Massachusetts Department of Public Health Council Meeting



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Safe Motherhood in Massachusetts

Pregnancy-associated injury deaths:
Violence, substance abuse, and
motor vehicle collisions, 1990-1999



Massachusetts Department of Public Health

Public Health Council Meeting

May 28, 2002

Outline

History of pregnancy-associated death review in MA

1941-1980s: Case review by MA Medical Society

1980s-1996: No case review - surveillance only

1997: Maternal Mortality and Morbidity Review Committee (MMMRC) convened

  • MDPH collaborators: BFCH, BHQM, Vital Records

  • Other collaborators: Chief Medical Examiner, clinical community

  • Review all deaths from 1995 onwards

Safe Motherhood

  • CDC campaign

  • Promote well-being of women to help achieve healthy pregnancy, birth, and parenthood

  • Prevent pregnancy-associated illness, injury, and death

Definitions and key terms

  • Maternal deaths:

Women who died while pregnant or up to 42 days following the end of pregnancy from causes related to or aggravated by pregnancy, but not including injuries. (WHO)

  • Pregnancy-associated deaths:

Women who died while pregnant or within one year following the end of pregnancy, from any cause including injuries. Includes maternal deaths. (CDC/ACOG)

Definitions and key terms

  • Medical deaths:

  • Underlying cause of death was acute or chronic medical condition

  • May be related or unrelated to pregnancy

  • Injury deaths:

  • Underlying cause of death was an injury

  • Injury may have been intentional, unintentional, or of undetermined intent

Case identification methods

  • Death certificates

  • Mandatory facility reporting to Division of Health Care Quality

  • Infant birth and fetal death certificates linked to death certificates of women of reproductive age

  • Newspaper reports

  • Domestic violence organizations

Case review process

  • Was the death pregnancy-related?

  • Was the woman screened during birth hospitalization for violence, substance abuse, and depression?

  • What public health, clinical, or institutional strategies might prevent similar deaths in the future?

Pregnancy-associated mortality
ratio, Massachusetts, 1990-1999

Pregnancy-Associated Mortality Ratio (PAMR):

  • # of pregnancy-associated deaths per 100,000 live births

  • 1990-1999 aggregate PAMR = 27.2

Distribution of injury and medical causes of pregnancy-associated death 1990-1999





  • There were 232 pregnancy-associated deaths.

  • Over one-third were injury-related.

There were 152 medical deaths which was 66 % of pregnancy-associated deaths.

80 deaths were injury related, which was 34% of pregnancy-associated deaths.

Leading causes of pregnancy-associated death 1990-1999

  • Homicide leading cause overall (n=30)

  • 2 out of 3 were cases of domestic violence

  • Other leading causes of injury deaths:

  • Motor vehicle collisions (n=21)

  • Drug overdose (n=16)

  • Suicide (n=7)

  • Leading causes of medical deaths:

  • Cancer (n=28)

  • Acute and chronic respiratory conditions (n=23)

  • Cardiovascular disease and conditions (n=11 )

  • Peripartum and postpartum cardiomyopathy (n=8)



PAMR by age at delivery for medical and injury deaths, 1990-1999

The abbreviation for Pregnancy-associated mortality ratio is PAMR. Pregnancy-associated mortality ratio is # of deaths per 100,000 live births.


Deaths per 100,000 live births

Mother’s age at Delivery

Medical Causes

Injury Causes

Under 25

14.7

19.1

25-39

17.1

6.4

40-44

74.0

4.9


PAMR by race and Hispanic ethnicity for medical and injury deaths, 1990-1999


The abbreviation for Pregnancy-associated mortality ratio is PAMR. Pregnancy-associated mortality ratio is # of deaths per 100,000 live births.


Deaths per 100,000 live births

Mother’s race and Hispanic ethnicity

Medical Causes

Injury Causes

White non-Hispanic

14.9

6.8

Black non-Hispanic

37.4

29.3

Hispanic

24.0

15.6



PAMR by source of payment at delivery for medical and injury deaths, 1990-99


The abbreviation for Pregnancy-associated mortality ratio is PAMR. Pregnancy-associated mortality ratio is # of deaths per 100,000 live births.
Deaths per 100,000 live births

Source of payment at delivery

Medical Causes

Injury Causes

Private Payor

12.1

3.1

Public Payor

25.7

23.5



Prevention of future deaths

  • All injury deaths are preventable from a public health perspective

  • Future deaths may be averted by one or more changes in the following:

  • Clinical care

  • Facility infrastructure

  • Public health infrastructure

  • Patient factors

Summary of findings:
Pregnancy-associated deaths in MA 1990-99

  • 232 women died while pregnant or in the first year postpartum

  • Disparities exist by

  • Age at delivery

  • Race and Hispanic ethnicity

  • Source of payment at delivery (Income level)

  • Injuries account for one-third of all pregnancy-associated deaths and are preventable

  • Homicide was leading cause of death

  • 2 out of 3 homicides were cases of domestic violence

Moving from data and review to action

Periods of risk

  • Pregnancy

  • Early postpartum (0-41 days)

  • Late postpartum

  • 42-179 days
  • 180-364 days

Number of injury deaths by cause and period of risk, 1990-1999



Timing of Death, Deaths per 100,000 live births

Cause of death

Pregnant

0-41 days

42-179 days

180-364 days

Homicide

1

1

11

17

Suicide

1

0

3

3

Motor Vehicle

4

3

5

9

Substance Abuse

0

4

7

5



Opportunities - Number of provider visits by period of risk, 1990-1999



Deaths per 100,000 live births

Provider type

Pregnant

0-41 days

42-179 days

180-364 days

OB

9

2

0

0

Pediatric

1

2

2

2

WIC

1

1

1

1

Primary Care

0

0

0

1

Hospital

0

1

0

0



Steps to Support Safe Motherhood

All providers of services and care to women and infants:

  • Educate all women about domestic violence, postpartum depression, substance use and proper seat belt use

  • Screen and re-screen all women for domestic violence, depression, suicide risk, substance use & seatbelt use

  • At regular intervals, including late postpartum

  • Document screening results and injuries

  • Advise & counsel women about resources & support

Steps to Support Safe Motherhood

  • Institute policies and protocols to standardize approaches

  • Reduce stigma associated with these issues

  • Respect the culture and recognize the complexity of women’s lives

  • Create a comprehensive community response to improve the health of women

  • Work for policy changes that support women

  • Continuity of services beyond obstetrical care

  • Mental health parity issues

Conclusions

  • Preventable causes of injury-related deaths indicate we need a public health approach to prevention

  • Many deaths occur in the late postpartum period when women don’t receive many services

  • Strategies need to address the timing of these deaths and enlist pediatric and adult primary care providers to join obstetrical providers in prevention efforts

Many thanks!

  • Members of Maternal Mortality & Morbidity Review Committee

  • Community providers from injury prevention & substance abuse programs & clinical providers who participated in DPH summit to formulate strategies

  • Co-Authors of Report

  • Angela Nannini, NP, PhD

  • Catherine Oelschig

  • Judith Weiss, ScD

Contact Information

Bureau of Family and Community Health

Massachusetts Department of Public Health

250 Washington Street, 5th Floor

Boston, MA 02108

http://www.mass.gov/?pageID=eohhs2subtopic&L=6&L0=Home&L1=Consumer&L2=Community+Health+and+Safety&L3=Family+and+Community+Health&L4=Pregnancy+and+Newborn&L5=Safe+Motherhood&sid=Eeohhs2




Angela Nannini: 617.624.6069

angela.nannini@state.ma.us

MA Maternal Mortality and Morbidity Review Committee

Benjamin Sachs, MB.BS, Dph, FACOG, Chair

Linda Clayton, MD

Christine Combs, RN

Susan DeJoy, CNM, MSN

Richard Evans, MD, CME

Fred Frigoletto, Jr., MD, FACOG

Yvonne Gomez-Carrion, MD, FACOG

Gary Kraus, MD

J.P. O’Grady, MD

Steven Ringer, MD, PhD

Drucilla Roberts, MD

Maria Valentin-Welch, CNM, MPH

Randy Wertheimer, MD



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