1. Classification of Pregnancy-Related Mortality based on Death Certificate versus Medical Chart Review Michigan, 1990-1998 Joanne G. Hogan, PhD Bao-Ping Zhu, MD, MS Division of Epidemiology Services Community Public Health Agency Michigan Department of Community Health

2. Background U.S. maternal mortality among the highest in industrialized nations No decline since 1982 Statistics based on Death certificate – ICD-9 630 - 676 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

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

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

5. 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

6. Pregnancy-Associated and Related Mortality Ratio by Race, Death Certificate NumberMortality Ratio (/100,000 live births) Pregnancy-Associated516 41.0 White 26927.4 Black 22892.8 Pregnancy-Related90 7.1 (.ICD-9 630-376 on birth certificate-365 days) White33 3.4 Black53 21.6 Black/White Ratio 6.4

7. Cases Reviewed Number Percent Selected for Review23244.9% Reviewed21793.5% No chart available 13 5.6% Awaiting review 2 0.1% Classified Pregnancy- 16977.9% Related by MMMS Committee

8. Death Certificate Pregnancy-Related Cause Committee Reclassification Pregnancy-Related - DC Total90 Selected for Review86 95.5% No chart/awaiting review 55.8% DC/Committee Agreement77 89.5% Reclassified Unrelated 22.3% (1 Black, 1 Native American) Reclassified Undetermined 2 2.3% (2 Black)

9. 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

10. 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)

11. Reclassification of Death Certificate Non-pregnancy-Related Cause NumberPercent Total cases reviewed217 Classified Pregnancy-Related by Committee169 77.9% Reclassified from Death Certificate by Committee as Pregnancy-Related 92 70.2%

12. 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

13. 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

14. Pregnancy-Related Mortality Ratio by Race Committee Review NumberMortality Ratio (/100,000 live births) Total169 13.4 White 73 7.4 Black 91 37.0 Black/White Ratio5.0

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

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

17. Time of Pregnancy-Related Death by Race Death Certificate

18. Time of Pregnancy-Related Death by Race Committee Review

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

20. 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

21. 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