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Feldman JM, Bassett MT. Monitoring Deaths in Police Custody: Public Health Can and Must Do Better. Am J Public Health 2021; 111:S69-S72. [PMID: 34314217 PMCID: PMC8495641 DOI: 10.2105/ajph.2021.306213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Justin M Feldman
- Justin M. Feldman and Mary T. Bassett are with the Harvard FXB Center for Health and Human Rights, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Mary T Bassett
- Justin M. Feldman and Mary T. Bassett are with the Harvard FXB Center for Health and Human Rights, Harvard T. H. Chan School of Public Health, Boston, MA
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Naik SS, Mohakud NK, Mishra A, Das M. Quality Assessment of Maternal Death Review: A Pilot Study in 10 High Priority Districts of Odisha State, India. Indian J Community Med 2020; 45:184-188. [PMID: 32905101 PMCID: PMC7467187 DOI: 10.4103/ijcm.ijcm_321_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Maternal death review (MDR) is a strategy that helps in identifying gaps in the care of a pregnant mother. OBJECTIVES The objective is to assess the quality of MDR, causes of maternal mortality, and finding corrective action in 10 high-priority districts of Odisha. MATERIALS AND METHODS MDR was undertaken by our team in 4-month timeline (August to November 2014). It included the development of tools, desk reviews, training of staffs, and data handling. The maternal deaths were estimated from the Annual Health Survey. It was compared to estimated maternal death of each district to get the under reporting/over reporting districts. A report was generated on MDR process indicators and program indicators after completion of the assessment. RESULTS Only 129 (52%) of the 247 deaths found suitable for community-based MDR. The proportion of maternal death reported versus estimated was 247 versus 367. Correct diagnoses were reported in 120 cases. The classification of deaths was not mentioned in 74 cases. Maximum deaths (55%) were in 18-25 years of age group (the most common cause being anemia). Majority (50%) of the deaths occurred during the postnatal period and majority (67%) at the health facility. Only 61 (47%) had received antenatal check-ups. Facility-based MDR showed, Type 1 delay (denotes about seeking care) being the most common (53%). Inaccurate and incomplete information available was also found to compound the above problems in addition. CONCLUSIONS The present study could contribute to a larger extent to address some of the gaps in the MDR process in the Odisha state.
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Affiliation(s)
- Sushree Samiksha Naik
- Department of Obstetrics and Gynecology, AIIMS, KIIT Deemed University, Bhubaneswar, Odisha, India
| | - Nirmal Kumar Mohakud
- Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India
| | - Abhipsa Mishra
- Department of Obstetrics and Gynecology, Kalinga Institute of Medical Sciences, KIIT Deemed University, Bhubaneswar, Odisha, India
| | - Mirabai Das
- Department of Medical, Kalinga Institute of Social Sciences, Bhubaneswar, Odisha, India
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Screening for Postpartum Depression by Hospital-Based Perinatal Nurses. MCN Am J Matern Child Nurs 2018; 43:324-329. [DOI: 10.1097/nmc.0000000000000470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Haas E, Truong C, Bartolomei-Hill L, Baier M, Bazron B, Rebbert-Franklin K. Local Overdose Fatality Review Team Recommendations for Overdose Death Prevention. Health Promot Pract 2018; 20:553-564. [DOI: 10.1177/1524839918797617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Erin Haas
- Maryland Department of Health, Catonsville, MD, USA
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Austin AE, Vladutiu CJ, Jones-Vessey KA, Norwood TS, Proescholdbell SK, Menard MK. Improved Ascertainment of Pregnancy-Associated Suicides and Homicides in North Carolina. Am J Prev Med 2016; 51:S234-S240. [PMID: 27745612 PMCID: PMC6863046 DOI: 10.1016/j.amepre.2016.04.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Injuries, including those resulting from violence, are a leading cause of death during pregnancy and the postpartum period. North Carolina, along with other states, has implemented surveillance systems to improve reporting of maternal deaths, but their ability to capture violent deaths is unknown. The purpose of this study was to quantify the improvement in ascertainment of pregnancy-associated suicides and homicides by linking data from the North Carolina Violent Death Reporting System (NC-VDRS) to traditional maternal mortality surveillance files. METHODS Enhanced case ascertainment was used to identify suicides and homicides that occurred during or up to 1 year after pregnancy from 2005 to 2011 in North Carolina. NC-VDRS data were linked to traditional maternal mortality surveillance files (i.e., death certificates with any mention of pregnancy or matched to a live birth or fetal death record and hospital discharge records for women who died in the hospital with a pregnancy-related diagnosis). Mortality ratios were calculated by case ascertainment method. Analyses were conducted in 2015. RESULTS A total of 29 suicides and 55 homicides were identified among pregnant and postpartum women through enhanced case ascertainment as compared with 20 and 34, respectively, from traditional case ascertainment. Linkage to NC-VDRS captured 55.6% more pregnancy-associated violent deaths than traditional surveillance alone, resulting in higher mortality ratios for suicide (2.3 vs 3.3 deaths per 100,000 live births) and homicide (3.9 vs 6.2 deaths per 100,000 live births). CONCLUSIONS Linking traditional maternal mortality files to NC-VDRS provided a notable improvement in ascertainment of pregnancy-associated violent deaths.
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Affiliation(s)
- Anna E Austin
- Centers for Disease Control and Prevention/CSTE Applied Epidemiology Fellowship, Atlanta, Georgia; North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch, Division of Public Health, Raleigh, North Carolina
| | - Catherine J Vladutiu
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland.
| | - Kathleen A Jones-Vessey
- North Carolina State Center for Health Statistics, Division of Public Health, Raleigh, North Carolina
| | - Tammy S Norwood
- North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch, Division of Public Health, Raleigh, North Carolina
| | - Scott K Proescholdbell
- North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch, Division of Public Health, Raleigh, North Carolina
| | - M Kathryn Menard
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Development of a Tool to Measure Nurse Clinical Judgment During Maternal Mortality Case Review. J Obstet Gynecol Neonatal Nurs 2016; 45:870-877. [DOI: 10.1016/j.jogn.2016.03.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 11/18/2022] Open
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Kleppel L, Suplee PD, Stuebe AM, Bingham D. National Initiatives to Improve Systems for Postpartum Care. Matern Child Health J 2016; 20:66-70. [DOI: 10.1007/s10995-016-2171-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Community based maternal death review: lessons learned from ten districts in Andhra Pradesh, India. Matern Child Health J 2016; 19:1447-54. [PMID: 25636651 DOI: 10.1007/s10995-015-1678-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Maternal death is as much a social phenomenon as a medical event. Maternal death review (MDR), a strategy for monitoring maternal deaths, provides information on medical, social and health system factors that should be addressed to redress gaps in service provision or utilisation. To strengthen MDR implementation in the state of Andhra Pradesh, India. The project involved development of state specific guidelines, technical assistance in operationalization and analysing processes and findings of MDR in ten districts. 284 deaths were recorded over 6 months (April-September 2012) of which 193 (75.4 %) could be reviewed. Post-partum haemorrhage (24 %) and hypertensive disorders (27.4 %) followed by puerperal sepsis in the post-partum period (16.8 %) were the leading causes of maternal deaths. 68.3 % deaths occurred at health facilities. 67 % of mothers dying during the natal or post-natal period, delivered at home, though the death occurred in a health facility. Type 1 delay (58.9 %) was the most common underlying cause of death, followed by type 3 delay (33.3 %). Under or nil reporting from the facilities was observed. Program staff could identify broad areas of intervention but lacked capacity to monitor, analyse, interpret and utilize the generated information to develop feasible actionable plans. Information gathered was incomplete and inaccurate in many cases. Challenges observed showed that it will require more time and continuous committed efforts of health staff for implementation of high quality MDR. Successful implementation will improve the response of the health system and contribute to improved maternal health.
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Hogan MC, Saavedra-Avendano B, Darney BG, Torres-Palacios LM, Rhenals-Osorio AL, Sierra BLV, Soliz-Sánchez PN, Gakidou E, Lozano R. Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study. Bull World Health Organ 2016; 94:362-369B. [PMID: 27147766 PMCID: PMC4850531 DOI: 10.2471/blt.15.163360] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 12/02/2022] Open
Abstract
Objective To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. Methods We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. Findings A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. Conclusion The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.
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Affiliation(s)
- Margaret C Hogan
- University of Washington, Seattle, United States of America (USA)
| | - Biani Saavedra-Avendano
- National Institute of Public Health, Av. Universidad 655, Col. Santa Maria Ahucatitlan, 62100, Cuernavaca, Morelos, Mexico
| | - Blair G Darney
- National Institute of Public Health, Av. Universidad 655, Col. Santa Maria Ahucatitlan, 62100, Cuernavaca, Morelos, Mexico
| | | | | | | | | | | | - Rafael Lozano
- National Institute of Public Health, Av. Universidad 655, Col. Santa Maria Ahucatitlan, 62100, Cuernavaca, Morelos, Mexico
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Comparing Two Review Processes for Determination of Preventability of Maternal Mortality in Illinois. Matern Child Health J 2015; 19:2621-6. [DOI: 10.1007/s10995-015-1782-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
A better understanding of why women die during pregnancy, childbirth, or postpartum offers valuable insight into strategies aimed at preventing maternal deaths and arresting the progression in the severity of a complication. The rate of severe maternal morbidity and maternal mortality in the United States has been trending upward in recent years and has garnered national attention with concentration on bolstering reviews of maternal deaths and implementing patient safety initiatives. The obstetric nurse is in a unique position to improve maternal outcomes through the anticipation, recognition, and communication of the early warning signs of impending deterioration in maternal condition. Presented in the context of the conceptual model of Stephen Covey's Circle of Influence, the professional nurse can proactively influence maternal outcomes directly, with actions defined by the scope of professional nursing practice or indirectly through professional interactions with others. Advancing one's education, knowledge, and technical skills broadens the influential capacity.
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Kilpatrick SJ. Next Steps to Reduce Maternal Morbidity and Mortality in the USA. WOMENS HEALTH 2015; 11:193-9. [DOI: 10.2217/whe.14.80] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Maternal mortality is rising in the USA. The pregnancy-related maternal mortality ratio increased from 10/100,000 to 17/100,000 live births from the 1990s to 2012. A large proportion of maternal deaths are preventable. This review highlights a national approach to reduce maternal death and morbidity and discusses multiple efforts to reduce maternal morbidity, death and improve obstetric safety. These efforts include communication and collaboration between all stake holders involved in perinatal health, creation of national bundles addressing key maternal care areas such as hemorrhage management, call for all obstetric hospitals to review and analyze all cases of severe maternal morbidity, and access to contraception. Implementation of interventions based on these efforts is a national imperative to improve obstetric safety.
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Affiliation(s)
- Sarah J Kilpatrick
- Cedars-Sinai Medical Center, Department of Obstetrics & Gynecology, 8635 W 3rd Street, Suite 160–W, Los Angeles, CA 90048, USA, Tel.: +1 310 423 7433, Fax: +1 310 423 3470,
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Geller SE, Koch AR, Martin NJ, Rosenberg D, Bigger HR. Assessing preventability of maternal mortality in Illinois: 2002-2012. Am J Obstet Gynecol 2014; 211:698.e1-11. [PMID: 24956547 DOI: 10.1016/j.ajog.2014.06.046] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/05/2014] [Accepted: 06/19/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to describe the potential preventability of pregnancy-related deaths in Illinois from 2002 through 2012 as determined by perinatal centers following the Illinois maternal death review process. STUDY DESIGN We conducted a retrospective review of all known maternal deaths in the state from 2002 through 2012 with complete records in the Illinois Department of Public Health's Maternal Mortality Review Form database. The association between causes of death and potential preventability was analyzed for pregnancy-related deaths. RESULTS There were 610 maternal deaths in Illinois during the study period (31.8 per 100,000 live births). One-third of maternal deaths (n = 210) were directly or indirectly related to pregnancy, 7.0% (n = 43) were possibly related, and 52.6% (n = 321) were unrelated. Vascular causes were the most common cause of pregnancy-related death, followed by cardiac causes and hemorrhage. One-third of deaths directly or indirectly related to pregnancy were deemed potentially preventable. Hemorrhage and deaths due to psychiatric causes were most likely to be considered avoidable, while cancer and vascular-related deaths were generally not considered preventable. CONCLUSION This analysis of pregnancy-related deaths in Illinois, the first in >60 years, found similar causes of death and potential preventability as pregnancy-related death reviews in other states. Analyzing the causes of pregnancy-related death is a critical and necessary step in improving maternal health outcomes, particularly in decreasing potentially preventable pregnancy-related deaths. Greater attention should be directed toward intervening on the provider, systems, and patient factors contributing to preventable deaths.
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Gil MM, Gomes-Sponholz FA. Declarações de óbitos de mulheres em idade fértil: busca por óbitos maternos. Rev Bras Enferm 2013; 66:333-7. [DOI: 10.1590/s0034-71672013000300005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/21/2013] [Indexed: 11/21/2022] Open
Abstract
No Brasil, há deficiência de registros completos na Declaração de Óbito, sendo questionada a confiabilidade, especialmente das causas relacionadas ao ciclo grávido-puerperal. Investigamos, em Declarações de Óbito de mulheres em idade fértil, o preenchimento dos campos que permitem identificar óbitos maternos. Pesquisa documental, conduzida a partir de prontuários hospitalares. Analisamos mortes maternas declaradas, não maternas, inconclusivas e mortes presumíveis. Para análise das causas básicas de morte utilizamos a Lista de Tabulação de Mortalidade da CID - BR-10. Das 301 declarações de óbito analisadas, 60% apresentaram os campos 43/44 preenchidos, e 40% apresentaram estes campos em branco e/ou ignorados. Encontramos 58,5% de mortes não maternas, 2% de mortes maternas declaradas e 39,5% mortes inconclusivas. A análise das mortes inconclusivas permitiu-nos classificar 4,3% como mortes presumíveis. Para sanar as incompletudes dos registros civis, é necessário o empenho de todos os profissionais de saúde para que a fidedignidade das informações seja uma meta atingida.
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