  | 2001 MD Live Births |  |
| --- | --- | --- | --- | --- | --- |
| Indicator | White | Black | Other | White | Black |
| Unmarried | 56 | 83 | 25 | 21 | 60 |
| Educ <12 yr | 22 | 17 | 0 | 8 | 17 |
| Educ 12 yr | 33 | 58 | 50 | ---- | ----- |
| Educ >12 yr | 44 | 25 | 50 | ----- | ----- |

## % Distribution by Gravida

|  | Preg-related Deaths |  |  | 2001 MD Live Births |  |
| --- | --- | --- | --- | --- | --- |
| Indicator | White | Black | Other | White | Black |
| Gravida 1 | 0 | 0 | 25 | ---- | ---- |
| Gravida 2-5  | 67 | 25 | 50 | ---- | ---- |
| Gravida 5+ | 33 | 75 | 25 | ---- | ---- |

## % Distribution by PNC

|  | Preg-related Deaths |  |  | 2001 MD Live Births |  |
| --- | --- | --- | --- | --- | --- |
| Indicator | White | Black | Other | White | Black |
| PNC 1st Trim | 22 | 17 | 100 | ----- | ----- |
| PNC 2nd Trim | 0 | 17 | 0 | ----- | ----- |
| PNC 3rd Trim | 0 | 0 | 0 | 
2 | 
6 |
| No PNC | 22 | 8 | 0 |  |  |
| PNC UK | 57 | 58 | 0 | ---- | ----- |

## Pregnancy-related Mortality Ratio

| Race/Ethnicity | MD PRMR
2000-2001 | U.S. PRMR
1991-1999 |
| --- | --- | --- |
| White | 11.2 | 8.1 |
| Black | 24.8 | 30.0 |
| Hispanic | 29.4 | ---------- |
| Asian | 13.7 | ---------- |
| Total | 17.6 | 11.8 |

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

## Pregnancy Outcome in Pregnancy-related Deaths, MD and U.S.

**Maryland, 2000-2001**

**U.S., 1991-1999**

## Preventability of Deaths

- Preventable – patient factor, provider practice, institutional systems
- homicide, suicide, unintentional injury; others determined through discussion

## 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%

## 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

## 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

## 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

## 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

## 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