maternal morbidity and mortality · advanced maternal age ama associated with: higher prevalence of...
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MATERNAL MORBIDITY AND
MORTALITYElyse Watkins, DHSc, PA-C, DFAAPA
What is a pregnancy-related death?
◦ The death of a woman during or within 1 year of
pregnancy
◦Caused by a pregnancy complication,
◦A chain of events initiated by pregnancy,
◦or the aggravation of an unrelated condition by the
physiologic effects of pregnancy.
http://www.pphproject.org/maternal-morbidity-mortality.asp
Pregnancy-related mortality ratio increased from 7.2 deaths per 100,000 live births in 1987 to 17.8 deaths per 100,000 live births in 2009 in the United States.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/
Pregnancy-related mortality ratios are 3–4 times higher among black women than white women and for specific mortality causes (e.g., ectopic pregnancy), this gap appears to be even greater.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/
A few interesting facts…
◦ In 2003 a pregnancy-related checkbox was
added to death certificates.
◦The higher mortality ratio in 2009 compared with
previous few years was due to the 2009 H1N1
influenza pandemic, which disproportionally
affected pregnant women.
◦Solution??
More sobering statistics
◦ The United States has now a higher ratio than those
reported for most high-income countries and the
Islamic Republic of Iran, Libya and Turkey
◦ This is NOT due simply to changes in reporting!
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC50017
99/)
https://www.who.int/bulletin/volumes/93/3/14-148627/en/
Racial/ethnic differences
◦ Compared with white mothers, black women experienced
disproportionately high rates of death from cardiomyopathy,
thrombotic pulmonary embolism, and hypertensive disorders of
pregnancy
◦ American Indian/Alaskan Native women experienced
disproportionately high rates of death from hemorrhage and
hypertensive disorders
MORBIDITY AND MORTALITY
CONFOUNDERS* *A confounder is a variable that influences both the dependent variable and
independent variable
Anemia◦ Of 515,270 women in a study population, 65,906 (12.8%) had anemia: 11.8%,
0.43%, and 0.02% had mild, moderate, and severe anemia, respectively.
◦ Categorization:
◦ No anemia (hemoglobin 11 g/dL or greater)
◦ Mild (9-10.9 g/dL)
◦ Moderate (7-8.9 g/dL)
◦ Severe (less than 7 g/dL)
◦ Anemic women experience:
◦ Longer hospitalization duration
◦ More antenatal admissions
◦ Higher rates of preeclampsia
◦ Higher rates of placenta previa
◦ Higher rates of cesarean delivery
https://www.ncbi.nlm.nih.gov/pubmed/31764734
Anemia
◦Also associated with:
◦Preterm birth
◦Small-for-gestational-age live births
◦Low 5-minute Apgar scores
◦Neonatal death
◦Perinatal death
Advanced maternal age
◦ AMA associated with:
◦ Higher prevalence of GDM, fetal aneuploidy, miscarriage,
placenta previa, cesarean delivery
◦ Increased risk of abruption, preterm delivery, low birth weight,
and perinatal mortality in women 40 years and older
◦ Morbidity and Mortality increased exponentially with maternal
age over 39 y, from OR = 1.2 (95% CI 1.2–1.3) among women
aged 35–39 y to OR = 5.4 (95% CI 2.4–12.5) among women aged
≥50 y
https://www.ncbi.nlm.nih.gov/pubmed/31770385
https://www.ncbi.nlm.nih.gov/pubmed/15863534
Advanced maternal age
◦ Adjusted rates of severe morbidity remained increased among
mothers ≥35 y
◦ Rates of amniotic fluid embolism (AOR = 8.0, 95% CI 2.7–23.7)
and obstetric shock (AOR = 2.9, 95% CI 1.3–6.6) among mothers
≥40 y
◦ Renal failure (AOR = 15.9, 95% CI 4.8–52.0), complications of
obstetric interventions (AOR = 4.7, 95% CI 2.3–9.5), and ICU
admission (AOR = 4.8, 95% CI 2.0–11.9) among those 45–49 y
https://www.ncbi.nlm.nih.gov/pubmed/15863534
Opioid use disorder
https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w
#F1_down
Prevalence of opioid use disorder per 1,000 delivery hospitalizations
https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w
#F1_down
Mental Health
◦Poor mental health may adversely impact pregnancy outcomes, maternal-infant bonding, maternal functioning, and infant health and development.
◦Among U.S. women with major depression, 89% have one or more chronic medical conditions (diabetes, obesity) or medical risk factors (smoking, binge or heavy drinking, physical inactivity).
◦What confounds mental health diagnosis and treatment?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/
What are the core problems?
◦ Hospitals across the US generally lack a standard approach to
managing obstetric emergencies
◦ The complications of pregnancy and childbirth are often
identified too late
◦ Increasing number of women who present with chronic
conditions (hypertension, diabetes and obesity)
https://www.who.int/bulletin/volumes/93/3/14-148627/en/
Core problems
◦ Only half of US states have maternal mortality review boards.
◦ Data that are collected are not systematically used to guide
changes that could reduce maternal mortality and morbidity.
https://www.who.int/bulletin/volumes/93/3/14-148627/en/
What are potential solutions?
◦Let’s discuss!
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