and Maternal Mortality Chris Glantz, MD, MPH Severe Maternal - - PowerPoint PPT Presentation

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and Maternal Mortality Chris Glantz, MD, MPH Severe Maternal - - PowerPoint PPT Presentation

Nov 28, 2022 337 likes •641 views

Severe Maternal Morbidity and Maternal Mortality Chris Glantz, MD, MPH Severe Maternal Morbidity (SMM) Severe/multisystem organ dysfunction or need for major intervention Defined by CDC as one or more of 18 conditions 1. Acute MI/aneurysm 10.

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SLIDE 1

Severe Maternal Morbidity and Maternal Mortality

Chris Glantz, MD, MPH

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SLIDE 2

Severe Maternal Morbidity (SMM)

Severe/multisystem organ dysfunction or need for major intervention Defined by CDC as one or more of 18 conditions

  • 1. Acute MI/aneurysm
  • 2. Acute renal failure
  • 3. ARDS
  • 4. AFE
  • 5. Cardiac arrest/V fib
  • 6. DIC
  • 7. Eclampsia
  • 8. CHF
  • 9. Stroke
  • 10. Pulmonary edema
  • 11. Severe anesthesia comps
  • 12. Sepsis
  • 13. Shock
  • 14. Sickle cell crisis
  • 15. Air or thrombotic embolism
  • 16. Blood transfusion
  • 17. Hysterectomy
  • 18. Temporary trach/vent

50-100x more common than death; Incidence ≈1.5%

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SLIDE 3

Severe Maternal Morbidity in the US

The lesser rise is mostly due to increases in hysterectomy and assisted ventilation

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

More common in Black women Increasing rates of PPH due to atony

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SLIDE 4

SPDS: Birth Certificate Database

  • Has fields for transfusion, unplanned hysterectomy,

eclampsia, and ICU admission

  • Does not have specific fields for the other 15 CDC

conditions, but most of these would be managed in an ICU

  • Collectively, ICU admission should capture these 15
  • Thus, SMM ≈ Transfusion | Eclampsia | Hyst | ICU
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SLIDE 5

Morbidities from Birth Certificate

0% 10% 20% 30% 40% 50% 60% 70% 80% Transfusion ICU Eclampsia Hyst Combination

Alone Total (in combination)

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SLIDE 6

SMM by Monroe County Hospital

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4%

HH UH RGH SMH

SMH: more trans, hyst, & ICU RGH: fewer hyst & trans

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SLIDE 7

Rochester’s Northern Crescent

Crescent = ZIP 14605, 14609, and 14621 High rates of poverty and unemployment, and low rates of education and home ownership

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SLIDE 8

Monroe County 2009 - 2018

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Crescent NonCrescent

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Severe Maternal Morbidity By Year

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 2.0% 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

NonCrescent Crescent TOTAL

Trend: Not Statistically Significant

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SLIDE 10

Severe Morbidity by Race

0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% Asian Black WhiteHisp WhiteNonHisp Other Total

Crescent 1.24% NonCrescent 0.97%

Blacks had the highest rates of transfusions, ICU admissions, and eclampsia

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SLIDE 11

Controlling for Possible Confounders Using Logistic Regression

  • Nulliparity
  • Diabetes
  • HTN (chronic or PIH)
  • Cong Anom
  • Mult Gest
  • Medicaid
  • AMA
  • Teen
  • College Deg
  • Not Fin HS
  • Poor PNC (<3 visits)
  • Smoking
  • Drugs
  • EtOH
  • Obesity
  • Race
  • Crescent
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SLIDE 12

Adjusted SMM: Odds Ratios

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5

The other 8 variables were not statistically significant (including Medicaid)

?

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SLIDE 13

Morbidity Conclusions

  • Transfusion accounts for the majority of SMM
  • After adjusting for multiple demographic and medical factors:
  • Black women have a higher rate of severe maternal morbidity
  • Hispanics do not differ significantly from non-Hispanic Caucasians
  • Medicaid, smoking, and living in the Crescent were not

independently associated with SMM

  • Caveat: there may be unmeasured factors influencing the

association

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Maternal Mortality

  • Various definitions (often confusing*)
  • Early (within 42 days of del) or late (within 1 year)
  • Pregnancy-related vs nonrelated
  • Related = due to complication of pregnancy or pregnancy-

related deterioration of an existing condition

  • Mat Mort Ratio (MMR) = deaths per 100,000 liveborns
  • ≈700 maternal deaths per year in US

*Early v late, preg-related v non-related, preg-associated v non-assoc, direct v indirect

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Worldwide Maternal Mortality

0% 5% 10% 15% 20% 25% 30% VTE Abortion Direct causes† Infection HTN Hemorrhage Indirect causes*

*e.g., HIV, other med dx †e.g., obstructed labor

Global causes of maternal death: a WHO systematic analysis, 2014

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USA: Causes of Maternal Death (CDC)

MMWR / May 10, 2019 / Vol. 68 / No. 18

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% AFE Unknown Hypertension Stroke VTE Cardiomyopathy Hemorrhage Infection Other non-CV Other CV

Top 3: Other CV, Other non-CV, Infection

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SLIDE 17

USA: Causes of Maternal Death (MMRIA)

From a nine-state review of 680 deaths: Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018. http://reviewtoaction.org/Report_from_Nine_MMRCs

Top 3: Hem, CV, Infection

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SLIDE 18

Causes of Maternal Death (NYS)

0% 5% 10% 15% 20% 25% 30% Cardiomyopathy Infection Stroke Other CV VTE Other non-CV HTN Hemorrhage

2006-8 2012-14 Number of cases ranged from 4 to 29

Top 3 2006-8: Hem, HTN, Other nonCV Top 3 2012-14: VTE, Hem, infection

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SLIDE 19

Timing of Death

MMRIA, 2018

31% 12% 57%

CDC, 2019

Percentages Vary

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Maternal Mortality in the USA

https://www.cdc.gov/reproductivehealth/maternalinfant health/pregnancy-mortality-surveillance-system.htm

Up to 50% of deaths are potentially preventable

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Making America Not-So-Great Again

Population heterogeneity? Lack of universal coverage? Large geographic areas underserved? Disparities in care? Sicker/heavier women? Too many unnecessary interventions? Not enough midwives? Tracking differently/more accurately?

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NYS: Maternal Mortality by Year

ROS = “Rest of State”...

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USA: Racial Disparity in Maternal Mortality

5 10 15 20 25 30 35 40 45 White Black Alaskan/indian Asian Hispanic

Maternal Deaths per 100,000 liveborns

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SLIDE 24

NYS: Maternal Mortality by Race

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Difficult to Track Local Rates

  • Fortunately, death is very uncommon
  • But small changes in # of deaths  large swings in rates
  • Difficult to ascertain deaths occurring up to 12 months

after delivery

  • Local stats either not available or out of date
  • Attribution: prenatal care office vs. delivery hospital
  • vs. hospital where death occurred
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Maternal Mortality: Women Delivered at Strong 2013-18

  • 12 deaths
  • 2 Antepartum
  • 1 ruptured ectopic and 1 heroin overdose at 23 wks
  • 2 during delivery admission
  • 1 AFE and 1 influenza
  • 8 Postpartum
  • 4 from cancer (1-11 mo pp)
  • 1 complications from lupus (3 mo pp)
  • 1 heroin overdose (5 mo pp)
  • 1 complications from neurosurgery (7 mo pp)
  • 1 complications from cystic fibrosis (11 mo pp)
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SLIDE 27

Two Examples

  • SMH: 2800 del/year, mean 2 deaths (inc. late)
  • MMR = (2/2800)*100000 = 71
  • If ±1 death in a given year, MMR = 36 or 107
  • If only early deaths tracked (conception to 42 days pp), SMH’s

MMR falls by half

  • If only pregnancy-related deaths tracked, SMH’s MMR = 18
  • Level 1 Hosp X: 1000 del/year, and no deaths in 10 years
  • MMR = 0 = perfect! 
  • If 1 death one year, MMR for that year = 100 = terrible 
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SLIDE 28

Mortality Conclusions

  • Although rare, maternal deaths do occur
  • US rate is rising (various possible explanations)
  • It’s declining in other countries
  • Stats on rates, timing, and cause of death vary by study

and by definitions used

  • Accurate local rates require very long time periods
  • Racial disparities persist after adjusting for other factors
  • Reason unclear—biases? unmeasured factors?
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SLIDE 29