Pregnancy-Related Deaths Due to Pulmonary Embolism: Findings from Two State-Based Mortality Reviews

This report presents findings from two state-based pregnancy-related reviews of deaths due to pulmonary embolism to describe prevalence, risk factors, and timing of symptoms and fatal events (N = 46). We examined the utility of state-based maternal mortality review teams as a means to gain more complete data on maternal deaths from which guidelines for prevention and intervention can be developed. The Florida Pregnancy-Associated Mortality Review Team and Virginia Maternal Mortality Review Team collaborated on findings from 9 years of pregnancy-related mortality review conducted in each state. Pregnancy-related deaths due to pulmonary embolism occurring within 42 days of pregnancy between 1999 and 2007 in Florida and Virginia were identified. Retrospective review of records was conducted to obtain data on timing of the fatal event in relation to the pregnancy, risk factors, and the presence and timing of symptoms suggestive of pulmonary embolism. Forty-six cases of pregnancy-related death due to pulmonary embolism were identified. The combined pregnancy-related mortality ratio (PRMR) was 1.6/100,000 live births. The PRMR for patients undergoing cesarean section delivery was 2.8 compared to 0.2 among those with vaginal deliveries (95 % CI = 1.8–4.2 and 0.1–0.5 respectively). Women aged 35 and older had the highest PRMR at 2.6/100,000 live births. BMI over 30 kg/m² and presence of chronic conditions were frequently identified risk factors. One in five decedents (21.7 %) reported at least two symptoms suggestive of pulmonary embolism in the days before death. This combined state-based maternal death review confirms age over 35 years, obesity, and the presence of chronic conditions are risk factors for pregnancy-related mortality due to venous thromboembolism in the US. Expanding and standardizing the process of state-based reviews offers the potential for reducing pregnancy-related mortality in the US.     

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

Background

The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data.

Methods

We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010.

Results

Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas.

Conclusions

Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

     

An assessment of pregnancy-related mortality in the United States

Deaths from pregnancy complications remain an important public health concern. Nationally, two systems collect information on the number of deaths and characteristics of the women who died from complications of pregnancy. The Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS) reports maternal mortality through the National Vital Statistics System (NVSS); CDC National Center for Chronic Disease Prevention and Health Promotion's Pregnancy Mortality Surveillance System (PMSS) conducts epidemiological surveillance of pregnancy-related deaths. The numbers of deaths reported by these two systems have differed over the past two decades; our objective was to determine the magnitude and nature of these differences. For 1995-97, we compared maternal deaths in the NVSS with pregnancy-related deaths in PMSS for the 50 States, Washington DC and New York City. Pregnancy-related deaths whose underlying cause was assigned to ICD-9 codes 630-676 by NVSS were classified as maternal deaths; those coded outside 630-676 were not. There were 1387 pregnancy-related deaths in PMSS and 898 maternal deaths in the NVSS; 54% of these deaths were reported in both systems, 40% in PMSS only, and 6% in NVSS only. Pregnancy-related deaths due to haemorrhage, embolism, and hypertensive complications of pregnancy were proportionately more often identified by NVSS as maternal deaths than those from cardiovascular complications, medical conditions or infection. From the 1471 unduplicated deaths classified as maternal or pregnancy-related from either reporting system, we estimated a combined pregnancy-related mortality ratio of 12.6/100,000 live births for 1995-97, compared with 11.9 for PMSS only and 7.5 for NVSS only. The identification and classification of these events is dependent on the provision of complete and accurate cause-of-death information on death certificates. Changes in the guidelines for coding maternal deaths under ICD-10 may change the relationship in the number of deaths resulting from pregnancy reported by these two systems.     

1999-2018年深圳市宝安区孕产妇死亡情况分析

目的 了解1999-2018年深圳市宝安区的孕产妇死亡情况及其变化趋势.方法 从原始登记表和深圳市妇幼保健管理系统获取宝安区近20年孕产妇死亡个案资料进行整理,统计分析孕产妇死亡率、死亡变化趋势、死亡特征及死亡原因.结果 1999-2018年宝安区年平均孕产妇死亡率为18.86/10万;总体呈下降趋势,从1999-20...     

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture–Recapture Methods

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture–recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture–recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35–44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37–46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147–391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146–389). Conclusion Application of capture–recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.     

Ectopic pregnancy mortality - Florida, 2009-2010

Ectopic pregnancy occurs when a fertilized ovum implants on any tissue other than the endometrial lining of the uterus. Approximately 1%-2% of pregnancies in the United States are ectopic; however, these pregnancies account for 3%-4% of pregnancy-related deaths. The ectopic pregnancy mortality ratio in the United States decreased from 1.15 deaths per 100,000 live births in 1980-1984 to 0.50 in 2003-2007. During 1999-2008, the ectopic pregnancy mortality ratio in Florida was similar to the national rate, 0.6 deaths per 100,000 live births, but increased abruptly to 2.5 during 2009-2010. Florida's Pregnancy-Associated Mortality Review (PAMR) identified ectopic pregnancy deaths during 1999-2010 through its routine process of identifying all pregnancy-related deaths. A multidisciplinary investigation committee reviewed the ectopic pregnancy deaths for cause of death, risk factors, and prevention opportunities. This report summarizes the investigation results, which identified 11 ectopic pregnancy deaths from 2009-2010 and 13 deaths from the 10-year period 1999-2008. The increase in ectopic mortality appears to be associated with illicit drug use and delays in seeking health care. The findings underscore the importance of ongoing, state-based identification and review of pregnancy-related deaths. Such reviews have the potential to identify emerging causes of deaths and associated risk factors, such as ectopic pregnancy deaths among women who use illicit drugs. Efforts to prevent ectopic pregnancy deaths need to ensure early access to care, promote awareness about early pregnancy testing and ectopic pregnancy risk, and raise public awareness about substance abuse health risks, especially during pregnancy.     

Maternal mortality in Giza, Egypt: magnitude, causes, and prevention.

This article presents results from a population-based study of the magnitude and causes of maternal mortality in the Giza governorate of Egypt in 1985-86. Deaths to women in the reproductive ages were identified through the death registration system. Family members of the deceased were interviewed using the "verbal autopsy" approach. Immediate and underlying causes of death were then assessed by a medical panel. This methodology allows for the classification of multiple causes of death and is appropriate when registration of adult deaths is nearly complete, but reporting on cause of death on death certificates is poor. Of all reproductive-age deaths, 19 percent were maternal deaths. The maternal mortality ratio for Giza is estimated to be, at minimum, 126 maternal deaths per 100,000 live births. The maternal mortality rate is estimated to be, at minimum, 22 maternal deaths per 100,000 women aged 15-49, over 100 times the rate in Sweden. An average of 2.3 causes per maternal death were reported; the most common causes were postpartum hemorrhage (31 percent of cases) and hypertensive diseases of pregnancy, such as toxemia and eclampsia (28 percent of cases). Women experiencing hemorrhage, hypertensive diseases of pregnancy, or other serious complications must have easy access to hospital and maternity centers equipped for handling these conditions. Since most deliveries occur at home, many with the help of traditional birth attendants, TBAs will need training in early diagnosis, treatment, and/or effective referral of problem pregnancies.     

Healthier mothers and babies

At the beginning of the 20th century, for every 1000 live births, six to nine women in the United States died of pregnancy-related complications, and approximately 100 infants died before age 1 year. From 1915 through 1997, the infant mortality rate declined >90% to 7.2 per 1000 live births, and from 1900 through 1997, the maternal mortality rate declined almost 99% to <0.1 reported death per 1000 live births (7.7 deaths per 100,000 live births in 1997). Environmental interventions, improvements in nutrition, advances in clinical medicine, improvements in access to health care, improvements in surveillance and monitoring of disease, increases in education levels, and improvements in standards of living contributed to this remarkable decline. Despite these improvements in maternal and infant mortality rates, significant disparities by race and ethnicity persist. This report summarizes trends in reducing infant and maternal mortality in the United States, factors contributing to these trends, challenges in reducing infant and maternal mortality, and provides suggestions for public health action for the 21st century.     

Maternal mortality in St. Petersburg, Russian Federation

OBJECTIVE: To study the levels and causes of maternal mortality in St. Petersburg, Russian Federation. METHODS: We collected data about all pregnancy-related deaths in St. Petersburg over the period 1992-2003 using several sources of information. An independent research group reviewed and classified all cases according to ICD-10 and the Confidential Enquiries into Maternal Deaths in the United Kingdom. We tested trends of overall and cause specific ratios (deaths per 100,000 births) for four 3-year intervals using the chi2 test. FINDINGS: The maternal mortality ratio for the study period was 43 per 100,000 live births. A sharp decline of direct obstetric deaths was observed from the first to fourth 3-year interval (49.8 for 1992-94 versus 18.5 for 2001-03). Sepsis and haemorrhage were the main causes of direct obstetric deaths. Among the total deaths from sepsis, 63.8% were due to abortion. Death ratios from sepsis declined significantly from the first to second study interval. In the last study interval (2001-03), 50% of deaths due to haemorrhage were secondary to ectopic pregnancies. The death ratio from thromboembolism remained low (2.9%) and stable throughout the study period. Among indirect obstetric deaths a non-significant decrease was observed for deaths from cardiac disease. Death ratios from infectious causes and suicides increased over the study period. CONCLUSIONS: Maternal mortality levels in St. Petersburg still exceed European levels by a factor of five. Improved management of abortion, emergency care for sepsis and haemorrhage, and better identification and control of infectious diseases in pregnancy, are needed.     

Evaluation of Pregnancy Mortality in Louisiana Using Enhanced Linkage and Different Indicators Defined by WHO and CDC/ACOG: Challenging and Practical Issues

Differences in definitions and methods of data collection on deaths occurring during or shortly after pregnancy have created confusion and challenges in evaluating research findings. The study aimed to determine if the use of enhanced linkage procedures improve data collection of deaths occurring during or shortly after pregnancy, and how different definitions of those deaths changed the results of data analysis. The study used 2000–2005 Louisiana Pregnancy Mortality Surveillance System (LPMSS) and 2000–2005 death certificates linked with 1999–2005 live birth and fetal death certificates. Five indicators of deaths occurring during or shortly after pregnancy using WHO and CDC/ACOG definitions were estimated. One-sided Spearman rank test was used to analyze maternal mortality trends from 2000 to 2005. Of 345 women who died within 1 year of pregnancy, 187 were identified through linkage; 38 of those were missed by the LPMSS. Total mortality ratios of deaths occurring within 1 year of pregnancy ranged from 13.4 to 88.9 per 100,000 live births depending on the indicator used. CDC/ACOG pregnancy-related death and pregnancy-associated death statistically increased, whereas WHO pregnancy-related death decreased between 2000 and 2005. The most common causes of death differed by indicator. Universal adoption of linkage procedures could improve data on deaths occurring during or shortly after pregnancy. Estimates, trends, and most common causes of death were markedly different depending on which indicator was used. Additionally, the use of different mortality indicators during analysis provides a more detailed picture of potential target areas for future research and interventions.     

Maternal mortality in Vietnam in 1994-95

This report presents the first population-based estimates of maternal mortality in Vietnam. All the deaths of women aged 15-49 in 1994-95 in three provinces of Vietnam were identified and classified by cause. Maternal mortality was the fifth most frequent cause of death. The maternal mortality ratio was 155 deaths per 100,000 live births. This ratio compares with the World Health Organization's estimates of 430 such deaths globally and 390 for Asia. The maternal mortality ratio in the delta regions of these provinces was half that of the mountainous and semimountainous regions. Because a larger proportion of the Vietnamese population live in delta regions than elsewhere, the maternal mortality ratio for Vietnam as a whole may be lower than that of the three provinces studied. Maternal mortality is low in Vietnam primarily because a relatively high proportion of deliveries take place in clinics and hospitals, where few women die in childbirth. Also, few women die of the consequences of induced abortion in Vietnam because the procedure is legal and easily available.     

Maternal mortality in a rural district of southeastern Tanzania: an application of the sisterhood method

BACKGROUND: Deaths from maternal causes represent the leading cause of death among women of reproductive age in most developing countries. It is estimated that the highest risk occurs in Africa, with 20% of world births but 40% of the world maternal deaths. The level of maternal mortality is difficult to assess especially in countries without an adequate vital registration system. Indirect techniques are an attractive cost-effective tool to provide estimates of orders of magnitude for maternal mortality. METHOD: The level of maternal mortality estimated by the sisterhood method is presented for a rural district in the Morogoro Region of Southeastern Tanzania and the main causes of maternal death are studied. Information from region-specific data using the sisterhood method is compared to data from other sources. RESULTS: The maternal mortality ratio (MMR) was 448 maternal deaths per 100,000 live births (95%CI : 363-534 deaths per 100,000 live births). Maternal causes accounted for 19% of total mortality in this age group. One in 39 women who survive until reproductive age will die before age 50 due to maternal causes. The main cause of death provided by hospital data was puerperal sepsis (35%) and postpartum haemorrhage (17%); this is compatible with the main causes reported for maternal death in settings with high levels of maternal mortality, and similar to data for other regions in Tanzania. The sisterhood method provides data comparable with others, together with a cost-effective and reliable estimate for the determination of the magnitude of maternal mortality in the rural Kilombero District.     

Maternal mortality surveillance, United States, 1979-1986

To understand further the epidemiology and causes of maternal death, the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, reviewed all identified maternal deaths in the United States, including Puerto Rico, for the period from 1979 through 1986. The maternal mortality ratio for the period was 9.1 deaths/100,000 live births. The ratios increased with age and were higher among women of black and other minority races than among white women for all age groups, particularly for women ages greater than or equal to 40 years. Unmarried women had a higher risk of death than married women. Women who had received any prenatal care had a lower risk of dying than women who had received no care (RR = 0.19, 95% confidence limits (CL) 0.15, 0.23). Women who received no prenatal care had a gestational age-adjusted risk of maternal death 5.7 times that of women receiving care defined as "adequate." The risk of maternal death increased with decreasing levels of education for all age groups, particularly among women ages greater than or equal to 35 years. The causes of death varied for different outcomes of pregnancy; pulmonary embolism was the leading cause of death following the delivery of a live birth. Future studies aimed at developing strategies to reduce the risk of maternal deaths in the United States should use enhanced surveillance and collect more information about each death, which would allow for better understanding of factors associated with maternal mortality.     

Access to care and maternal mortality in Jamaican hospitals: 1993-1995

BACKGROUND: As part of the reproductive health quality assurance programme, the Ministry of Health sought to review maternal deaths in public hospitals. These hospitals attend 95% of institutional births and 82% of all births. METHODS: Deaths among females 10-50 years in public hospitals during 1993-1995 were reviewed to identify pregnancy-related deaths. Cause of death and access to care were compared with previous studies (1981-1983 and 1986-1987 [12 months]). RESULTS: The maternal mortality ratio of 106.2 per 100 000 live births, was no different than the 119.7 observed in 1986-1987 and 118.6 for 1981-1983. The leading causes of death remained pre-eclampsia/eclampsia and haemorrhage. The only significant cause-specific decline occurred among deaths due to ruptured ectopic pregnancy (P = 0.012). While in 1986-1987 access to care was associated with risk of death from gestational hypertension (P = 0.02), these differences are no longer significant. Differences persist, however, for haemorrhage and all other causes, which were less likely to occur at the more skilled institutions. The region with the least obstetricians had the highest mortality ratio but the one with the most did not have the lowest ratio, indicating that quality is more important than quantity. CONCLUSIONS: Regional differences indicate the capacity to reduce maternal mortality by at least 50% with re-allocation of skilled personnel and improved quality. All hospitals must be able to manage haemorrhage cases as patients are unlikely to survive referral.     

Maternal Mortality Decline in the Kassena-Nankana District of Northern Ghana

Objective In the absence of an adequate vital registration system in Ghana, the Navrongo demographic surveillance system (NDSS) established in 1993 presents a viable alternative to monitor, in a poor rural district, the UN Millennium Development Goal on maternal health (MDG) of reducing maternal mortality by 75% between 1990 and 2015. Methods Of the 518 women aged 12–49 years identified in the NDSS database to have died in the Kassena-Nankana district in the period January 2002–December 2004, spouses or family members completed verbal autopsy interviews for 516 female deaths. Results Of the 516 female deaths, 45 were identified as maternal deaths. 71% of the maternal deaths were attributed to direct maternal causes while 29% were due to indirect maternal causes. Abortion-related deaths were the most frequent cause of maternal deaths. The maternal mortality ratio for the period 2002–2004 was 373 maternal deaths per 100,000 live births indicating a 40% reduction of maternal mortality from the 1995–1996 level of 637 maternal deaths per 100,000 live births. However, the health-facility based maternal mortality ratio in the district (which excludes maternal deaths outside health facilities) was 141 maternal deaths per 100,000 live births for the period 2002–2004. Conclusion This district may be on track to achieve the MDG on maternal health. Ultimately, strengthening vital registration systems to provide timely information to policymakers should supersede the other methods of measuring maternal mortality.     

Mortality of women in reproductive age in the municipality of S?o Paulo (Brazil), 1986. I. Methodology and general results

The purpose of this study was to evaluate the accuracy of the death certificates of a sample of a quarter of all deaths in women of reproductive age (10-49 years) resident in the Municipality of S. Paulo, SP, Brazil, in 1986. For each death, further data were gathered by means of household interviews and from medical records and autopsy information where available. Nine hundred and fifty-three deaths were analysed, for whom there were good quality death certificates except with regard to maternal deaths an terminal respiratory diseases, the former being greatly under-reported. The official maternal mortality rate was 44.5 per 100,000 live births but the true rate was 99.6 per 100,000 live births. The three main causes of death were cardiovascular diseases, neoplasms and external causes. A great proportion of smokers was found among the deceased women (40.4%). Eleven percent of the deceased consumed large amounts of alcoholic beverages regularly.     

Epidemiological features of maternal deaths occurred in Recife, PE, Brazil (2000-2006)

This was a cross-sectional study that aimed to describe the epidemiological characteristics of maternal deaths among women living in Recife, PE, Brazil that occurred between 2000 and 2006. The data source consisted of investigation files on maternal deaths. To analyze the data, the EpiInfo 6.04d software was used. The analysis considered 111 deaths, corresponding to a maternal death ratio of 65.99/100,000 live births. The obstetric data showed that these women had had fewer than six prenatal consultations, between one and four previous pregnancies, cesarean deliveries and hospital admission in a severe condition. Hypertensive disorders were the main cause of death. Most of the deaths were considered avoidable. The results indicate the need to improve the healthcare for pregnant women prenatally, at delivery and during the puerperium.     

Differing First Year Mortality Rates of Term Births to White, African-American, and Mexican-American US-Born and Foreign-Born Mothers

To determine whether maternal nativity (US-born versus foreign-born) is associated with the first year mortality rates of term births. Stratified and multivariable binomial regression analyses were performed on the 2003–2004 National Center for Health Statistics linked live birth-infant death cohort files. Only term (37–42 weeks) infants with non-Latina White, African-American, and Mexican-American mothers were studied. The infant mortality rate (<365 days, IMR) of births to US-born non-Latina White mothers (n = 3,684,569) exceeded that of births to foreign-born White mothers (n = 226,621): 2.4/1,000 versus 1.3/1,000, respectively; relative risk (RR) = 1.8 [95 % confidence interval (CI) 1.6–2.0]. The IMR of births to US-born African-American mothers (n = 787,452) exceeded that of births to foreign-born African-American mothers (n = 118,246): 4.1/1,000 versus 2.2/1,000, respectively; RR = 1.8 (1.6–2.1). The IMR of births to US-born Mexican-American mothers (n = 338,337) exceeded that of births to Mexican-born mothers (n = 719,837): 2.4/1,000 versus 1.8/1,000, respectively; RR = 1.3 (1.2–1.4). These disparities were not limited to a singular cause of death and were widest among deaths due to Sudden Infant Death Syndrome. In multivariable binomial regression models, the adjusted RR of infant mortality for non-LBW, term births to US-born (compared to foreign-born) for White, African-American, and Mexican-American mothers equaled 1.5 (1.3–1.7), 1.7 (1.5–2.1) and 1.6 (1.4–1.8), respectively. The IMR of term births to White, African-American, and Mexican-American mothers exceeds that of their counterparts with foreign-born mothers independent of traditional individual level risk factors.     

Cause of Death in Women of Reproductive Age in Rural Nepal Obtained Through Community-Based Surveillance: Is Reducing Maternal Mortality the Right Priority for Women's Health Programs?

We used a community surveillance system to gather information regarding pregnancy outcomes and the cause of death for women of reproductive age (WRA) in Kanchanpur, Nepal. A total of 784 mother groups participated in the collection of pregnancy outcomes and mortality data. Of the 273 deaths among WRA, the leading causes of death reported were chronic diseases (94, 34.4%) poisoning, snake bites, and suicide (grouped together; 55, 20.1%), and accidents (29, 10.6%), while maternal mortality accounted for 7%. Nevertheless, the calculated maternal mortality ratio was quite high (259.3 per 100,000 live births).     

吉林省2014-2019年孕产妇死亡分析

目的 探讨孕产妇死亡的相关因素,为卫生行政部门制定相关政策提供依据,进一步降低孕产妇死亡率.方法 收集2014-2019年发生在吉林省的孕产妇死亡共计167例,将基本情况、死因诊断、省级评审结果等逐一进行统计分析.结果 6年间,孕产妇死亡率总体呈下降趋势(P＜0.05),近三年孕产妇死亡年龄较前升高(P＜0.05),死...