Pregnancy-related mortality among women aged 35 years and older, United States, 1991-1997

Exploring ethnic minority women's experiences of maternity care during the SARS-CoV-2 pandemic: a qualitative study

OBJECTIVE

To explore the experiences of pregnancy, childbirth, antenatal and postnatal care in women belonging to ethnic minorities and to identify any specific challenges that these women faced during the SARS-CoV-2 pandemic.

DESIGN

This was a qualitative study using semistructured interviews of pregnant women or those who were 6 weeks postnatal from Black, Asian and minority ethnic backgrounds. The study included 16 women in a predominantly urban Scottish health board area.

RESULTS

The finding are presented in four themes: 'communication', 'interactions with healthcare professionals', 'racism' and 'the pandemic effect'. Each theme had relevant subthemes. 'Communication' encompassed respect, accent bias, language barrier and cultural dissonance; 'interactions with healthcare professionals': continuity of care, empathy, informed decision making and dissonance with other healthcare systems; 'racism' was deemed to be institutional, interpersonal or internalised; and 'the pandemic effect' consisted of isolation, psychological impact and barriers to access of care.

CONCLUSIONS

This study provides insight into the specific challenges faced by ethnic minority women in pregnancy, which intersect with the unique problems posed by the ongoing SARS-CoV-2 pandemic to potentially widen existing ethnic disparities in maternal outcomes and experiences of maternity care.

Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age

Although the influence of advanced maternal age (AMA) and delayed childbearing on adverse maternal and perinatal outcomes has been studied extensively, no universal consensus on the definition of AMA exists. This terminology currently refers to the later years of a woman's reproductive life span and generally applies to women age ≥35 years. AMA increases the risk of pregnancy complications, including ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, placenta previa and abruption, gestational diabetes, preeclampsia, and cesarean delivery. Such complications could be the cause of preterm birth and increase the risk of perinatal mortality. For women who have a chronic illness, pregnancy may lead to additional risk that demands increased monitoring or surveillance. The management of pregnant women of AMA requires understanding the relationship between age and preexisting comorbidities. The outcomes from pregnancy in AMA may have a negative impact on women's health as they age because of both the changes from the pregnancy itself and the increased risk of pregnancy-related complications. Postpartum depression affects women of AMA at higher rates. Links between preeclampsia and the risk of future development of cardiovascular disease require follow-up surveillance. The association between hypertensive pregnancy disorders and cognitive and brain functions needs further investigation of sex-specific risk factors across the life span. Educating providers and women of AMA is crucial to facilitate clinical decision making and such education should consider cultural influences, risk perception, and women's health literacy, as well as providers' biases and system issues.

Pregnancy-Related Deaths, Florida, 1999-2012: Opportunities to Improve Maternal Outcomes

Objectives To examine pregnancy-related deaths (PRDs) in Florida, to identify quality improvement (QI) opportunities, and to recommend strategies aimed at reducing maternal mortality. Methods The Florida Pregnancy-Associated Mortality Review (PAMR) Committee reviewed PRDs occurring between 1999 and 2012. The PAMR Committee determined causes of PRDs, identified contributing factors, and generated recommendations for prevention and quality improvement. Information from the PAMR data registry, and live births from Florida vital statistic data were used to calculate pregnancy-related mortality ratios (PRMR) and PRD univariate risk ratios (RR) with 95% confidence intervals (CI). Results Between 1999 and 2012, the PRMR fluctuated between 14.7 and 26.2 PRDs per 100,000 live births. The five leading causes of PRD were hypertensive disorders (15.5%), hemorrhage (15.2%), infection (12.7%), cardiomyopathy (11.1%), and thrombotic embolism (10.2%), which accounted for 65% of PRDs. Principal contributing factors were morbid obesity (RR = 7.0, 95% CI 4.9-10.0) and late/no prenatal care (RR = 4.2, 95% CI 3.1-5.6). The PRMR for black women was three-fold higher (RR = 3.3, 95% CI 2.7-4.0) than white women. Among the five leading causes of PRDs, 42.5% had at least one clinical care or health care system QI opportunity. Two-third of these were associated with clinical quality of care, which included standards of care, coordination, collaboration, and communication. The QI opportunities varied by PRD cause, but not by race/ethnicity. Conclusion Gaps in clinical care or health care systems were assessed as the primary factors in over 40% of PRDs leading the PAMR Committee to generate QI recommendations for clinical care and health care systems.

Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978-2012

BACKGROUND

Maternal mortality ratios (MMR) appear to have increased in the United States over the last decade. Three potential contributing factors are (1) a shifting maternal age distribution, (2) changes in age-specific MMR, and (3) the addition of a checkbox indicating recent pregnancy on the death certificate.

OBJECTIVE

To determine the contribution of increasing maternal age on changes in MMR from 1978 to 2012 and estimate the contribution of the pregnancy checkbox on increases in MMR over the last decade.

STUDY DESIGN

Kitagawa decomposition analyses were conducted to partition the maternal age contribution to the MMR increase into 2 components: changes due to a shifting maternal age distribution and changes due to greater age-specific mortality ratios. We used National Vital Statistics System natality and mortality data. The following 5-year groupings were used: 1978-1982, 1988-1992, 1998-2002, and 2008-2012. Changes in age-specific MMRs among states that adopted the standard pregnancy checkbox onto their death certificate before 2008 (n = 23) were compared with states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (n = 11) to estimate the percentage increase in the MMR due to the pregnancy checkbox.

RESULTS

Overall US MMRs for 1978-1982, 1988-1992, and 1998-2002 were 9.0, 8.1, and 9.1 deaths per 100,000 live births, respectively. There was a modest increase in the MMR between 1998-2002 and 2008-2012 in the 11 states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (8.6 and 9.9 deaths per 100,000, respectively). However, the MMR more than doubled between 1998-2002 and 2008-2012 in the 23 states that adopted the standard pregnancy checkbox (9.0-22.4); this dramatic increase was almost entirely attributable to increases in age-specific MMRs (94.9%) as opposed to increases in maternal age (5.1%), with an estimated 90% of the observed change reflecting the change in maternal death identification rather than a real change in age-specific rates alone. Of all age categories, women ages 40 and older in states that adopted the standard pregnancy checkbox had the largest increase in MMR-from 31.9 to 200.5-a relative increase of 528%, which accounted for nearly one third of the overall increase. An estimated 28.8% of the observed change was potentially due to maternal death misclassification among women ≥40 years.

CONCLUSION

Increasing age-specific maternal mortality seems to be contributing more heavily than a changing maternal age distribution to recent increases in MMR. In states with the standard pregnancy checkbox, the vast majority of the observed change in MMR over the last decade was estimated to be due to the pregnancy checkbox, with the greatest change in MMR occurring in women ages ≥40 years. The addition of a pregnancy checkbox on state death certificates appears to be increasing case identification but also may be leading to maternal death misclassification, particularly for women ages ≥40 years.

The intergenerational effects on birth weight and its relations to maternal conditions, São Paulo, Brazil

Background and Objectives. Parents' birth weight acts as a predictor for the descendant birth weight, with the correlation more strongly transmitted through maternal line. The present research aims to study the correlation between the child's low or increased birth weight, the mother's birth weight, and maternal conditions. Methods. 773 mother-infant binomials were identified with information on both the baby's and the mother's birth weight recorded. Group studies were constituted, dividing the sample according to birth weight (<2,500 grams (g) and ≥3,500 grams (g)). The length at birth was also studied in children ≤47.5 cm (lower quartile). Chi² test or Fisher's exact test, Spearman's Rho, and odds ratio were performed in order to investigate the relation between the children's weight and length at birth and the mothers' and children's variables. Results. The girls were heavier at birth than their mothers, with an average increase at birth weight between the generations of 79 g. The child's birth weight <2,500 g did not show any correlation with maternal birth weight <2,500 g (Fisher 0.264; Spearman's Rho 0.048; OR 2.1 and OR lower 0.7) or with maternal stature below the lower quartile (<157 cm) (Chi² sig 0.323; with Spearman's Rho 0.036; OR 1.5 and OR lower 0.7). The child's low birth weight (<2,500 g) was lightly correlated with drug use by the mother during pregnancy (Fisher 0.083; Spearman's Rho 0.080; OR 4.9 and OR lower 1.0). The child's birth weight <2,500 g showed increased correlation with gestational age lower than 38 weeks and 3 days (Chi² sig 0.002; Spearman's Rho 0.113; OR 3.2 and OR lower 1.5). The child's weight at birth ≥3,500 g showed strong correlation with maternal weight at birth ≥3,500 g (Chi² sig 0; Spearman's Rho +0.142; OR 0.5 and OR upper 0.7). It was also revealed that the higher the maternal prepregnancy BMI, the stronger the correlation with child's birth weight ≥3,500 g ((maternal prepregnancy BMI > 25.0 with Chi² sig 0.013; Spearman's Rho 0.09; OR 1.54 and OR upper 2.17) and (maternal prepregnancy BMI > 30.0 with Chi² sig 0 Spearman's Rho 0.137; OR 2.58 and OR upper 4.26)). The child's length at birth in the lower quartile (≤47.5 cm) showed strong correlation with drug use by the mother during pregnancy (Chi² sig 0.004; Spearman's Rho 0.105; OR 4.3 and OR lower 1.5). Conclusions. The mother's increased weight at birth and the prenatal overweight or obesity were correlated with increased weight and length at birth of the newborn, coupled with the tendency of increasing birth weight between generations of mothers and daughters. Also, descendants with smaller length at birth are the children of women with the lowest statures.

Has there been a change in peripartal maternal mortality in a tertiary care obstetric European center over the last five decades?

OBJECTIVE

Maternal mortality still remains a significant problem in obstetrics worldwide. Unchanged or even rising maternal mortality has been reported in several countries. The present study analyzed whether the pattern of maternal mortality has changed over the last five decades at the Department of Obstetrics and Gynecology of the Medical University of Graz.

STUDY DESIGN

Starting in 1981, a registry of maternal deaths was established and regularly updated at our institution based on retrospective data. Between 1963 and 2012, a total of 187,917 women delivered. Thirty-five consecutive maternal deaths were observed and subdivided into 10 year cohorts.

METHODS

The registry of maternal deaths included deliveries after 28+0 weeks of gestation. Puerperal deaths were defined as deaths up to day 42 post partum.

MAIN OUTCOME MEASURES

Clinical data from maternal deaths were extracted from hospital records and autopsy reports.

RESULTS

Maternal mortality rates declined from 35.0, 29.0, 2.4, 13.1 to 3.6 per 100,000 deliveries in the five subsequent periods, respectively. Sixty-six percent of women who died were 30 years or older. The cesarean section rate was 49%. Ninety-one percent of the 35 maternal deaths occurred in women with no significant medical history or risk factors. Seventy-five percent of deaths occurred after the 37+0 weeks of gestation. During all study periods, the prevalence of infections and hemorrhage was highest. The main causes of bleeding were uterine rupture and placental abruption, respectively.

CONCLUSION

Even nowadays, peripartal maternal deaths occur mainly due to infections and hemorrhage and also in women with no significant medical history.

Contemporary and historical evidence to suggest that women's preference for age at birth of first child remains consistent across time

Women's ability to reproduce is restricted by menarche and menopause. First children are, however, not typically born until some years after the onset of puberty. Other factors therefore contribute towards this delay. In this context, women's hips do not reach full adult form until they are in their mid-20s. Therefore, physiological and morphological factors appear to determine an optimum age-range for reproduction. The following studies were conducted in order to investigate this hypothesis. Study 1 asked nulliparous women questions about ages at which particular life events related to reproduction should ideally occur. This revealed their preferred age at birth of first child to be approximately 27 years old. Study 2 replicated these findings and further showed that women with children actually had their first child at a very similar age (27.93 [±0.79]). Findings from Study 3 were also remarkably consistent (28.15 [±0.39]). Study 4 examined the 1901 U.K. Census record and incorporated an analysis of the influence of wealth. Middle class women were on average 24.88 (±0.22) years old at the birth of their first child. Poor women were on average 23.50 (±0.20) years old. These figures at least approximate to findings from Studies 1-3, which is noteworthy given that modern contraceptive methods were not widely available at the time. It is concluded that female strategies to delay giving birth to their first child until they are of an age that approaches or coincides with their full hip maturation are enduring across time.

Popular contraceptive methods in women aged 35 years and older attending health centers of 4 cities in khuzestan province, iran

Background

The prevalence of unintended pregnancy and associated risks are higher in late reproductive years. Limited studies have focused on contraceptive choices in these women. The aim of the study was to identify contraceptive choices and their related factors in women 35 years or older attending health centers of Khuzestan province.

Objectives

Additionally, several line of evidence indicated relationship between increasing maternal age and poor pregnancy outcomes (1, 2). Pregnancies above the age of 35 are accompanied with more risks for complication related to pregnancy as compared to younger women (3-5). Risk of spontaneous abortion is 74.4% in mothers aged 45 years or more.

Patients and Methods

In a cross-sectional study 1584 women aged 35 years and older attending public health centers of four cities of Khuzestan were studied. We used an interviewer-administered questionnaire for data collection. Women investigators were recruited for interview and filling the questionnaire. Participants were assured of the confidentiality of their responses.

Results

The mean age of women was 39.8 ± 4.2 years. The most popular contraceptive methods used in this age group were oral contraceptive pills (31.4%), condom (28.1%), and tubal ligation (14.8%). Less effective contraceptive methods were used in 41.5% of women. Significant associations were found between the use of effective methods and literacy of husband (OR = 0.80, 95% CI: 0.75, 0.91), city of residence (OR = 0, 92, 95%CI: 0.87-0.97), women age (OR = 0.97, 95% CI; 0.94-0.99), and women education (OR = 0.87, 95%CI: 0.76-0.99) (P < 0.01).

Conclusions

In spite of risk of pregnancy and unintended pregnancy in this age group, about a half of them used less effective contraceptive methods, hence family planning education, and counseling to older women should be a priority in health centers.

Overview of maternal mortality in the United States

Although dramatic improvements in pregnancy care and in general population health facilitated a dramatic decline in maternal mortality in the United States during the 20th century, women still die from complications of pregnancy. Moreover, rates appear to have increased during the early 21st century. This overview will provide context for understanding the problem of maternal mortality in the United States by outlining how maternal mortality rates are reported from National Vital Statistics data, and how pregnancy-related mortality ratios are reported from a national surveillance system. Trends and patterns in these deaths as well as emerging issues concerning causes of maternal deaths and the difficulty with interpreting trend data will be discussed.

Understanding regional differences in maternal mortality: a national case-control study in France

OBJECTIVES

To assess the risk of postpartum maternal death associated with region, and to examine whether the quality of care received by the women who died differed by region.

DESIGN

A national case-control study.

SETTING

France.

POPULATION

Selected from recent nationwide surveys, 328 postpartum maternal deaths from 2001 through 2006 as cases; and a representative sample (n = 14 878) of women who gave birth in 2003 as controls.

METHODS

Crude and adjusted odds ratios (aOR) of maternal death associated with region were calculated with logistic regression, and the quality of care for women who died was compared according to region with chi-square tests or Fisher's exact tests.

MAIN OUTCOME MEASURES

Risk of postpartum maternal death associated with region, and quality of care.

RESULTS

After adjustment for maternal age and nationality, the risk of maternal death was higher in the Ile-de-France region (aOR 1.6, 95% CI 1.2-2.0) and the overseas districts (aOR 3.5, 95% CI 2.4-5.0) than in the group for the rest of continental France. In both regions, the excess risk of death from haemorrhage, amniotic fluid embolism and hypertensive disorders was significant. In continental France, after further controlling for women's obstetric characteristics, the risk of maternal death in Ile-de-France remained higher (aOR 1.8. 95% CI 1.3-2.6). The women in the cases groups received suboptimal care more frequently in Ile-de-France than in the other continental regions (64% versus 43%, P = 0.01).

CONCLUSIONS

These results suggest that quality of care and organisation of health services may play a role in the differential risk of maternal mortality between regions in France. Research on severe maternal morbidity and its determinants is needed to clarify the mechanisms involved.

Assisted reproductive technologies: medical safety issues in the older woman

Abstract Previous study has shown that in the United States, most maternal deaths and severe obstetric complications due to chronic disease are potentially preventable through improved medical care before conception. Many women who need assisted reproductive technology (ART) because of infertility are older than the average pregnant woman. Risks for such chronic diseases as obesity, diabetes mellitus, chronic hypertension, cardiovascular disease (CVD), and malignancy greatly increase with maternal age. Chronic illness increases the risk of the in vitro fertilization (IVF) procedure and is also associated with increased obstetric risk and even death. The objective of this review is to outline the potential risks for older women who undergo ART procedures and pregnancy and to characterize guidelines for evaluation before enrollment in ART programs. A PubMed search revealed that very few studies have related to pre-ART medical evaluation. Therefore, we suggest a pre-ART medical assessment, comparable to the recommendations of the American Heart Association before noncompetitive physical activity and the American Society of Anesthesiologists before elective surgery. This assessment should include a thorough medical questionnaire and medical examination. Further evaluation and treatment should follow to ensure the safety of ART procedures and of ensuing pregnancies.

Contraceptive methods and use by women aged 35 and over: A qualitative study of perspectives

BACKGROUND

More than 30% of the pregnancies in women aged 35 and over are unintended. This paper compares perceptions about contraceptive methods and use among women with and without an unintended pregnancy after turning age 35.

METHODS

Semi-structured, in-depth interviews were conducted with 17 women. They were all 35 to 49 years old, regularly menstruating, sexually active, not sterilized, not desiring a pregnancy in the near future, and at least 3 months postpartum. We purposely sampled for women who had had at least one unintended pregnancy after age 35 (n = 9) and women who did not (n = 8). We assessed partnership, views of pregnancy and motherhood, desired lifestyle, perceived advantages and disadvantages of using and obtaining currently available well-known reversible contraceptives in the U.S. ''We also assessed contraceptive methods used at any time during their reproductive years, including current method use and, if appropriate, circumstances surrounding an unintended pregnancy after age 35.'' Each interview was taped and transcribed verbatim. Data were analyzed using Grounded Theory. Analysis focused on partnership, views of pregnancy, motherhood, desired lifestyle and perceived advantages and disadvantages of various reversible contraceptive methods.

RESULTS

The women without an unintended pregnancy after age 35 were more likely to (1) use contraceptive methods that helped treat a medical condition, (2) consider pregnancy as dangerous, or (3) express concerns about the responsibilities of motherhood. The women who experienced an unintended pregnancy after age 35 were more likely to (1) report unstable partnerships, (2) perceive themselves at lower risk of pregnancy, or (3) report past experiences with unwanted contraceptive side effects. There was a greater likelihood a woman would choose a contraceptive method if it was perceived as easy to use, accessible, affordable and had minimal side effects.

CONCLUSIONS

Women's perspective on contraceptive use after age 35 varies. Public health messages and health providers' care can help women in this age group by reviewing their fertility risks, as well as all contraceptive methods and their associated side effects. The impact of such interventions on unintended pregnancy rates in this age group should be tested in other areas of evidence-based medicine.

Nicotine and cotinine affect the release of vasoactive factors by trophoblast cells and human umbilical vein endothelial cells

OBJECTIVE

To examine nicotine (N) and cotinine (C) effects on trophoblast cells (TCs) and human umbilical vein endothelial cells (HUVEC) secretion of soluble fms-like tyrosine kinase (sFlt-1), soluble endoglin (sENG), placental growth factor (PlGF), transforming growth factor-beta (TGF-beta) and vascular endothelial growth factor (VEGF).

STUDY DESIGN

Human placentas and umbilical cords were collected from uncomplicated pregnancies at term from a total of 24 non-smoking women with a history of normal blood pressure. TCs and HUVEC were cultured for 24 h with C or N (from 10(-12) to 10(-7) M).

MAIN OUTCOME MEASURES

sFlt-1, sENG, PlGF, TGF-beta and VEGF release and messenger RNA (mRNA) expression were evaluated by ELISA and real-time polymerase chain reaction (PCR), respectively.

RESULTS

N and C reduced sFlt-1, sENG and PlGF release by TCs and TGF-beta release by HUVEC. Conversely, N and C increased PlGF secretion, while N alone increased sFlt-1 release by HUVEC. N and C were able to modulate VEGF mRNA expression in HUVEC.

CONCLUSIONS

Our results suggest that N and C affect the balance of some important vasoactive factors released by TCs and HUVEC. This might be one of the possible mechanism through which smoke reduces the risk of hypertensive disorders during pregnancy as well as contributes to the well known detrimental effects of smoking on fetal development.

A perspective on CDC's efforts in safe motherhood: 2001 to the present

This article reviews selected activities to promote Safe Motherhood through scientific and programmatic activities conducted by CDC's Division of Reproductive Health.

Severe obstetric maternal morbidity: a 15-year population-based study

Using a provincial perinatal database for 15 years, 1988-2002. Cases were identified with one or more of the following markers of severe maternal morbidity: blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia, intensive care (ICU) admission. There were 159,896 mothers delivered of whom 313 (2.0/1000) had 385 markers of severe morbidity (257 had one, 42 had two, 12 had three, and two had four). The following rates of morbidity were recorded: blood transfusion > or = 5 units 119 (0.74/1000); emergency hysterectomy 88 (0.55/1000); uterine rupture 49 (0.31/1000); eclampsia 46 (0.28/1000); ICU 83 (0.52/1000). There was a statistically significant association between multiparity > or = 1, and emergency hysterectomy and uterine rupture; between age > or = 35 years, and emergency hysterectomy, uterine rupture and ICU; and between caesarean delivery and blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia and ICU. The main contributing obstetric complications were haemorrhage (64.7%) and complications of hypertensive disorders (16.8%).

Epidemiology of obstetric critical care

In the last 20 years, in developed countries, maternal mortality rates have fallen such that analysis of cases of severe maternal morbidity is necessary to provide sufficient numbers to give a clinically relevant assessment of the standard of maternal care. Different approaches to the audit of severe maternal morbidity exist, and include need for intensive care, organ system dysfunction and clinically defined morbidities. In both developed and developing countries, the dominant causes of severe morbidity are obstetric haemorrhage and hypertensive disorders. In some low-resource regions, obstructed labour and sepsis remain significant causes of severe maternal morbidity. The death to severe morbidity ratio may reflect the standard of maternal care. Audits of severe maternal morbidity should be complementary to maternal mortality reviews.

Maternal mortality in the United States

Despite a significant improvement in the US maternal mortality ratio since the early 1900s, it still represents a substantial and frustrating burden, particularly given the fact that - essentially - no progress has been made in most US States since 1982. Additionally, the US Centers for Disease Control and Prevention has stated that most cases are probably preventable. Two disheartening issues within this topic include a gross underestimation of the magnitude of maternal mortality - particularly before 1987, but which likely persists to a lesser degree today - and the continued significant racial disparity in maternal mortality. Explanations for the plateau in maternal mortality include the recent trend of delayed childbearing, with the potential accompanying complications associated with older reproductive age (particularly over 35 years) and multiparity. The impressive increase in multifetal pregnancies related to delayed childbearing and assisted reproductive technology also plays a role. Finally, peripartum cardiomyopathy has become an increasingly recognized source of maternal mortality. Pregnancy-related mortality is largely accounted for by thromboembolic disease, hemorrhage, hypertension and its associated complications, and infection. However, since the inclusion of maternal deaths occurring after 42 days post-delivery as pregnancy related, traumatic injuries - including homicides and suicides - are an alarming source of maternal mortality. An especially important contemporary issue to consider within this topic is cesarean delivery "on maternal request", opponents of which cite concerns not only for immediate morbidity and mortality increased over that associated with a vaginal birth, but also for potential morbidity and mortality associated with future pregnancies. One particularly appealing opportunity to reduce maternal mortality is to recognize, examine, and learn from so-called "near-miss" cases.

Maternal chronological age, prenatal and perinatal history, social support, and parenting of infants

The role of maternal chronological age in prenatal and perinatal history, social support, and parenting practices of new mothers (N=335) was examined. Primiparas of 5-month-old infants ranged in age from 13 to 42 years. Age effects were zero, linear, and nonlinear. Nonlinear age effects were significantly associated up to a certain age with little or no association afterward; by spline regression, estimated points at which the slope of the regression line changed were 25 years for prenatal and perinatal history, 31 years for social supports, and 27 years for parenting practices. Given the expanding age range of first-time parents, these findings underscore the importance of incorporating maternal age as a factor in studies of parenting and child development.

Disparities in Mortality Among High Risk Pregnant Women in Illinois: A Population Based Study

PURPOSE

Researchers are increasingly studying maternal mortality in the context of maternal morbidity in order to identify risk and protective factors operating at each point along the morbidity-mortality continuum. This study examined factors associated with mortality in pregnant women with severe morbidity. In particular, the Black-White disparity was examined.

METHODS

Illinois vital records data were linked to identify maternal deaths and other pregnant women with severe morbidity. Pregnancy-related deaths and high risk survivors were compared and case fatality rates were computed. Condition-specific and multivariable analyses were conducted, and time of death was examined.

RESULTS

The overall risk of maternal death was 37.1 per 10,000 high risk pregnant women in Illinois from 1994 to 1998. Women who were older, African American, unmarried, or living in Chicago were at elevated risk of death. The adjusted relative risk for the Black-White disparity was 3.7 among all high risk pregnant women and 8.5 among women with hypertensive disorders. A greater proportion of African American and Hispanic women died within 7 days of delivery compared to White women.

CONCLUSIONS

Medical risk status alone cannot explain disparities in maternal mortality. The Black-White disparity for risk of death persisted in both overall and condition-specific analyses.

Pulmonary embolism during and after pregnancy

BACKGROUND

Venous thromboembolic disease is among the most common causes of morbidity and mortality during pregnancy. The clinical evaluation alone is insufficient for the diagnosis of venous thromboembolic disease, and the normal pregnant state makes this evaluation even more challenging.

DIAGNOSIS

Objective testing is the mainstay of diagnosis, including compression ultrasound, impedance plethysmography, ventilation-perfusion scanning, computed tomography scanning, and pulmonary angiography. All of these tests can be safety performed during pregnancy.

TREATMENT

If deep vein thrombosis or pulmonary embolism is diagnosed, anticoagulation should be initiated. Either (unfractionated) heparin or low molecular weight heparin is an acceptable treatment for acute venous thromboembolic disease. Both have risks and benefits, but both can be used safely during pregnancy. Intravenous heparin is the treatment of choice surrounding delivery due to its short half life. Because of the risk of adverse effects on the fetus, warfarin is not generally used during pregnancy. Unstable pulmonary embolism is difficult to treat during pregnancy, as there are minimal data regarding the safety and efficacy of thrombolytic therapy, inferior vena cava filters, and embolectomy during pregnancy. Case reports and case series suggest that thrombolytic therapy may be associated with lower risks of fetal loss than embolectomy.

CONCLUSIONS

Venous thromboembolic disease is a significant cause of morbidity and mortality during pregnancy and the puerperal period. Objective testing is critical to establish the diagnosis and can be safely performed during pregnancy. Anticoagulation with heparin is the mainstay of therapy during the pregnancy, but patients may be transitioned to warfarin after delivery.

Preventability of pregnancy-related deaths: results of a state-wide review

OBJECTIVE

Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced.

METHODS

The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995-1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented.

RESULTS

Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women.

CONCLUSION

Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer.

Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios

OBJECTIVE

Our study's objective was to determine the relationship between state-specific maternal mortality ratios and the density of maternal-fetal medicine specialists.

STUDY DESIGN

State maternal mortality ratios from 1994 to 2001 were calculated from the Centers for Disease Control and Prevention WONDER database. Practitioner distribution data were obtained from professional associations. Demographic information regarding states was gathered from the 2000 US census data. Bivariable and multivariable analyses were conducted with the use of Spearman correlations and Poisson regression, respectively.

RESULTS

The median state maternal-mortality ratio was 7.5/100,000 live births. Our study showed that an increase of 5 maternal-fetal specialists per 10,000 live births results in a 27% reduction in the risk of maternal death (relative risk [RR] = 0.73, 95% CI = 0.58-0.93, P = 0.012). This risk reduction was based on a multivariable Poisson regression model that included the following variables and their significant interactions: state-specific percentages of mothers in poverty, mothers without a high school diploma, minority mothers, and teenage mothers.

CONCLUSION

The density of maternal-fetal medicine specialists is significantly and inversely associated with maternal mortality ratios, even after controlling for state-level measures of maternal poverty, education, race, age, and their significant interactions.

Pulmonary embolism and pregnancy

Pulmonary embolism is a significant cause of morbidity and mortality during pregnancy and the puerperium. The spectrum of venous thromboembolism is difficult to diagnose. Objective diagnostic testing is crucial and should not be delayed. Anticoagulation is the mainstay of therapy for deep vein thrombosis and pulmonary embolism. Most of the literature and practice protocols for the treatment of pregnant women are based on data extrapolated from the nonpregnant population, and more research is needed to improve the understanding of the efficacy and safety of testing and therapy in the pregnant population.