The risk of childbearing re-evaluated

Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis

OBJECTIVES

Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.

METHODS

MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.

RESULTS

Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.

CONCLUSIONS

Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

Pregnancy-associated death: a qualitative systematic review of homicide and suicide

A systematic review of the literature on maternal homicide and suicide was performed to understand the causes of pregnancy-associated death. Forty-four studies examined homicide and/or suicide and pregnancy-associated death (defined as the death of a woman, from any cause, while she is pregnant or within 1 year of termination of pregnancy) (1). Of these studies, 747 homicides and 349 suicides were identified. All studies were included except duplicate datasets, case reports of less than 3 events, suicide attempts, unpublished manuscripts, review articles, or non-English studies. Homicide is a leading cause of pregnancy-associated death and suicide is also an important cause of death among pregnant and recently pregnant women. Healthcare providers should understand that homicide is a leading cause of pregnancy-associated death, most commonly as a result of partner violence. Therefore, screening for both partner violence and suicidal ideation are essential components of comprehensive medical care for women during and after pregnancy.

Quality of registration of maternal deaths in Mozambique: a community-based study in rural and urban areas

Maternal mortality is an important indicator used to assess the level of development of a country and particularly the coverage of health services. In Africa where the maternal mortality ratios are about 100 times higher than those of developed countries the situation is even worse due to problems of underregistration. In Mozambique the figures officially used are derived from the data of some hospitals in the main cities. This leaves out the 60% of pregnant women who do not attend health facilities. It was against this background that the present study was designed to be a prospective community-based study carried out in the central region of Mozambique involving a population of 207,369 inhabitants. The study covered a 12-month period, from 01/08/96 to 31/07/97 and found 214 deaths among women in reproductive age (15-49 yr) of whom 40 were classified as maternal deaths. Gross underregistration was revealed, as the health institutions failed by 86% in recording maternal deaths, the same happening with other official sources, like the Civil Register and the Funeral Services registering only 9% of the maternal deaths. This kind of study is however complex and labour intensive and a practical way of monitoring has to be found; for the region where the study took place close collaboration with private cemeteries appears to be a way to be further explored.

Motor vehicle crashes and maternal mortality in New Mexico: the significance of seat belt use

In recent years, as deaths from medical complications during pregnancy have declined, injuries-specifically those sustained in motor vehicle crashes-represent a growing proportion of all pregnancy-associated deaths. To investigate pregnancy-associated deaths in motor vehicle crashes in New Mexico, we scrutinized the database of the New Mexico Office of the Medical Investigator for all deaths during pregnancy and up to 6 weeks postpartum from 1986 through 1995. A total of 97 deaths were identified, 47 of which were injury-related. Motor vehicle crashes accounted for 33 (approximately 70%) of the injury-related deaths. We analyzed the data on motor vehicle crashes for decedent's age and ethnicity, fetal gestational age, time of crash, rural vs urban location of crash, seat belt use, and drug and alcohol use. Compared with non-Hispanic white women, proportionately higher numbers of Hispanic and American Indian pregnant women were killed in motor vehicle crashes. In searching for modifiable risk factors, we noted that 45% of the crashes involved alcohol and that the majority of pregnant women killed (77%) were not wearing seat belts at the time of the crash. We conclude that education about seat belt use during pregnancy (as well as the dangers of alcohol use and riding with intoxicated drivers while pregnant) is a promising strategy to reduce motor vehicle fatalities.

Pregnancy-related mortality in New Jersey, 1975 to 1989

OBJECTIVES

National data are thought to underestimate pregnancy-related mortality in the United States. A multisource surveillance system for pregnancy-associated deaths in New Jersey offers an opportunity to identify the magnitude of and the trends in pregnancy-related mortality at the state level.

METHODS

Data from all reported pregnancy-related deaths in the state from 1975 to 1989 were studied, and pregnancy mortality ratios were calculated.

RESULTS

The New Jersey pregnancy mortality ratio decreased from the late 1970s to the early 1980s but began to rise in the late 1980s. The pregnancy mortality ratio for non-Whites was 3.6 times that for Whites for the 15-year period. The causes of pregnancy-related deaths changed over the 15-year period, with direct obstetrical causes playing a decreasing role. AIDS has become the major cause of pregnancy-related mortality in New Jersey. Finally, approximately 44% of the pregnancy-related deaths were considered to be preventable by the physician or patient or both.

CONCLUSIONS

New efforts must be made to combat the recent rise in pregnancy-related deaths, with special attention to preventing deaths among non-White women.

Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean

OBJECTIVE

To present estimates of maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean, and to discuss strategies to prevent these deaths.

DESIGN

Retrospective review of all available data.

SETTING

Database of the World Health Organization's Maternal Health and Safe Motherhood Programme.

MAIN OUTCOME MEASURES

Estimates of the total maternal mortality and the proportions of deaths associated with hypertensive disorders of pregnancy.

RESULTS

Estimates of mortality associated with hypertensive disorders of pregnancy were similar in Africa, Latin America and the Caribbean, despite considerably higher total mortality in Africa. Variations in both overall mortality and that associated with hypertensive disorders of pregnancy were greatest in Asia. Despite their limitations, these data suggest that between 10-15% of maternal deaths are associated with hypertensive disorders of pregnancy, and that 10% are associated with eclampsia.

CONCLUSIONS

Where maternal mortality is relatively high, the excess is likely to be due to a high mortality associated with haemorrhage and infection and reductions are most likely to come from reductions in these deaths. Evidence from both developed and developing countries suggests that deaths associated with hypertensive disorders of pregnancy are the most difficult to prevent. More rigorous assessment of interventions designed to prevent these deaths is urgently required.

Ascertainment of maternal deaths in New York City

Maternal deaths in New York City are defined as deaths from any cause in a woman while pregnant or within six months of pregnancy termination. Pilot studies seeking to improve maternal death ascertainment found that selected medical examiner reports contributed an additional 10.5 percent of the total maternal deaths, vital statistics review contributed 6.3 percent, linkage of death tapes of women of reproductive age to live birth and fetal death tapes contributed 1.0 percent. Medical examiner cases should be incorporated into surveillance data for accurate ascertainment of pregnancy associated deaths.

Oral public health programs for the elderly: 1989

Forty-eight of the 50 state dental directors, program managers, or state health officials were interviewed by telephone about the nature of current oral health programs for the elderly and factors that aided or hindered the development of such programs. Oral health programs for the elderly were reported in 30 states (63 percent of respondents). A majority of respondents indicated that a perceived or documented need for oral health programs for the elderly and lobbying by local advocacy groups were instrumental in implementing or planning such programs.

Pregnancy-related mortality in New York City, 1980 to 1984: causes of death and associated risk factors

To identify causes and risk factors for pregnancy-related mortality in New York City, we analyzed 224 pregnancy-related deaths that occurred from 1980 to 1984. The leading causes of death were ectopic pregnancy complications, embolism, intrapartum cardiac arrest, and hypertension. Mortality ratios were determined by comparing the characteristics of the women whose death was pregnancy-related with those of women who had survived delivery of a live infant in New York City during the same period. Black and Hispanic women had mortality ratios that were respectively 4.2 and 2.0 times higher than those for white, non-Hispanic women. In comparison with women aged 20 to 24, those older than 30 were more than twice as likely to die from pregnancy-related causes, and those older than 40 were five times as likely to do so. Other factors that were associated with an increased risk of pregnancy-related mortality included 9 to 11 years of education, lack of private medical insurance, more than five previous pregnancies, and fewer than five prenatal visits. This study suggests that changes in current maternal-health and family-planning services will be required to achieve further reductions in preventable pregnancy-related mortality.

Maternal mortality: levels, causes and promising interventions

About two-thirds of the world's population live in areas where registration of vital statistics is unsatisfactory (Tietze, 1977), and in many countries such statistics from rural areas are unavailable or grossly underestimated (WHO, 1971). Most of the women who die in pregnancy and childbirth are poor and live in remote areas or city slums. Their deaths are accorded little importance and fail to enter registers.

Maternal deaths in the less developed world: preventable tragedies

A half million women die yearly around the world as a result of pregnancy. Many of these deaths are inaccurately classified and many others are not reported at all, but new demographic techniques have clarified causes of maternal mortality and improved estimates of rates. New data from several less developed countries suggest that many maternal deaths could be prevented by measures already demonstrated to be effective elsewhere. These include better antenatal and intrapartum care, contraception for women who want no more pregnancies, legal abortion to terminate unwanted pregnancies, and uterine aspiration and antibiotics for treatment of septic abortion.

A thirty-year review of maternal mortality in Oklahoma, 1950 through 1979

Oklahoma's Maternal Mortality Committee has been active since 1941. During the 30-year period 1950 through 1979, the committee reviewed in detail 75.9% of the pregnancy-related deaths that occurred in Oklahoma. The maternal mortality ratio in 1950 was 95.1/100,000 live births, and for 1979 it was 8.1/100,000 live births, a decrease of 91.5%. The risk of death from childbearing remained greater for black women than for American Indian or white women throughout the three decades. For American Indian women, the risk of death associated with pregnancy has decreased and is almost equal to the risk for white women. The Maternal Mortality Committee estimated that two thirds of Oklahoma's maternal deaths were preventable. The proportion of deaths judged preventable did not vary substantially during the study period. We conclude that maternal mortality in Oklahoma can be reduced to fewer than three deaths per 100,000 live births. Intensive monitoring and investigation of deaths and their causes by local maternal mortality committees continues to be an important mechanism for obtaining information to assist health workers in the prevention of deaths.

An assessment of the incidence of maternal mortality in the United States

Recent studies in several states have found that the incidence of maternal mortality is higher than traditional vital statistics reports indicate. Since no comprehensive national study has been done to evaluate the completeness of maternal mortality ascertainment through the national vital statistics reporting system, the Centers for Disease Control (CDC) undertook such a study with the assistance of the National Center for Health Statistics and state health departments. The state health departments provided CDC with death certificates for all pregnancy-related deaths occurring during 1974-78. We reviewed and classified these certificates using both International Classification of Diseases, Adapted, Eighth Revision (ICDA-8) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) maternal death codes. We found that the actual incidence of maternal mortality for 1974-78 was approximately 20 per cent and 30 per cent greater than that published in national vital statistics reports using ICDA-8 and ICD-9-CM, respectively.