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Maternal Mortality Review in Maryland. Meena Abraham, M.P.H. MedChi, The Maryland State Medical Society. Maternal Mortality Ratio by Race Maryland and U.S., 1997-2001. Establishing MMR in Maryland. Legislation passed in 2000

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maternal mortality review in maryland

Maternal Mortality Review in Maryland

Meena Abraham, M.P.H.

MedChi, The Maryland State Medical Society

establishing mmr in maryland
Establishing MMR in Maryland
  • Legislation passed in 2000
  • MD State Health Department contracts with MedChi, The Maryland State Medical Society
  • Enhanced surveillance approach
    • not limited to traditional definition of maternal death (<42 days limit)
    • Identify all deaths up to 1 year postpartum
    • Determine deaths that are pregnancy-related
mmr process in maryland
MMR Process in Maryland
  • Identify pregnancy-associated deaths (1 yr)
    • Death certificate - cause of death or contributing factor related to pregnancy
    • Death certificate – pregnancy status and date of delivery items (revised in 2001)
    • Linkage of death certificates with fetal death certificates and birth certificates
    • Manual review of Medical Examiner files
    • Other notification
slide5

MMR Process in Maryland, cont.

  • Abstract records from hospital of death, hospital of delivery, Office of CME
  • Classify by category to group cases and invite specialist to assist w/review
    • Suicide
    • Homicide
    • Substance abuse
    • Injury/accident
    • Cancer
    • Cardiovascular
    • Other
slide6

MMR Process in Maryland, cont.

  • Review cases with MedChi’s Maternal and Child Health Committee plus invited specialist as needed
    • Pregnancy-relatedness
    • Preventability
    • Recommendations
cases by method of identification

Method of Identification

Pregnancy-associated Deaths

2000

n=32

(%)

2001

n=43 (%)

Total

N=75 (%)

Death certificate cause of death

8 (25)

7 (16)

15 (20)

Death certificate checkbox

-------

12 (28)

12 (16)

Birth/fetal certificate linkage

21 (66)

31 (72)

52 (69)

Medical examiner chart review

12 (38)

6 (14)

18 (24)

Other (ME communication, newspaper)

1 (3)

1 (2)

2 (3)

Cases by Method of Identification
pregnancy associated deaths in maryland 2000 01

Year

Deaths

2000

n (%)

2001

n (%)

Total

n (%)

Pregnancy-associated

32

43

75

-Pregnancy-related

13 (41)

12 (28)

25 (33)

-Pregnancy-relatedness undetermined

7 (22)

16 (37)

23 (31)

-Not pregnancy-related

11 (34)

15 (35)

26 (35)

-Unknown cause of death

1 (3)

0

1 (1)

Pregnancy-associated Deaths in Maryland, 2000-01
preventability of deaths

Classification

Pregnancy-associated Deaths N=75 (%)

Pregnancy-related Deaths

n=25 (%)

Preventable

37 (49)

4 (16)

Not preventable

32 (43)

19 (76)

Not Determinable

6 (8)

2 (8)

Preventability of Deaths
  • Preventable – patient factor, provider practice, institutional systems
    • homicide, suicide, unintentional injury; others determined through discussion
summary of key findings
Summary of Key Findings
  • Enhanced surveillance increased identification of pregnancy-related deaths.
  • Cardiac disease leading cause of death
    • 44% of pregnancy-related deaths
    • 10% deaths in 15-44 yr old females
  • Obesity contributor to preg-related deaths
    • BMI <25: 24%
    • BMI 25-29: 24%
    • BMI>30: 52%
summary of key findings cont
Summary of Key Findings, cont.
  • Racial disparity—48% preg-related deaths compared to 33% births
  • Women >35 yrs disproportionate high rates of deaths compared to live births (#11)
  • Possible increased rates among Hispanic women—higher suicide rate
  • PNC initiation/utilization
    • No PNC in 12% preg-related deaths vs late/no PNC in 3.7% live births
special focus maternal suicides
Special Focus: Maternal Suicides
  • Reviewed 10 cases occurring 1993-2001
    • 3 pregnant
    • 7 postpartum: between 30-276 days
  • In-depth discussion with MCH Committee and psychiatrist consultant
  • Determined maternal depression is under-diagnosed and under-treated
  • Opportunity to decrease maternal and infant morbidity
maternal depression project
Maternal Depression Project
  • Formed Maternal Depression Team
  • Identified need to assess clinical practice and barriers to diagnosis/treatment
  • Developed survey and distributed to OB/Gyn, Pediatric and Family Practice departments at all hospitals in Md; separately mailed to certified nurse midwives
  • Identified differences by specialty and barriers
  • Identified need for patient educational materials and referral resources
maternal depression project23
Maternal Depression Project
  • Directing efforts toward
    • Compiling resources in Maryland including referral list
    • Developing provider toolkit for educating, diagnosing, treating or referring women with depression
    • Educating clinicians about the prevalence and impact of maternal depression
acknowledgements
Acknowledgements
  • MedChi’s Maternal and Child Health Committee members and consultants
  • Preventive Medicine Resident—

Sayeedha Uddin, MD, MPH

  • MCH Committee member and consultant—

Cara Krulewitch, PhD, CNM

  • Center for Maternal and Child Health, DHMH—Maureen Edwards, MD, MPH, Diana Cheng, MD
  • MD Vital Statistics Administration—

Isabelle Horon, DrPH