Transcript Continuum of Maternal Morbidity and Mortality: Factors

Morbidity and Mortality in
Pregnancy:
Laying the Groundwork for Safe
Motherhood
Stacie E. Geller, PhD
Department of Obstetrics and Gynecology, University of Illinois,
Chicago
Suzanne Cox, MPH
School of Public Health, University of Illinois, Chicago
William Callaghan MD
Maternal and Infant Health Branch, CDC
Cynthia J. Berg, MD
Maternal and Infant Health Branch, CDC
Safe Motherhood Initiative
Nairobi 1987
Raise awareness
Develop program priorities
Stimulate research
Mobilize resources
Share information
Safe Motherhood
Multifaceted Model
Safe and healthy women throughout
pregnancy & childbirth
High quality maternal health services
Economic and social conditions
Maternal Mortality
The Tip of the Iceberg
Outcome indicator traditionally used in
Safe Motherhood
Maternal Mortality
The Tip of the Iceberg
Most devastating outcome
Huge burden of disease on the woman’s
family and society
Death is a discrete outcome
Maternal Mortality
The Tip of the Iceberg
Actual numbers of maternal deaths may
be small in developed countries
By looking only at maternal deaths, other
major problems in obstetric care may be
overlooked
A Continuum of Maternal Health
NORMAL PREGNANCY
MORBIDITYSEVERE MORBIDITY
NEAR MISS DEATH
A Continuum of Maternal Health
NORMAL PREGNANCY MORBIDITY NEAR MISS DEATH
 Morbidity is an important outcome
 Morbidity affects many women
 Morbidity provides more cases for
clinical review/monitoring of care
 Knowledge gained can improve
treatment & prevent progression to more
severe morbidity
Mortality Definitions
Ideal
All deaths caused by the adverse effects
of pregnancy
Pragmatic
Consistent classification
Ability to make comparisons
Mortality Definitions
Maternal Death (WHO)
 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.
Mortality Definitions
 Maternal death – WHO/NCHS
 Pregnancy-related death – CDC/ACOG
Mortality Definitions
 Maternal death – WHO/NCHS
 < 42 days
 ICD code for underlying cause of death
 Pregnancy-related death – CDC/ACOG
 < 365 days
 All available information
Maternal Mortality in the 20th
Century
1
,
0
0
0
8
0
0
6
0
0
Deathsper10,0livebrths
4
0
0
2
0
0
0
1
9
0
0
1
9
1
0
1
9
2
0
1
9
3
0
1
9
4
0
1
9
5
0
1
9
6
0
1
9
7
0
1
9
8
0
1
9
9
0
2
0
0
0
Y
e
a
r
25
20
15
10
5
19
90
19
80
0
19
70
Deaths per 100,000 Live Births
Maternal Mortality Has Not
Changed Since 1982
Year
Pregnancy-Related Mortality
Rates
 Overall pregnancy-related mortality ratio
for the U.S. in 1999
 13.2 pregnancy-related deaths per
100,000 livebirths
Pregnancy-Related Mortality Ratios
by Race and Ethnicity, US, 1991-97
50
40
29.6
30
20
10.3
11.3
Hispanic
Asian/Pacific
Is.
12.2
7.3
10
0
Am.
Ind/Alaskan
Non-His Bl
Non-His Wh
Pregnancy-Related Mortality Ratios
by Country of Birth, U.S. 1991-97.
50
40
PRMR
US Born
30
30.0 29.5
Non-US Born
20
12.7
11.8
10
8.0
6.1
7.6 6.2
0
Hispanic
Asian/Pacific
Islander
Non-Hisp.
White
Non-Hisp.
Black
Pregnancy-Related Mortality Ratios
by Age and Race, US, 1991-97
175
150
PRMR
125
100
75
White
Black
50
25
0
Total
15-19
20-24
25-29
Age
30-34
35-39
40 +
Trends in Cause of PregnancyRelated Deaths
30
% Deaths
25
79-86
87-90
91-97
20
15
10
5
0
hem
emb hdp
inf
cm anes
cva other
Preventability of Mortality
 Some believe that the U.S. has
reached an irreducible level of maternal
mortality
Preventability of Mortality
 Disparities exist in the world
 US ranks 30th, behind:
Austria, Australia, Belgium, Canada, Croatia,
Czech Republic, Denmark, Finland, Germany.
Greece, Hungary, Ireland, Iceland, Italy, Japan,
Kuwait, Lithuania, Netherlands, New Zealand,
Norway, Poland, Portugal, Qatar, Serbia,
Slovakia, Spain, Sweden, Switzerland, UK.
Preventability of Mortality
 Disparities exist within the U.S.
Preventability of Mortality
Disparities exist within the U.S.
 By age
 Women 35 years and older
Preventability of Mortality
Disparities exist within the U.S.
 By race
 Black & American Indian/Alaskan Native
Preventability of Mortality
Disparities exist within the U.S.
 By place of birth
 Hispanic and Asian/Pacific Islanders
Preventability of Mortality
 Multiple studies from US and Europe
show that 30-60% of maternal deaths
are preventable
Preventability of Mortality
 Most important contributing factor
to preventable deaths is
“substandard” quality of care.
Pregnancy-Related Mortality
 Deaths caused by pregnancy complications
have decreased from a century ago but still
occur too frequently.
 Many of these are preventable today by
applying the knowledge that we have to all
women to make their lives healthier before,
during and after pregnancy.
Maternal Morbidity
The Importance of Studying
Maternal Morbidity
Represents a huge burden of disease
on the woman and her family
Can strengthen the study of maternal
death
Focuses research on the nature of how a
morbid condition can lead to death,
recognizing that death is the last stop on a
continuum of adverse events
The Continuum
NORMAL PREGNANCY MORBIDITY NEAR MISS DEATH
Continuum can be partitioned into
meaningful clinical & epidemiologic
ranges to differentiate deaths, near
misses, & severe morbidities
Death is easily identified and labeled
Defining a normal pregnancy & locating
intermediate points is far more complex
Definitions of Morbidity
 Various definitions of morbidity, beginning
with less severe complications of pregnancy &
extending to near-miss morbidity
 A general state of morbidity during L&D as
conditions that adversely affects a woman’s
physical health beyond what is expected in a
normal delivery (Danel et al 2003)
 In the US the prevalence of any specific morbidity
was low, but the burden of total morbidity was high
Definitions of Morbidity
 Historically, maternal hospitalization has
served as a proxy for complications of
pregnancy
 Between 8-27% of women are hospitalized at
least once during pregnancy
 Most common reasons for hospitalizations
during pregnancy include:
 preterm labor, vomiting, genitourinary
complications, & hypertensive disorders (Bacak etal.
2005)
Definitions of Morbidity
Use of hospitalization without
measures of clinical and non-clinical
status will not allow precise
identification of maternal morbidity & is
certainly an overestimate of the
incidence of near miss morbidity
Other Measures to Assess
Severe/Near Miss Morbidity
 Admission to critical care or ICU
 Organ system failure/dysfunction
 Severe obstetrical complications
 Maternal diseases
 Single measures can under- or over-identify
cases of near miss/severe morbidity
 ICU admissions may identify the most critically ill
patients, but dependent upon a # of factors
(hospital structure or level of care available)
 May still fail to capture some cases of critically ill
women
Multiple Variable Model
 Using multiple factors may improve the ability to
report life-threatening morbidity
 Near miss morbidity defined by life-threatening
conditions
 hemorrhage, PIH, pulmonary embolus, & uterine rupture (Stones
et al 1991)
 Study in South Africa proposed a broader clinical
definition for near miss
 organ system based, or management based (emergency
hysterectomy) (Mantel etal. 1998)
 Case-control approach to identify predictors of severe
obstetric morbidity
 advanced maternal age, social factors, and previous obstetric
complications (Waterstone etal. 2001)
Near Miss Morbidity
 Many health conditions & morbid events may
put women at increased risk for death, but
may not be near death
 To precisely define near miss morbidity need
to:
 distinguish near miss from severe morbidity as a
separate & distinct category
 consider multiple measures since any one single
criterion such as hospitalization, ICU admission,
or organ system failure is imperfect proxy
A Scoring System to Define Near
Miss/Severe Morbidity
 Scoring system to identify women with near
miss morbidity & differentiate them from
severe but not life threatening conditions
(Geller etal 2004)
 Delineate a numeric scoring for identification
of near miss events that other researchers
and clinicians can replicate
 Initially identified 11 factors
Initial 11 Factors: Sensitivity and Specificity
Factor
Weight Sensitivity Specificity
Resuscitation
11
54.6
98.8
Organ Failure (> 1 system)
10
95.5
87.8
Extended Intubation (>12 hrs.)
9
72.7
98.8
Temperature (>105)
8
0
1.8
ICU admission
7
86.4
87.8
Surgical Interventions
6
72.7
82.9
Blood Transfusion (> 3 Units)
5
81.8
88.4
Organ Dysfunction (> 2
4
50.0
80.5
Blood Loss (>1500cc)
3
50.0
86.0
Hospital Admissions (>2)
2
40.9
61.6
Length of Hospital Stay > 8
1
77.3
62.2
system)
days
Scoring System
 5 clinical factors: OSD, intubation, ICU
admission, surgical intervention, & transfusion
 high sensitivity (100%) & specificity (93%)
 constellation of factors related to women who are
most severely ill
 captured a wide range of morbidities
 4 factor system, eliminated OSF
 high sensitivity (100%) & specificity (78%) but
defined a category of near miss that was broader &
more inclusive
 1-2 factor simpler system lost sensitivity &
specificity depending on the variables chosen
Defining Morbidity
 In choosing a model to define severe and/or
near miss morbidity, the best one to be
utilized would vary depending upon a
number of factors:
 Type of institution utilizing the system (is there an
ICU and what is the rate of use?)
 Availability of data and databases (can data on
organ system failure be accessed without time
consuming medical record review?)
 Time & resources available to collect/analyze data
 Intended use of the scoring system
Defining Morbidity
 Use of a multifactor model for estimates of
incidence of life-threatening conditions where
more precise identification is important
 Most comprehensive system
 Captures a wide range of morbidities
 Mirrors continuous nature of severity of morbidity
 Reflects a constellation of factors related to
women who are most severely ill
 Most time intensive in terms of data collection &
may require chart review
Defining Morbidity
 Use of a simpler system for monitoring
hospital or state-based obstetric care &
identifying quality of care issues since a
broader estimate of morbidity is acceptable
 Simple & less time consuming
 Easy to collect data & integrate into electronic
record system
 Loss of sensitivity & specificity depending on
the variables chosen
Sensitivity & Specificity of Different Scoring
Systems for Identifying Near-Miss Morbidity
Sensitivity
Specificity
True Near
miss
False near
miss
5 factor
100%
93.3%
22
11
5 factor
100%
85.4%
22
24
4 factor
100%
78.1%
22
36
3 factor
100%
86.6%
22
22
2 factor A
100%
78.1%
22
36
2 factor B
100%
80.5%
22
32
1 factor A
95.5%
87.8%
21
20
1 factor B
86.4%
87.8%
19
20
Defining Morbidity
 These models are important attempts to:
 Facilitate the comparison of women with near
miss or severe morbidity to women who die
 Increase our understanding of the range of
morbidity during pregnancy
 Improve Attempts to objectively describe &
identify extremely ill women
 Develop interventions aimed at reducing both
mortality & morbidity
Assessing the Magnitude of
Maternal Morbidity
 Maternal morbidity related to inpatient care during
pregnancy
 1986-87, 22 pregnancy hospitalizations/100
deliveries (Franks etal. 1992)
 1991-92, updated definition including hosp for nonobstetric causes 18 hospitalizations/100 deliveries
(Bennett etal. 1998)
 Decline was attributable to the drop in hospitalizations for
pregnancy loss (ectopic pregnancies & spontaneous
abortions)
 1999-2000 there were 12.8 hospitalizations/100
deliveries (Bacak et al., 2005)
 Decline likely due to increased use of outpatient
management of conditions such as mild preeclampsia,
preterm labor, & ectopic pregnancies.
The Magnitude of Maternal
Morbidity
 Population based study 1993-97 showed:
 43% of women (1.7 million women annually)
experienced some form of maternal morbidity,
much of which was preventable
 30.7% of women (1.2 million women annually)
were reported to have either an obstetric
complication excluding cesarean section, a
preexisting medical condition, or both (Danel etal.,
2003)
Causes of Morbidity
 Of all the women giving birth during this time:
 3.6% had a hemorrhage
 3.0% had preeclampsia or eclampsia
 10.6% had an obstetric trauma such as a 3rd/4th degree
laceration or a hematoma
 8.4% had an infection such as amnionitis
 2.8% had gestational diabetes
 4.1% had preexisting medical conditions (Danel et al., 2003)
 Other conditions were also present in the population
at much lower incidence rates
 The more rare & severe conditions & complications
occur in <0.1% of population (pulmonary & amniotic
embolisms, hemorrhage) mirror the causes of death
Causes of Morbidity
 Mothers Mortality and Severe Morbidity (MOMS)
 A European population based survey to assess the
incidence of three conditions of acute severe maternal
morbidity (pre-eclampsia, postpartum hemorrhage, and
sepsis) in 9 countries
 Wide variations in the incidence of the 3 conditions,
ranging from 14.7/ 1000 deliveries in Belgium to 6.0/
1000 deliveries in Austria.
 Severe hemorrhage was the most common followed by
severe preeclampsia
 Countries with the highest incidence of morbidity were not
necessarily those with the highest maternal mortality (Zhang,
etal. 2005)
Disparities in Morbidity
 Morbidity is greatest among socio-economically
disadvantaged groups
 adolescents, unmarried women, &African-American women
 African-American women at higher risk of morbidity
compared to white women
 40% higher rate of hospitalization
 a greater burden of disease or less access to preventive
prenatal care or a combination of both (Bacak et al., 2005; Bennett et
al., 1998; Franks et al., 1992; Scott et al., 1997)
 Among socio-economically disadvantaged groups,
racial & ethnic differences were sometimes greatly
reduced
 Among pregnant teens, the hospitalization ratios were 20.2
per 100 deliveries for blacks and 19.8 for whites
 Unmarried black women had a hospitalization ratio of 22.7
versus 19.6 for unmarried white women
Case-fatality rates and relative risks
among high risk pregnant women
Risk of death per
10,000
Overall
Relative
risk (RR)
95% CI
1.2
0.8-1.8
37.1
Age
10-19
34.6
20-34*
29.3
35-49
73.6
2.5
1.9-3.2
African American
109.6
5.6
4.3-7.3
Hispanic
28.5
1.5
0.98-2.2
White*
19.7
Asian/Other/Unknown
28.3
1.4
0.7-2.8
Race/Ethnicity
*Reference group
Case-fatality rates and relative risks
among high risk pregnant women (cont)
Risk of death per
10,000
Overall
Relative
risk (RR)
95% CI
37.1
Marital status
Married*
23.7
Unmarried
67.0
2.8
2.2-3.6
City of Chicago
73.4
4.0
2.7-5.9
Suburban Cook
36.7
2.0
1.3-3.2
Collar counties*
18.3
Rest of Illinois
25.9
1.4
0.9-2.1
Residence
*Reference group
Diagnosis specific case fatality rates
and relative risks
Risk of death per
10,000
PIH
Relative
risk (RR)
95% CI
8.3
African American
26.6
17.5
5.0-61.0
Hispanic
20.3
13.4
3.5-51.7
White*
1.5
Hemorrhage
8.9
African American
25.2
6.3
1.2-34.5
Hispanic
10.0
2.5
0.2-27.5
White*
4.0
*Reference group
Risk Factors and Morbidity
Study of women experiencing severe
morbidity & death found that 3 factors
placed women at higher risk of a more
severe outcome (Geller et al., 2004)
Lack of health insurance
Certain clinical diagnoses
A preventable event
Preventability
Significant association between
preventability & progression along the
continuum after controlling for clinical
diagnosis & sociodemographic factors
Due specifically due to provider factors,
such as incomplete or inappropriate
management, as opposed to system or
patient factors
Overall Preventability
50
45.5
45
40.5
40
% Preventable
35
30
25
20
16.7
15
10
5
0
Death (n=37)
p < 0.01
Near Miss Morbidity
(n=33)
Other Severe
Morbidity (n=101)
Proportion of Preventable Events
Potentially Preventable
Outcomes*
Types of Preventability
Death Near-miss
n=15
n=15
Severe
Morbidity
n=17
Overall Provider
86.7
93.3
88.2
Overall System
33.3
46.7
29.4
Overall Patient
20.0
13.3
17.7
* Multiple types of preventable events could have been noted for each
woman.
Provider Related Preventability
 A woman with near-miss morbidity was more
than 4 times as likely to have had providerrelated preventability factors compared to
her counterpart with other severe morbidity
 A woman who died was 2 times more likely to
have had provider-related preventability
factors compared to her counterpart with
near-miss morbidity
Preventability
 Changes in provider decision-making could
reduce the severity of disease experienced
by high-risk women
 Changes in provider behavior may have a
bigger impact for women at earlier stages
along the continuum
 May be more difficult to impact the outcome
once the woman has had a preventable event
Preventability
If all the women with preventable factors
were reassigned to the next less severe
point along the continuum:
41% fewer women would have died & would
instead be in the near-miss group
45% fewer women would have been near
misses & would instead be in the severe
morbidity group
 17% fewer women would have been other
severe morbidities & would be even farther
back along the continuum
Preventability
 The farther along the continuum—the more
severe the morbidity—the less opportunity
there is for clinical control or effective
intervention
 Once a woman reaches the near-miss level of
morbidity, whether she lives or dies becomes
difficult to predict
 Important because changes in provider
decision-making could reduce the severity of
disease experienced by high-risk women
Strategies For Change
Multiple stakeholders to involve including:
 Clinicians caring for pregnant women
 Hospitals providing services
 State and local health agencies charged with
monitoring mortality and morbidity
 Research and public health communities
studying this problem
 Federal government
Strategies For Change:
Clinicians and Hospitals
 Departmental & institutional review committees
 Moving beyond traditional M&M
 Local peer review committees have the benefit of
involving hospitals and clinicians in resolving provider
& system related problems
 Policy and procedure issues unique to an institution
can be uncovered






Lack of foreign language translation services
Lack of appropriate counseling or screening for patients
Poor communication between depts.
Under-staffing
Lack of adequate guidelines for oversight of critically ill patients
Lack of emergency equipment and clear procedures
Strategies For Change:
Health Agencies
 Review committees are an important strategy
at the state and city level
 Maternal death review committees have been
put into practice in several states
 Expert committees review all maternal deaths, but
the scope of their work could be expanded to
include cases of near-miss morbidity
 Review issues related to preventability
 Identify patterns of adverse outcomes
 Address non-medical & system-related factors
that may have contributed to a maternal death or
a near-miss morbidity
Strategies For Change:
Regional or Local Level
Development of a system of perinatal
referral, care, & review, with guidelines
for appropriate transfer of high-risk
women
In-depth review of all maternal deaths
at Perinatal Centers with appropriate
follow-up and education
Strategies For Change: Research
& the Public Health Community
 Defining a comprehensive research agenda
including:
 Studying pregnancy across the entire continuum,
from a normal pregnancy on….
 Considering medical, individual, & system factors
in their effect on maternal health
 Addressing disparities between different racial/
ethnic groups, as well as between different socioeconomic groups
 Qualitative & quantitative studies of preventability
Strategies For Change: Research
& the Public Health Community
 Evidence-based guidelines and protocols
 Confidential Enquiry into Maternal Deaths
(CEMD)-- a review of all maternal deaths in the
United Kingdom published every 3 yrs
 Each CEMD ends with a list of recommendations
to reduce maternal deaths
 Selected ones are developed into clinical
guidelines by the Royal College of Obstetricians
and Gynaecologists
 An audit of the effect of these guidelines found
that clinicians made many of the suggested
change, (e.g., thromboprophylaxis for women
undergoing cesarean delivery) (Benbow etal. 1998)
Strategies For Change:
Federal Agencies
 Multiple federal agencies are involved in
maternal health issues
 CDC
 NIH, particularly the NICHD
 FDA
 MCHB of the HRSA
 No single federal agency is designated as
having the ultimate responsibility & authority
to oversee the scope of activities involved in
monitoring maternal mortality & morbidity
 Federal agencies have a variety of
overarching roles in the area of maternal
health
Strategies For Change:
Federal Agencies
Federal agencies can:
Conduct national surveillance of
pregnancy-related mortality
Encourage states & other groups to do
comprehensive pregnancy-related
mortality surveillance as well as
surveillance of maternal morbidity
Strategies For Change:
Federal Agencies
 Federal agencies can:
 Provide technical assistance & resources to
states to improve the identification of maternal
deaths through computer-linkage of vital records
 Organize & sponsor regional workshop for states
on mortality & morbidity, helping staff to
understand how to do comprehensive reviews,
analyze their data, & develop appropriate
interventions
 Fund research on pregnancy and its
complications and services for pregnant women
Conclusions
 Each death that occurs during pregnancy is
a devastating event for the family and friends
of the woman
 Although the number of pregnancy-related
deaths in the US is relatively low, the ratio
has not decreased in the last two decades
 Broadening the research focus to include the
study of maternal morbidity can strengthen
the study of ways to improve women's health
in pregnancy
Conclusions
 By identifying a larger number of women with
serious, life-threatening complications of
pregnancy, the study of maternal morbidity can be
incorporated into clinical case review, improving the
opportunity for identifying quality of care issues
related to preventability of both morbidity &
maternal death
 Issues of preventability remain a critical concern in
decreasing maternal mortality and morbidity
 Through an increased understanding of preventable
events, we can begin to develop the interventions
necessary to improve healthcare delivery systems
and decrease the associated risk for mortality and
morbidity
Thank You!