Classification of Pregnancy-Related Mortality based on Death Certificate versus Medical Chart Review Michigan, Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services Community Public Health Agency Michigan Department of Community Health

Background U.S. maternal mortality among the highest in industrialized nations No decline since 1982 Statistics based on Death certificate – ICD World Health Organization Definition Death within 42 days of end of pregnancy Due to complications of pregnancy Chain of events initiated by pregnancy Aggravation by physiologic or pharmacological effects of pregnancy

Goal of Study Improve Identification, Classification and Knowledge of Pregnancy-Related Deaths

Methods Review medical charts and supporting documentation to compare classifications Death Certificate and Michigan Maternal Mortality Study Medical Review Committee

Study Definition and Data Sources Maternal death: –Death matched to live birth in previous 365 days –Death of woman while pregnant Reporting sources for maternal deaths –Hospitals –Medical Examiners –Michigan Department of Community Health, Division of Vital Records

Pregnancy-Associated and Related Mortality Ratio by Race, Death Certificate NumberMortality Ratio (/100,000 live births) Pregnancy-Associated White Black Pregnancy-Related (.ICD on birth certificate-365 days) White Black Black/White Ratio 6.4

Cases Reviewed Number Percent Selected for Review % Reviewed % No chart available % Awaiting review 2 0.1% Classified Pregnancy % Related by MMMS Committee

Death Certificate Pregnancy-Related Cause Committee Reclassification Pregnancy-Related - DC Total90 Selected for Review % No chart/awaiting review 55.8% DC/Committee Agreement % Reclassified Unrelated 22.3% (1 Black, 1 Native American) Reclassified Undetermined 2 2.3% (2 Black)

Characteristics of Reclassified Cases Pregnancy-Related on Death Certificate Death Certificate Cause Committee Cause Abortion/spontaneous Ventricular fibrillation and induced (3) Cardiac arrest Bacteremia Obstetric air embolism (1) Pulmonary embolism

Characteristics of Reclassified Cases Pregnancy-Related on Death Certificate Number Number Time of DeathNo Live Birth 3 >42 days1 AutopsyYes 3 No1 Place of DeathDOA/ER 3 Inpatient1 Prenatal CareYes 1 No3 (Native American 1) (Black 3)

Reclassification of Death Certificate Non-pregnancy-Related Cause NumberPercent Total cases reviewed217 Classified Pregnancy-Related by Committee % Reclassified from Death Certificate by Committee as Pregnancy-Related %

Reclassified Cases - Cause Non-Pregnancy-Related on Death Certificate No patterns for RacePrenatal care Place of DeathTime to death ResidenceBirth attendant EducationBirth place Birth outcomePayment source Medical risk factors Complications of pregnancy

Characteristics of Reclassified Cases Non-Pregnancy-Related on Death Certificate Percent of Death certificates coded as underlying cause ReviewedReclassified Circulatory System 56.5%56.2% Respiratory System 12.3% 83.3% Reclassification of remaining reviewed causes evenly distributed

Pregnancy-Related Mortality Ratio by Race Committee Review NumberMortality Ratio (/100,000 live births) Total White Black Black/White Ratio5.0

Comparison of Black/White Ratio Committee Review and Death Certificate Pregnancy-Related deaths, three-year running average

Black/White Ratio by Age Group Committee Review and Death Certificate

Time of Pregnancy-Related Death by Race Death Certificate

Time of Pregnancy-Related Death by Race Committee Review

Study Limitations Inability to identify all cases Small numbers of events for analysis

Summary Reclassification as pregnancy -related resulted in a decrease of the black/white discrepancy Increased identification of black and white women with circulatory system complications Decreased racial discrepancy for pregnancy-loss

Public Health Recommendations Increase information to physicians about need to specify pregnancy on death certificate Increase information to physicians and women at risk about cardiovascular compromise in pregnancy-related mortality