MEENA ABRAHAM: Thank you. This presentation is actually three different presentations actually crammed together. The first, I want to talk about the process in Maryland, then I want to present some of the data, and then also to let you know some of the activities that we’re doing in Maryland. I’m not going to go over definitions because the other speakers have covered it, but looking at maternal mortality ratio in Maryland compared to the U.S., you can see that the all races is 13.8 compared to 9 for the U.S. and the white rate is higher in Maryland than the U.S. and this is just to say, okay where do we stand in relation to the rest of the country? In looking at how did we establish maternal mortality review in Maryland. We got some legislation passed in 2000 that established the program and this was really to help us work with institutions to get access to records. There is also other legislation in Maryland that allows medical review committees to have access to medical records, so that helps a lot. The Maryland state health department in contrast the MedChi, the Maryland state medical society to operate maternal mortality review, and in Maryland we’re using the enhanced surveillance approach. So were not leaning to the traditional definition of maternal death less than 42 days, but really we’re looking at all deaths out to one year post-partum and then we look to see which of those deaths are pregnancy-related.
So in how do we identify these pregnancy-associated deaths or deaths out to one year? We look at death certificates to look at the cause of death or contributor factor. We also look at the death certificate where we now pregnancy status questions added in 2001. We also use linkage of death certificates with fetal death certificates and live birth certificates. We do a manual review of medical examiner files, especially to identify those women who were undelivered and would not be linked to fetal death or live birth certificates, and then other forms of notification like newspaper clippings, et cetera. We then abstract our records from the hospital of death/hospital of delivery and also the office of the chief medical examiner. We then take the cases and classify them by a category to group cases, so then we can see which ones we might need to have an outside specialist assist with the review, and this is just an example of some of the categories, suicide, homicide, substance abuse. So we’re including the traditional medical causes, but also looking outside at some of the other contributing factors.
We review the cases with MedChi’s maternal and child health committee, plus as I said, invited specialists, and this committee is tasked with determining whether the case was pregnancy-related or not, whether it was preventable or not, and also for developing recommendations. This table is a breakdown of the method of identification and what percentage of the pregnancy-associated deaths were identified. So if we look just at the death certificate cause of death and contributing factors, we would identify 20 percent of the pregnancy-associated deaths. Using the checkbox, unfortunately, it was introduced in 2001, so we don’t have a lot of data, but in 2001, we identified 28 percent of the cases using the checkbox or the questions. Using birth and fetal certificate linkage, we identify 69 percent of total cases. Using medical examiner chart review, we identify 24 percent of total cases and then the other newspaper or medical examiner telling us, we identify and additional 3 percent. In looking at the number of deaths, in 200, the deaths, the denominator that we looked at, pregnancy-associated deaths over 32 in 2000 and 43 and 2001, so a total of 75 that we then looked at. Out of those 25 deaths or 33 percent were deemed pregnancy‑related, 31 percent we could not determine pregnancy-relatedness, 35 were deemed not pregnancy-related and then there was one where we did not have the cause of death.
This slide is looking at the distribution by maternal race ethnicity, and in this, as a comparison, I just wanted to show you what the live births in 2001 looked like. So if we look at the pregnancy-related deaths, then 36 percent of them were among white non-Hispanic women, and if we look at the U.S. data from the pregnancy-related mortality report that was put out, 55 percent were among whites. The key is really to look at the black non‑Hispanic population, 48 percent of our pregnancy‑related deaths were in this population compared to 33 percent of live births. This is just distribution by age group, and again, this was just to say, okay where are our deaths occurring and is it different between the distribution in the live births versus pregnancy-related deaths in Maryland, compared pregnancy-related deaths nationally? This slide we took the age group and then looked at it by race. So if you look at pregnancy-related deaths compared to 2001 Maryland live births. We look at the age group 30 to 34, you can see that 33 percent of the pregnancy-related deaths among black non-Hispanic women occurred in this age group, where 21 percent of black non-Hispanic women in this age group give birth, and then if we look at the deaths, you can see that over 35, there’s a higher distribution among deaths compared to those giving birth. Then we looked at marital status and education among pregnancy-related deaths.
We have a higher proportion of unmarried women compared to women who gave birth in 2001, 56 compared to 21 among white non-Hispanics, 83 compared to 60 among black non-Hispanics. Then looking at educational level, unfortunately, I don’t have it for all of the breakdown, but if we looked at pregnancy-related deaths, we have 22 percent among whites less than 12 years education compared to 8 and 17 compared to 7, so there isn’t that much difference there. Then looking at gravida, I didn’t want to neglect or include the number of total pregnancies, because we have a fair number of fetal mortality in Maryland, so that’s why I put it this way, so it don’t have a comparison group, but if you look at white non-Hispanic, black non-Hispanic and the other includes a Hispanic and one Asian women, the higher gravida occurs, the gravida high plus is a higher proportion among the black non-Hispanic women compared to other women. Then looking at distribution by prenatal care initiation, there were actually no, and again compared to Maryland live births, what we want to look at is the group that had no prenatal care among pregnancy-related deaths, 22 percent among white Hispanic and 8 among black, and I want to point out that pregnancy prenatal care utilization was unknown in the majority of these cases, but if we look at the 22 and 8 compared to 2 and 6 for live births, we have a higher proportion of no prenatal care use among women who died of pregnancy-related deaths compared to live births. Then looking at pregnancy-related mortality ration, you can see the breakdown by race.
The white rate was 11.2 compared to the U.S. of 8, black 24.8 compared to 30 in the U.S. comparison and Hispanic, even though the numbers are really small, we still wanted to break it down, because this something we want to keep an eye on. This Hispanic rate was 29.4. Our total pregnancy-related mortality ratio for 2000 to 2001 in Maryland was 17.6 compared to 11.8 in the 91 to 99 for the U.S. Then we also wanted to look at the timing of pregnancy-related deaths and I didn’t have, unfortunately, the figure for the undelivered women for the U.S. comparison group, but let’s take a look at Maryland compared to the U.S., 48 percent of our cases that were pregnancy-related deaths the women that were undelivered were pregnant at the time they died. Then we 8 percent died on the day that they delivered, so within 24 hours. Then we had 32 percent within that 42 day period and then we had 12 percent beyond that 42 day time period. So this is actually important because it shows us that the enhanced surveillance definition was actually helpful because we identified more deaths. Then we also looked at pregnancy outcomes and Maryland for the pregnancy-related deaths, 48 percent were live births and 32 percent were undelivered compared to 60 percent live birth and 10 percent undelivered for the pregnancy-related deaths nationally.
We also wanted the duties of the maternal child health committee was to for each of these case determine whether they were preventable or not, and this is very difficult and impossible to compare across jurisdictions, but we looked at patient factors, provider practice issues and also institutional systems and the committee (inaudible) into that homicide/suicide and unintentional injury were all preventable deaths and then for other causes of death each case was reviewed individually. So out of the 25 pregnancy-related deaths, 16 percent were deemed preventable, 76 percent not preventable and 8 percent they could not determine whether it was preventable or not. So some of our key findings, the enhanced surveillance increased identification in pregnancy-related deaths in Maryland, cardiac disease was the leading cause of death, 44 percent of pregnancy-related deaths compared to 10 percent of deaths in 15 to 44—year-old females. Obesity was a contributor to pregnancy-related deaths. More than 75 percent of our cases were in the overweight or obese category. Racial disparity, clearly there’s racial disparity, 48 percent of pregnancy-related deaths were to African-American women compared to black non-Hispanic women compared to 33 percent of the births, women over 35 years, especially among black non-Hispanics have a disproportionate high rates of deaths compared to live births. We also want to keep an eye on possible rates among Hispanic women for maternal mortality in Maryland. We also saw a higher suicide rate, which I’ll get to in a minute. Prenatal care utilization, no prenatal care and 12 percent of pregnancy‑related deaths compared to 3.7 percent for live births.
Okay, that’s summary key findings. I want to talk very briefly. I don’t know how much time I have left. Two minutes. One of the things that we did was, we really wanted to look at a nontraditional cause of maternal death. So we looked at maternal suicides. We reviewed ten cases from 93 to 2001, three of the women were pregnant, seven of them were post partum. We had an end up discussion with the committee and with the psychiatrist consultants. We determined that maternal depression is under diagnosed and under treated and we though this was an opportunity to increase maternal and infant morbidity. We then developed a maternal depression project. So formed the maternal depression team, we identified the need to assess clinical practice, we developed a survey and distributed to OB GYN pediatric and family practice providers and we also did a separate mailing to certified nurse midwives, we identified a number of differences in practice, as well as barriers by specialty and we identified a need, we were surprised among providers for patient educational materials because we see so many different types of pamphlets out there, and there’s clearly a need for referral resources that was a major barrier for treatment.
The project is directing efforts toward compiling resources in Maryland including a referral list, developing a provider tool kit for educating diagnosing, treating or referring women with depression and then also, we’d like to do some kind of outreach educate clinitions about the prevalence and impact of maternal depression, and these are the acknowledgments and MedChi’s maternal and child health committee, prevent a medicine resident who worked on the case reviews, *Sieta *Udene, MCH committee member *Cara *Krualege who did a lot work with us at the center for maternal and child health, Dr. *Moing-Edwards and Diana Chang and then at the Maryland vital statistics administration, Isabel *Horay. Thank you.