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California Maternal Mortality and Pregnancy-Associated Mortality
Review
Elizabeth Lawton MHS
California Department of Public Health
Maternal, Child, Adolescent Health Division
Empowering Oklahoma’s Women Conference
November 13, 2015
The Problem: Maternal Mortality California Pregnancy-Associated Mortality Review
(CA-PAMR) What did we learn from CA-PAMR? What other resources were developed?
Strengthened public health programs Move upstream to preventive, life course model QI Activities for Maternity Care Providers
Status of Maternal Mortality since 2006 What contributed to the decline?
Next direction of PAMR
What This Talk Will Address
Maternal Mortality Rate, California and United States; 1999-2006
Ma
tern
al
De
ath
s p
er
10
0,0
00
Liv
e B
irth
s
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
Maternal Mortality Rates by Age Group, California Residents; 1999-2006
7.6
12.1
8.211.710.1
15.416.3
13.8
51.7
36.9
42.8
64.361.6
59.3
55.757.7
0
10
20
30
40
50
60
70
1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008
Three-Year Moving Average
20-24 Years 25-29 Years 30-34 Years 35-39 Years 40-54 Years
Ma
tern
al
De
ath
s p
er
10
0,0
00
Liv
e B
irth
s
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2006
7.1
12.4
27.729.0
32.2
35.3
45.7
41.5
51.0
46.1
9.1
12.8
9.37.6
0
10
20
30
40
50
60
1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008
Three-Year Moving Average
White, Non-Hispanic African-American, Non-Hispanic
Hispanic Asian, Non-Hispanic
Mat
ern
al
Dea
ths
per
100
,000
Liv
e B
irth
s
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
Initiated in 2004-2006 in order to:
Investigate the rise in maternal mortality and the widening racial/ethnic disparity
Identify possible reasons for the rise
Direct policy and programmatic interventions
California Health and Safety Codes give CDPH the broad authority to investigate sources of morbidity and mortality.
California Pregnancy-Associated Mortality Review
CA-PAMR Project Partners
California Department of Public Health (CDPH),
Center for Family Health, Maternal Child and Adolescent Health Division (MCAH)
Public Health Institute (PHI); Sue Holtby MPH and Christy McCain, MPH
California Maternal Quality Care Collaborative (CMQCC); Elliott Main, MD, Christine Morton, PhD
CA-PAMR Committee
CA-PAMR Committee
CA-PAMR Status and Publications
Concluded review of deaths from 2002-2007 Initial CDPH report
‘Made the Case’ and describes methodology Findings from review of 2002-2003 maternal deaths
Follow-up report 2016
THE CALIFORNIA PREGNANCY-ASSOCIATED
MORTALITY REVIEW (CA-PAMR)
Report from 2002-2003 Maternal Death Reviews
April 2011
ARTICLE in MATERNAL AND CHILD HEALTH JOURNAL
California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings Connie Mitchell • Elizabeth Lawton • Christine Morton • Christy McCain • Sue Holtby • Elliott Main
CA-PAMR Status and Publications
Key Steps of CA-PAMR Methodology
STEP 1: Hospital discharge data linked to birth, death certificates Identifies women who died within one year postpartum from any cause
(Pregnancy-Associated Cohort)
STEP 2: Additional data gathered for each death Coroner Reports, Autopsy Results, and additional information from the Death Certificate (e.g., multiple causes of death, recent surgeries, etc) are obtained
STEP 3: Cases selected for CA-PAMR Committee review Documented (ICD-10 obstetric (“O”) code) and suspected pregnancy-related
deaths are prioritized for review
STEP 4: Medical records abstracted and summarized All available labor and delivery, prenatal, hospitalization, transport, and
outpatient and emergency department records are obtained and summarized
STEP 5: Cases reviewed by CA-PAMR Committee Committee determines whether the death was pregnancy-related, the
cause of death, contributing factors and quality improvement opportunities
Source: The California Pregnancy-Associated Mortality Review. Report from 2002-2003 Maternal Deaths. California Department of Public Health, April 2011.
CA-PAMR Pregnancy-Related Causes of Death, 2002-2005 (After CA-PAMR case review)
Cause of Pregnancy-Related Deaths N (%) Rate (95% CI)Cardiovascular disease 49 (23.7) 2.3 (1.6-2.9)
Cardiomyopathy 33 (15.9)
Other cardiovascular 16 (7.7)
Preeclampsia/eclampsia 36 (17.4) 1.7 (1.1-2.2)
Obstetric hemorrhage 20 (9.7) 0.9 (0.5-1.3)
Deep vein thrombosis/pulmonary embolism 20 (9.7) 0.9 (0.5-1.3)
Amniotic fluid embolism 18 (8.7) 0.8 (0.5-1.2)
All Other Causes (Sepsis, Cerebral vascular accident, Anesthesia complications, Acute fatty liver, etc)
64 (30.9) 3.0 (2.3-3.7)
TOTAL 207 9.7 (8.4-11.0)
Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015
Risk Factor: Obesity; CA-PAMR 2002-2005
Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015
Preventability – or – Chance to Alter Outcome; CA-PAMR 2002-2005
* Significantly more likely to have good-to-strong chance than CVD and AFE deaths
**Significantly less likely to have good-to-strong chance than all causes
Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015
Contributing Factors by Health Care Professionals CA-PAMR 2002-2005
Source: Main E, et al. Obstetrics and Gynecology, vol 125, No.4, April 2015
In-Depth Review of Pregnancy-Related Cardiovascular Disease CA-PAMR 2002-2006 (N=64 CVD out of 257 P-R)
Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.
Key Findings (1): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006
Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.
Racial/Ethnic disparity even more pronounced
African-American women 5.5% of CA births
22% of all pregnancy-related deaths
40% of cardiovascular pregnancy-related deaths
Other risk factors
Obesity, Hypertensive disorders (20%), Substance use (38%), especially stimulants (11%) and alcohol (17%)
Key Findings (2): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006
Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.
Time to death from birth or fetal demise
ALL CVD: 9d median, 56d mean, range (0,340d)
CMP: 67d median, 112d mean, range (0,340d)
Timing of CVD diagnosis
Preexisitng disease: 3%
Prenatal period: 8%
At labor and delivery: 65%
Postpartum period: 34%
Postmortem: 48%
Key Findings (3): Pregnancy-Related Cardiovascular Deaths, CA-PAMR 2002-2006
Source: Hameed, et al. American Journal Obstetrics and Gynecology, 2015; 213:379e1-10.
Presented with Signs and Symptoms of CVD
Prenatal period: 43%
At labor and delivery: 51%
Postpartum period: 80%
Shortness of Breath (61%) and Edema (44%)
52% Identified as Pregnancy-Related on Death Certificate (before case review)
69% Autopsy performed (critical for diagnosis of cardiomyopathy)
Between 2006-2010, CDPH MCAH also:
Invested in Preconception Health Program
Funded local Maternal Health Programs to develop interventions for regional issues
Revamped Black Infant Health Program
Began mapping out more 1o and 2o prevention strategies to move MCAH activities upstream
Incorporated the Life Course Model throughout
Developed surveillance capacity to monitor maternal morbidity, including severe maternal morbidity and composite measures.
Maternal Public Health Programs and Surveillance Strengthened in California
QI Activities for Maternity Care Providers
Translation of CA-PAMR findings into Quality Improvement Activities
California Maternal Quality Care Collaborative
Volunteer Task Force, CA-PAMR Committee members
CDPH MCAH Title V funds
Series of Toolkits to Transform Maternity Care
Hospital Learning Collaboratives
Improve Response and Recognition to:
Obstetric Hemorrhage
Preeclampsia
Cardiovascular Disease
Available – at no cost – at www.CMQCC.org
Quality Improvement Toolkits
First Version released July 2010
Quality Improvement Toolkits
First Version released July 2010
Quality Improvement Toolkits
First Version released July 2010
Maternal Mortality Rate, California and United States; 1999-2013
11.1
7.7
10.0
14.6
11.8 11.7
14.0
7.47.3
10.9
9.7
11.6
9.2
6.2
16.9
8.9
15.1
13.1
12.19.99.9
9.8
13.3
12.7
15.5 16.916.6
19.3
19.9
22.0
0
3
6
9
12
15
18
21
24
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
California Rate
United States Rate
Ma
tern
al
De
ath
s p
er
10
0,0
00
Liv
e B
irth
s
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
With this decline, California has achieved and surpassed the Healthy
People 2020 objective for maternal mortality of 11.4 deaths per
100,000 live births. The decline in maternal mortality even continued during 2009 and
2010 when pregnant women were disproportionally impacted by the
H1N1 influenza epidemic.
In 2013, the U.S. rates are projected to be nearly three times
California’s rates.
California’s maternal mortality rates declined while U.S. maternal
mortality rates increased, even though California accounts for one in
eight births nationally.
Maternal Mortality Decline
Maternal Mortality Rates by Age Group, California Residents; 1999-2013
39.9
34.8
5.37.6 4.38.2
6.910.1
10.213.8
22.424.4
51.7
41.8
36.9
42.8
64.361.6
59.355.757.7
0
10
20
30
40
50
60
70
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
2005-2007
2006-2008
2007-2009
2008-2010
2009-2011
2010-2012
2011-2013
Three-Year Moving Average
20-24 Years 25-29 Years 30-34 Years 35-39 Years 40-54 Years
Ma
tern
al
De
ath
s p
er
10
0,0
00
Liv
e B
irth
s
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Beginning in 1999, maternal mortality for California (deaths < 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95, O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
a
aa
b
b
b
c
cc
d
dd
Maternal Mortality Rates by Race/Ethnicity, California Residents; 1999-2013
7.0
7.1
26.4
37.2
33.8
41.1
46.1
51.0
41.5
45.7
35.332.2
29.0 29.527.7
4.9
9.1 7.8
7.6
0
10
20
30
40
50
60
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
2005-2007
2006-2008
2007-2009
2008-2010
2009-2011
2010-2012
2011-2013
Three-Year Moving Average
White, Non-Hispanic African-American, Non-Hispanic
Hispanic Asian, Non-Hispanic
Mat
ern
al
Dea
ths
per
100
,000
Liv
e B
irth
s
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
a
a
a
b
b
b
c
cc
Disparities in Maternal Mortality by Race/Ethnicity, California Residents; 1999-2013
7.0
41.1
37.2
26.4
9.56.9
10.710.99.5
10.9 10.912.2 11.511.8
7.1
12.4
29.533.8
27.7
29.0
32.2
35.5
41.5
45.7
51.0
46.1
3.84.3
3.9
3.2
3.83.9
3.1 3.0 3.0
3.8 3.8
4.4
3.7
0
10
20
30
40
50
60
1999-2001
2000-2002
2001-2003
2002-2004
2003-2005
2004-2006
2005-2007
2006-2008
2007-2009
2008-2010
2009-2011
2010-2012
2011-2013
Year
0
1
2
3
4
5
6
7
8
9
10White, Non-Hispanic
African-American, Non-Hispanic
Maternal Mortality Disparity Ratio
Mat
ern
al
Dea
ths
per
100
,000
Liv
e B
irth
sR
atio o
f Afric
an-A
merican
to W
hite
Matern
al M
ortality
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality rates for California (deaths ≤ 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
Mortality rates for African-American women are the lowest they have
been since 1999.
In 2011-2013, 26.4 deaths among African-American women per
100,000 live births, half of the peak in 2005-2007.
African-American women continue to have a three- to four-fold higher
risk of maternal mortality compared to White women.
African-Americans are disproportionately impacted by negative
social determinants of health such as lower wages, access to
housing, unsafe environments and racism.
African-American women may have higher rates of underlying
health conditions such as hypertension, obesity, and
cardiovascular disease that complicate their pregnancies.
Maternal Mortality Decline: Racial Disparities Persist (1)
The disparities may also reflect a disparity in health care that can
be attributed to differences in health insurance, entry to prenatal
care, and access or quality of care.
Finally, the persistent disparity indicates that maternal mortality rates
are decreasing proportionally among both African-American and White
women. One group is not showing a greater increase or decline, thus
the ratio remains steady.
Maternal Mortality Decline: Racial Disparities Persist (2)
Maternal Mortality Rate (early and late deaths),
California Residents; 1999-2013
Ma
tern
al
De
ath
s p
er
10
0,0
00
Liv
e B
irth
s
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (Early maternal deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) and code O96 is also included when calculating Early and Late Maternal Deaths up to one year postpartum. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.
Late maternal deaths did not decline as dramatically
15.2 deaths per 100,000 live births in 2013.
Decline from 2005 peak rate of 19.1 deaths per 100,000 live births
Not as strong as that observed among the early maternal deaths.
Maternal mortality may be shifting to late postpartum deaths as chronic
diseases, like cardiovascular disease, play a prominent role in maternal
deaths.
This is especially true for peripartum cardiomyopathy, a type of
cardiovascular disease unique to pregnancy which typically occurs in
the last month of pregnancy through the fifth month postpartum
Consistent with data published by the Centers for Disease Control.
Maternal Mortality Decline: Late Maternal Deaths
What Contributed to the Decline in Maternal Mortality in California? (1)
We do not fully know what caused the rise in maternal mortality and
cannot fully explain what has caused its decline. Some hypotheses
for the recent decline include: Improved attention to the issue of maternal mortality and morbidity by
public health officials and maternity care providers through the
following activities. California Pregnancy-Associated Mortality Review (CA-PAMR) Hospital quality improvement strategies have been developed by
Stanford University’s California Maternal Quality Care Collaborative
(CMQCC) with funding from CDPH MCAH. To date, CMQCC has
developed three quality improvement toolkits and sponsored learning
collaboratives for the maternity care community.
What Contributed to the Decline in Maternal Mortality in California? (2)
Maternal mortality may be shifting to late postpartum deaths as
chronic diseases, like cardiovascular disease, play a prominent role. The impact of the economic downturn in 2008.
Reduction of the overall California birth rate Women who gave birth in the last six years may have been
healthier and had lower risk pregnancies Emigration from California due to job loss, cost-of-living, or
housing issues Women may have delayed having children until more economically
certain times. Vital statistics data reporting may be contributing to the apparent
decline, either through improvements in identification of pregnancy
prior to death or in the coding for causes or timing of death.
Next Direction for California and CA-PAMR
Continued analysis of CA-PAMR 1.0 (2002-2007) case reviews Racial Ethnic Disparities Congential CVD and Genetic conditions related to CVD Preeclampsia deaths from stroke Validation of the death certificate’s ability to identify pregnancy-
related deaths Continued examination of the decline
CA-PAMR 2.0 – investigation of violent and accidental pregnancy-
related deaths Suicides, Homicides, Drug Overdoses
Strengthening Maternal Mental Health capacity at CDPH Collaboration with CDPH Office of Health Equity Changes to Vital Statistics forms Venous Thromboembolism Toolkit
Thank you and GOOD LUCK Oklahoma!!!
Questions, Comments, Request for Resources:
Elizabeth Lawton
916-650-0364; Elizabeth.Lawton@cdph.ca.gov
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