Virginia Maternal Mortality Data Quality & Data Collection Melanie J. Rouse, Ph.D., Coordinator Maternal Mortality Projects Meagan Robinson, MCH Epidemiologist & Evaluation Supervisor

Case Identification ICD 10 Code: Pregnancy-related death. Vital records match: Fetal death certificate or birth certificate with maternal death certificate. Virginia Violent Death Reporting System Death certificate check box: In Virginia, woman was pregnant within three months of her death. The “O Codes”

Preparation for Case Review Office of Health Statistics provides death certificates and birth/fetal death certificates to Women’s and Infants’ Health who then provides them to the Team Coordinator. 2. Record collection begins with information on those certificates: Hospital where death occurred Hospital where birth occurred Birth attendant The Virginia Maternal Mortality Review Team requests records from all known providers of services to the decedent for the five years prior to death. There is no statutory mandate that records be provided to this project. Virginia Code allows for review of medical records “in the course of investigation, research or studies of diseases or deaths of public health importance.” In general, records are requested from the following providers of care and/or services:

Typical Records Reviewed Child Protective Services Hospital and Emergency Room Labor and Delivery Law Enforcement Medical Examiner (autopsy, toxicology, scene investigation, circumstances) Medical Specialists Mental Health Prenatal Care Primary Health Care Social Services Substance Abuse Treatment

Potential Sources of Data Inaccuracies Inability to obtain pertinent records Missing information in the medical record Illegible information written in the records Conflicting information within and between records. All reasonable efforts are made to insure the completeness and accuracy of data abstracted from the available records. The nature of this method of data collection carries intrinsic potential for inaccuracies. Just a few of the more obvious but potential sources of inaccuracy include

Case Summary The Team Coordinator prepares a de-identified, narrative case summary which includes medical, surgical, and psychiatric history; family history; social history; obstetrical history; prenatal care; delivery; events of death, pathological/toxicological findings and law enforcement involvement.

Case Review - three primary questions Was this death-pregnancy related? Was this death preventable? What factors contributed to the death and what reasonable changes could have been made to alter the outcome?

Pregnancy-Related1 Maternal Mortality Pregnancy-Related: pregnancy-associated death resulting from one or more of the following: complications of the pregnancy itself (direct); the chain of events initiated by the pregnancy that led to death (indirect); aggravation of an unrelated condition by physiological effects of the pregnancy that subsequently caused death (indirect). 1Berg C, Danel I, Atrash H, Zane S, Bartlett L (Editors). Strategies to reduce pregnancy-related deaths from identification and review to action. Atlanta: Centers for Disease Control and Prevention: 2001.

Preventable? Preventable death is broadly defined as a death that may have been averted by one or more changes in: clinical care facility infrastructure community systems response to patient factors These determinations were made with the benefit of retrospective review and current clinical practice guidelines.

The Purple Sheet As each case was reviewed, the Team identified factors within those four categories that contributed to death in that case.

Databases Pregnancy-Associated Mortality Surveillance System Virginia Maternal Mortality Database Maternal Mortality Review Information App The Maternal Mortality Review Information App (MMRIA) is a public health software tool created to collect, store, analyze and summarize information relevant to maternal deaths. We will move to this system once CDC is able to host the database centrally. IT will give us the opportunity to have data that is comparable to other states for improved analysis and assessment of where Virginia stands in regards to Maternal Mortality Nationally.

Virginia Vital Stats VA population, births, deaths, induced terminations (ITOPS), fetal deaths

Vital Stats Overview Division of Health Statistics collects and disseminates population-based health data National Center for Health Statistics Live births, fetal deaths, ITOPS, population data Over 300 columns/variables within the birth file Can stratify indicators by race, age, locality… (no income variable)

Examples of MCH indicators Infant mortality, fetal death rate, teen pregnancy, preterm births, low birth weight births, non-marital births, and ITOPS Data Tables: http://166.67.66.226/HealthStats/stats.htm

Data portal http://www.vdh.virginia.gov/data/maternal-child-health/ Developed to provide a convenient access point for health-related data for Virginia Comprehensive source for community health assessment, public, and population health data http://www.vdh.virginia.gov/data/maternal-child-health/

Program Contact Melanie J. Rouse, PhD Maternal Mortality Projects Coordinator Office of the Chief Medical Examiner 400 East Jackson Street Richmond, VA 23219 (804) 205-3853 Melanie.rouse@vdh.virginia.gov http://vdhweb/medexam/index.asp