Maternal Death and Severe Morbidity Review William M. Callaghan, MD, MPH Chief, Maternal and Infant Health Branch Division of Reproductive Health Centers for Disease Control and Prevention Oklahoma Every Mother Counts Initiative April 24, 2015 National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health

I have no conflicts of interest to disclose.

Overview How do we account for maternal deaths in the United States? What is the difference between state and national review? Ideas for severe morbidity. Is state-level review the answer? Can we do it better?

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http://www.mchlibrary.info/history/childrensbureau.html#pubs

Maternal Mortality:1900-2010

Factors Contributing to the Decline of Maternal Mortality in the 20th Century Improved standard of living Improved obstetric training and delivery practices Hospital deliveries Use of aseptic techniques Contraception Medical advances Antibiotics Blood transfusion Oxytocin Better management of hypertensive disorders

Role of Maternal Mortality Review 1930: Maternal Welfare Committee, Philadelphia County Medical Society 1933: Maternal Mortality in New York City: A study of all Puerperal Deaths, 1930-1932 AMA Committee on Maternal and Child Care “Guide for Maternal Death Studies”

Terminology and definitions Classification of causes Organization and operation of maternal mortality review committees Locations Composition Case finding Analysis Findings for action Future expansion to maternal morbidity

Colonial period births, deaths and marriages recorded by local clergy Nineteenth century births and deaths accounted for by census 1880 Census Bureau accepts vital registrations from states and cities 1933 complete state-based reports to Census Bureau 1946 National Office of Vital Statistics in the Public Health Service 1960 National Center for Health Statistics 1987 NCHS incorporated into CDC Hetzel AM. History and Organization of the Vital Statistics System. Hyattsville, Md: National Center for Health Statistics; 1997. Appendix II

Definitions WHO ICD-9 Maternal Death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes Cause of Death in pregnancy chapter (630-676) Maternal mortality rate (MMR)

Definitions WHO ICD-10 Used for mortality beginning 1999 Maternal Death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes Late Maternal Death - New Used for mortality beginning 1999 Pregnancy chapter O00-O99

2003 and beyond: Pregnancy checkbox 2002: 21 states with checkbox or prompt 2005: 35 states with checkbox or prompt 2010:41 states and DC with checkbox or prompt (5 different question formats)

Recent Trend CDC WONDER http://wonder.cdc.gov/

Xu , JQ, et al. Deaths: Final data for 2007. NVSR 58 (19). NCHS 2010 In 2012 there were 787 deaths from maternal causes with no increases (in fact decreases in some instances) for hemorrhage, hypertensive disorders, embolisms and ectopics. This 40% increase was largely attributed to the category O99 – “other maternal diseases classifiable elsewhere but complicating pregnancy.” Perhaps the checkbox is finding true disease or perhaps disease unrelated to pregnancy but at this point it is not known. Xu , JQ, et al. Deaths: Final data for 2007. NVSR 58 (19). NCHS 2010

Pregnancy-Mortality Surveillance System ACOG/CDC Maternal Mortality Study Group (1986) Pregnancy-associated All deaths during pregnancy and within the 1 year following the end of pregnancy Pregnancy-related (subset of pregnancy-associated) Complication of pregnancy Aggravation of a unrelated condition by the physiology of pregnancy Chain of events initiated by the pregnancy Pregnancy Mortality Surveillance System (PMSS) Pregnancy-related mortality ratio (PRMR)

Deaths per 100,000 live births

MMR, United States, 1999-2013 CDC WONDER Quintile 1:<10 Suppressed

Obstet Gynecol 1996;88:161-7 Obstet Gynecol 2003;101:289–96 Obstet Gynecol 2010;116(6):1302-9 Obstet Gynecol 2015;125:5–12

“PMSS Team” <3 FTEs Carol Bruce, Team Lead Bill Callaghan, Branch Chief Andreea Creanga, Senior Scientist Kristi Seed, Contractor (full time) Carla Syverson, Contractor Danielle Suchdev, Epidemiologist <3 FTEs

Yearly Operations PMSS DATA REQUEST & RECEIPT PMSS CODING & DATA ENTRY ON-GOING ABORTION DATA REQUEST & RECEIPT STARTING W/ 2011 DATA PMSS & ABORTION DATA REVIEW ANALYSIS

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

Pregnancy-related mortality by year and race-ethnicity: United States, 2006-2010 * Number of pregnancy-related deaths per 100,000 live births.

Pregnancy-related mortality ratios by age, race and ethnicity: United States, 2006–2010. * Number of pregnancy-related deaths per 100,000 live births.

Cause-specific proportionate pregnancy-related mortality: United States, 1987–2010.

Hemorrhage Mortality Proportionate=percent of all deaths Cause specific=deaths from hemorrhage per 100,000 live births

Hemorrhage and decrease in ectopic deaths Creanga et al., Obstet Gynecol 2011;117: 837-43

Pregnancy-Associated Mortality in Oklahoma, 2007-2013 Mortality per 100,000 Live Births Year N Pregnancy Associated Pregnancy Related Not Pregnancy Related 2007 37 67.34 20.02 47.32 2008 21 38.35 18.26 20.09 2009 40 73.34 27.50 45.84 2010 30 56.39 34.48 21.91 2011 23 44.02 32.53 11.48 2012 43.61 24.65 18.96 2013 28 52.48 28.12 24.37 TOTAL 202 53.65 26.51 27.14

The surveillance cycle Identify cases Review cases Evaluate and refine Analyse the results Act

Maternal Morbidity

Morbidity: The Problem Maternal morbidity is difficult to define Broad range of complications and conditions Broad range of severity Maternal morbidity cannot be captured by a defined set of metrics We need to start somewhere Healthy mom Death

Severe Maternal Morbidity: Near Miss Life-threatening events at delivery hospitalization ‘‘a very ill pregnant or recently delivered woman who would have died had it not been but luck and good quality care was on her side’’ (Mantel et al. Br J Obstet Gynecol, 105:985-90, 1998) “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” (Say et al. Best Pract Res Clin Obstet Gynaecol 2009; 23: 287-96 doi: 10.1016/j.bpobgyn.2009.01.007 ) Variety of data sources to identify cases based on indicators Near miss by expert opinion Geller et al., JAMWA, 2002

Severe Maternal Morbidity: Near Miss 5 factor scoring system identified women with “near miss” morbidity Organ system failure Extended intubation ICU admission Surgical intervention Transfusion ≥4 units blood Geller et al., J Clin Epidemiol, 2004

Severe Maternal Morbidity: Near Miss Overcomes the issue of severity Requires multiple sources or a dedicated perinatal database for identification Most scoring system factors not available in administrative databases Less useful in smaller institutions Cumbersome for state-level and national surveillance Organ system failure performs well by itself (Se 95%; Sp 88%) Indicators of such in administrative data are attractive candidates Transfusion ≥4 units and/or ICU admission is nearly as sensitive as the 5-factor system (Se 100%; Sp 78%) Geller et al. construct has been validated (You et al., Am J Perinatol 2013;30:21-4)

Nationwide Inpatient Sample database Aim to capture indicators of organ system failure Use mortality hospitalizations to identify morbidity not previously considered Length of stay >90th percentile for diagnosis-identified cases by mode of delivery >2 days vaginal >3 days repeat cesarean >4 days primary cesarean Include postpartum admissions Callaghan et al. Obstet Gynecol 2012;120:1029-36

Maternal morbidity Codes ICD-9-CM Codes Diagnosis code Procedure code   Acute renal failure 584, 669.3 x Cardiac arrest/ventricular fibrillation 427.41, 427.42, 427.5 Heart failure during procedure or surgery 669.4x, 997.1 Shock 669.1, 785.5x, 995.0, 995.4, 998.0 Sepsis 038.0-038.9, 995.91, 995.92 Disseminated intravascular coagulation 286.6, 286.9, 666.3 Amniotic fluid embolism 673.1 Thrombotic embolism 415.1x, 673.0, 673.2, 673.3, 673.8 Puerperal cerebrovascular disorders 430, 431, 432.x, 433.x, 434.x, 436, 437.x, 671.5, 674.0, 997.2, 999.2 Severe anesthesia complications 668.0, 668.1, 668.2 Pulmonary edema 428.1, 518.4 Adult respiratory distress syndrome 518.5, 518.81, 518.82, 518.84,799.1 Acute myocardial infarction 410.xx Eclampsia 642.6x Blood transfusion 99.00-99.09 Hysterectomy 68.3-68.9 Ventilation 93.90, 96.01-96.05, 96.7x Sickle cell anemia with crisis 282.62, 282.64, 282.69 Intracranial injuries 800.xx, 801.xx, 803.xx, 804.xx, 851.xx-854.xx Internal injuries of thorax, abdomen, and pelvis 860.xx—869.xx Aneurysm 441.x Operations on heart and pericardium 35.xx, 36.xx, 37.xx, 39.xx Cardio monitoring 89.6x Temporary tracheostomy 31.1 Conversion of cardiac rhythm 99.6x

Callaghan et al. Obstet Gynecol 2012;120:1029-36

Severe Morbidity Between 1998-1999 and 2008-2009 severe morbidity during delivery hospitalization increased ~75% (7.4-12.9 per 1,000 deliveries). blood transfusions, acute renal failure, and aneurysms all more than doubled Severe morbidity at postpartum hospitalizations more than doubled (1.4-2.9 per 1000 deliveries). 13 of 25 indicators of severe morbidity at least doubled. Large proportions of women who died in hospital had indicators for severe morbidity e.g. 1/3 had transfusion; nearly 2/3 had ventilation Severe morbidity 100 times more common than mortality

Facility surveillance AND REVIEW: Transfusion ≥4 units ICU admission Obstet Gynecol 2014;123:978-81

https://www.npeu.ox.ac.uk/downloads/files/mbrraceuk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf

Alignment The “M” in MFM Every Mother Initiative (AMCHP) Alliance for Innovation in Maternal Health (AIM) http://www.safehealthcareforeverywoman.org/maternal-safety.html

http://www.safehealthcareforeverywoman.org

Alignment

Alignment https://www.cmqcc.org/ob_hemorrhage

Alignment https://www.cmqcc.org/preeclampsia_toolkit

Alignment http://www.albany.edu/sph/cphce/mch_nyspqc_hypertensive_resources.shtml

Alignment

Alignment

http://www.nj.gov/health/fhs/professional/documents/maternal_mortality_review_team.pdf

Frieden TR. Am J Public Health 2010;100:590-95

Thank You wgc0@cdc.gov National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health