Putting the "M" back in the Maternal and Child Health Bureau: reducing maternal mortality and morbidity

Maternal mortality and severe morbidity are on the rise in the United States. A significant proportion of these events are preventable. The Maternal Health Initiative (MHI), coordinated by the Maternal and Child Health Bureau at the Health Resources and Services Administration, is intensifying efforts to reduce maternal mortality and severe morbidity in the U.S. Through a public-private partnership, MHI is taking a comprehensive approach to improving maternal health focusing on five priority areas: improving women's health before, during and beyond pregnancy; improving the quality and safety of maternity care; improving systems of maternity care including both clinical and public health systems; improving public awareness and education; and improving surveillance and research.

Meeting the emerging public health needs of persons with blood disorders

In its decades-long history, the Division of Blood Disorders (DBD) at CDC has evolved from a patient-focused, services-supporting entity at inception, to one of the world leaders in the practice of public health to improve the lives of people at risk for or affected by nonmalignant blood disorders. The DBD's earliest public health activities consisted of working with care providers in a network of hemophilia treatment centers to provide AIDS risk reduction services to people with hemophilia. Because this infectious disease threat has been reduced over time as a result of the development of safer treatment products, the DBD--under the auspices of congressional appropriations guidance--has expanded its core activities to encompass blood disorders other than hemophilia, including hemoglobinopathies such as thalassemia and sickle cell disease, and Diamond Blackfan anemia. Simultaneously, in transitioning to a greater public health role, the DBD has expanded its network of partners to new consumer and professional organizations, as well as state and other federal health agencies. The DBD has also developed and maintains many surveillance and registry activities beyond the Universal Data Collection system aimed at providing a better understanding of the health status, health needs, and health-related quality of life of people with nonmalignant blood disorders. The DBD has integrated applicable components of the Essential Services of Public Health successfully to promote and advance the agenda of blood disorders in public health.

Clustering patterns of comorbidities associated with in-hospital death in hospitalizations of US adults with venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a significant source of mortality, morbidity, disability, and impaired health-related quality of life in the world.

OBJECTIVE

We aimed to evaluate the clustering patterns and associations of 29 comorbidities with in-hospital death among adult hospitalizations with a diagnosis of VTE in the United States by analyzing data from the 2009 Nationwide Inpatient Sample.

METHODS

This cross-sectional study included 153,124 adult hospitalizations with a diagnosis of VTE. Adjusted rate ratios and 95% confidence intervals (CI) for in-hospital death were generated by using multivariable log-linear regression models to measure independent associations between comorbidities and in-hospital death.

RESULTS

We estimated that 44,200 in-hospital deaths occurred in 2009 among 773,273 US adult hospitalizations with a diagnosis of VTE. Subgroups of hospitalizations with comorbidities of "congestive heart failure," "chronic pulmonary disease," "coagulopathy," "liver disease," "lymphoma," "fluid and electrolyte disorders," "metastatic cancer," "peripheral vascular disorders," "pulmonary circulation disorders," "renal failure," "solid tumor without metastasis," or "weight loss" were positively and independently associated with 1.07 (95% CI: 1.02-1.12 ) to 2.06 (95% CI: 1.97-2.16) times increased likelihoods of in-hospital death, when compared to those without the corresponding comorbidities. The clustering patterns of these comorbidities by 4 disease categories (i.e., "cancer," "cardiovascular/respiratory/blood," "gastrointestinal/urologic," and "nutritional/bodyweight") were associated with 2.74 to 10.28 times increased likelihoods of in-hospital death, as compared to hospitalizations without any of these comorbidities. The overall increase in the cumulative number of comorbidities corresponded to significantly elevated risks (P-trend<0.01) for in-hospital death among hospitalizations with a diagnosis of VTE.

CONCLUSION

The presence of multiple comorbidities is ubiquitous among hospitalizations of adults with VTE and among in-hospital deaths with VTE in the United States. The findings of our study further suggest that, among hospitalizations of adults with VTE, the presence of certain comorbidities or clustering of these comorbidities significantly elevates the risk of in-hospital death.

Is polycystic ovary syndrome another risk factor for venous thromboembolism? United States, 2003-2008

OBJECTIVE

We sought to determine prevalence and likelihood of venous thromboembolism (VTE) among women with and without polycystic ovary syndrome (PCOS).

STUDY DESIGN

We performed a cross-sectional analysis using Thomson Reuters MarketScan Commercial databases for the years 2003 through 2008. The association between VTE and PCOS among women aged 18-45 years was assessed using age-stratified multivariable logistic regression models.

RESULTS

Prevalence of VTE per 100,000 was 374.2 for PCOS women and 193.8 for women without PCOS. Compared with women without PCOS, those with PCOS were more likely to have VTE (adjusted odds ratio [aOR] 18-24 years, 3.26; 95% confidence interval [CI], 2.61-4.08; aOR 25-34 years, 2.39; 95% CI, 2.12-2.70; aOR 35-45 years, 2.05; 95% CI, 1.84-2.38). A protective association (odds ratio, 0.8; 95% CI, 0.73-0.98) with oral contraceptive use was noted for PCOS women.

CONCLUSION

PCOS might be a predisposing condition for VTE, particularly among women aged 18-24 years. Oral contraceptive use might be protective.

Prevalence of polycystic ovary syndrome among the privately insured, United States, 2003-2008

OBJECTIVE

The purpose of this study was to estimate the prevalence of polycystic ovary syndrome (PCOS) and its phenotypes as defined by the National Institutes of Health, Rotterdam criteria, and Androgen Society.

STUDY DESIGN

Thomson Reuters MarketScan Commercial databases (Thomson Reuters Healthcare Inc, New York, NY) for 2003-2008 were used to calculate the prevalence of PCOS and to assess differences in demographic characteristics and comorbid conditions among women who were 18-45 years old with and without PCOS.

RESULTS

The prevalence of PCOS was 1585.1 per 100,000; women with phenotype A or classic PCOS were most prevalent at 1031.5 per 100,000. Women with PCOS were more likely than those without PCOS to be 25-34 years old, be from the South, be infertile, have metabolic syndrome, have been seen by an endocrinologist, and have taken oral contraceptives.

CONCLUSION

This is the first study to use all available criteria to estimate the prevalence of PCOS. Providers should evaluate women with menstrual dysfunction for the presence of PCOS.

Correlates of in-hospital deaths among hospitalizations with pulmonary embolism: findings from the 2001-2008 National Hospital Discharge Survey

BACKGROUND

Deep vein thrombosis and pulmonary embolism (PE) are responsible for substantial mortality, morbidity, and impaired health-related quality of life. The aim of this study was to evaluate the correlates of in-hospital deaths among hospitalizations with a diagnosis of PE in the United States.

METHODS

By using data from the 2001-2008 National Hospital Discharge Survey, we assessed the correlates of in-hospital deaths among 14,721 hospitalizations with a diagnosis of PE and among subgroups stratified by age, sex, race, days of hospital stay, type of admission, cancer, pneumonia, and fractures. We produced adjusted rate ratios (aRR) and 95% confidence intervals using log-linear multivariate regression models.

RESULTS

Regardless of the listing position of diagnostic codes, we observed an increased likelihood of in-hospital death in subgroups of hospitalizations with ages 50 years and older (aRR = 1.82-8.48), less than 7 days of hospital stay (aRR = 1.43-1.57), cancer (aRR = 2.10-2.28), pneumonia (aRR = 1.79-2.20), or fractures (aRR = 2.18) (except for first-listed PE), when compared to the reference groups with ages 1-49 years, 7 days or more of hospital stay, without cancer, pneumonia, or fractures while adjusting for covariates. In addition, we observed an increased likelihood of in-hospital death for first-listed PE in hospitalizations of women, when compared to those of men (aRR = 1.45).

CONCLUSIONS

The results of this study provide support for identifying, developing, and implementing effective, evidence-based clinical assessment and management strategies to reduce PE-related morbidity and mortality among hospitalized PE patients who may have concurrent health conditions including cancer, pneumonia, and fractures.

Prevention of venous thromboembolism in pregnancy: a review of guidelines, 2000-2011

INTRODUCTION

Pregnant women are four to five times more likely than nonpregnant women to develop venous thromboembolism (VTE). The aim of this review is to provide an overview of guidelines in the literature on VTE risk assessment, screening for thrombophilias, and thromboprophylaxis dissemination among pregnant women.

METHODS

We performed a review of the published literature to identify evidence-based guidelines published between the years 2000 and 2011. We searched for guidelines from U.S. and international organizations that identified clinically based practice recommendations to healthcare providers on how VTE risk should be assessed, thrombophilias screened, and thromboprophylaxis disseminated among pregnant women.

RESULTS

We found nine guidelines that met our requirements for assessing VTE risk and found seven guidelines addressing thrombophilia screening. Seven of the nine agreed that all women should undergo a risk factor assessment for VTE either in early pregnancy or in the preconception period. Seven of the nine agreed that pregnant women with more than one additional VTE risk factor be considered for thromboprophylaxis, and five of the seven groups addressing thrombophilia screening agreed that selected at-risk populations should be considered for thrombophilia screening.

CONCLUSIONS

There is some agreement between U.S. and international guidelines that women should be assessed for VTE risk during preconception and again in pregnancy. Although there is agreement that the general population of women should not be screened for thrombophilias, no agreement exists as to the clinical subgroups for which screening should be done.

Sickle cell disease in Africa: a neglected cause of early childhood mortality

Sickle cell disease (SCD) is common throughout much of sub-Saharan Africa, affecting up to 3% of births in some parts of the continent. Nevertheless, it remains a low priority for many health ministries. The most common form of SCD is caused by homozygosity for the β-globin S gene mutation (SS disease). It is widely believed that this condition is associated with very high child mortality, but reliable contemporary data are lacking. We have reviewed available African data on mortality associated with SS disease from published and unpublished sources, with an emphasis on two types of studies: cross-sectional population surveys and cohort studies. We have concluded that, although current data are inadequate to support definitive statements, they are consistent with an early-life mortality of 50%-90% among children born in Africa with SS disease. Inclusion of SCD interventions in child survival policies and programs in Africa could benefit from more precise estimates of numbers of deaths among children with SCD. A simple, representative, and affordable approach to estimate SCD child mortality is to test blood specimens already collected through large population surveys targeting conditions such as HIV, malaria, and malnutrition, and covering children of varying ages. Thus, although there is enough evidence to justify investments in screening, prophylaxis, and treatment for African children with SCD, better data are needed to estimate the numbers of child deaths preventable by such interventions and their cost effectiveness.

Sickle cell disease: the need for a public health agenda

Sickle cell disease (SCD) is a collection of inherited blood disorders that affect a substantial number of people in the U.S., particularly African Americans. People with SCD have an abnormal type of hemoglobin, Hb S, which polymerizes when deoxygenated, causing the red blood cells to become misshapen and rigid. Individuals with SCD are at higher risk of morbidity and mortality from infections, vaso-occlusive pain crises, acute chest syndrome, and other complications. Addressing the public health needs related to SCD is an important step toward improving outcomes and maintaining health for those affected by the disorder. The objective of this study was to review public health activities focusing on SCD and define the need to address it more comprehensively from a public health perspective. We found that there has been some progress in the development of SCD-related public health activities. Such activities include establishing newborn screening (NBS) for SCD with all states currently having universal NBS programs. However, additional areas needing focus include strengthening surveillance and monitoring of disease occurrence and health outcomes, enhancing adherence to health maintenance guidelines, increasing knowledge and awareness among those affected, and improving healthcare access and utilization. These and other activities discussed in this paper can help strengthen public health efforts to address SCD.

Public health implications of sickle cell trait: a report of the CDC meeting

Although the issue of whether sickle cell trait (SCT) is clinically benign or a significant health concern has not yet been resolved, the potential health risk to affected individuals is of vital importance and represents a tremendous challenge in protecting, promoting, and improving the health of the approximately 300 million people worldwide and 3 million people in the U.S. who possess the trait. In response to a request by the Sickle Cell Disease Association of America, in December 2009, the CDC convened a meeting of partners, stakeholders, and experts to identify the gaps in public health, clinical health services, epidemiologic research, and community-based outreach strategies and to develop an agenda for future initiatives. Through facilitated discussion and presentations in four topic areas, participants discussed pertinent issues, synthesized clinical research findings, and developed a coherent framework for establishing an agenda for future initiatives. A primary outcome of the meeting was to provide the first step of an iterative process to move toward agreement regarding appropriate counseling, care, and, potentially, treatment of people with SCT.

Developing public health surveillance for deep vein thrombosis and pulmonary embolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE), are an important and growing public health issue, associated with considerable morbidity and mortality. Presently, there is no national surveillance for DVT and PE. This article provides a summary of an expert workgroup meeting convened January 12, 2010, by the CDC. The purpose of the meeting was to inform CDC on the development of U.S. population-based public health surveillance activities for DVT/PE. Topics discussed included: (1) stakeholders, needs, gaps, and target populations; (2) requirements of surveillance systems; (3) challenges, limitations, and potential barriers to implementation of surveillance activities; and (4) integration of research and education with surveillance activities.

Parents' Death and its Implications for Child Survival

Reduction of child mortality is a global public health priority. Parents can play an important role in reducing child mortality. The inability of one or both parents to care for their children due to death, illness, divorce or separation increases the risk of death of their children. There is increasing evidence that the health, education, and socioeconomic status of mothers and fathers have significant impact on the health and survival of their children. We conducted a literature review to explore the impact of the death of parents on the survival and wellbeing of their children and the mechanisms through which this impact is mediated. Studies have generally concluded that the death of a mother significantly increased the risk of death of her children, especially during the early years; the effect continues but is significantly reduced with increasing age through the age of 15 years. The effect of the loss of a father had less impact than the effect of losing a mother although it too had negative consequences for the survival prospect of the child. A mother's health, education, socioeconomic status, fertility behavior, environmental health conditions, nutritional status and infant feeding, and the use of health services all play an important role in the level of risk of death of her children. Efforts to achieve the Millennium Development Goal No. 4 of reducing children's under-5 mortality in developing countries by two thirds by 2015 should include promoting the health and education of women.

Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999-2007

BACKGROUND

Patients with sickle cell disease (SCD) often use emergency department services to obtain medical care. Limited information is available about emergency department use among patients with SCD.

PURPOSE

This study assessed characteristics of emergency department visits made nationally by patients with SCD.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 1999-2007 were analyzed. The NHAMCS is a survey of hospital emergency department and outpatient visits. Emergency department visits by patients with SCD were identified using ICD-9-CM codes, and nationally weighted estimates were calculated.

RESULTS

On average, approximately 197,333 emergency department visits were estimated to have occurred each year between 1999 and 2007 with SCD as one of the diagnoses listed. The expected source of payment was private insurance for 14%, Medicaid/State Children's Health Insurance Program for 58%, Medicare for 14%, and other/unknown for 15%. Approximately 29% of visits resulted in hospital admission; this was 37% among patients aged 0-19 years, and 26% among patients aged >/=20 years. The episode of care was indicated as a follow-up visit for 23% of the visits. Patient-cited reasons for the emergency department visit included chest pain (11%); other pain or unspecified pain (67%); fever/infection (6%); and shortness of breath/breathing problem/cough (5%), among other reasons.

CONCLUSIONS

Substantial numbers of emergency department visits occur among people with SCD. The most common reason for the emergency department visits is pain symptoms. The findings of this study can help to improve health services delivery and utilization among patients with SCD.

Blood disorders among women: implications for preconception care

The objectives of preconception care for women with blood disorders are to provide women and their partners with information on the implications of blood disorders for pregnancy; reproductive choices; and the management of potential or future pregnancies. Advances in hematology have led to improved diagnosis and treatment of blood disorders, thereby contributing to longevity and quality of life for women who are either affected by or are carriers of blood disorders. Women with blood disorders pose unique challenges: physiologic events such as pregnancy and menstruation influence the manifestations of blood disorders; blood disorders are a risk factor for adverse pregnancy outcomes; pregnancy imposes the risk of potential genetic transmission of the blood disorder to the offspring;and medications used for treatment of blood disorders pose additional challenges to conception and pregnancy. Hence, it is crucial that women of childbearing age with blood disorders be provided proper care for their conditions and be counseled before they become pregnant, in time to prevent complications to mothers and infants related to blood disorders. The purpose of this paper is to provide a brief overview of the current knowledge related to blood disorders in women of reproductive age, the interventions needed to manage these conditions, and the implications of these conditions and their management for the health of women and their infants.

The public health response to blood disorders

Nonmalignant blood disorders meet all criteria for qualifying, as a group, as a very important public health problem with serious morbidities affecting over 1 million Americans every year, not including an additional 8 million individuals suffering from anemia. Many of these conditions and the morbidities and mortalities associated with them are, to a large extent, preventable. Further, the changing demographic composition of the American population is sure to increase the number of individuals affected by these conditions. Yet, nonmalignant blood disorders have not been recognized as important public health priorities. Immediate action is needed to meet the increasing challenge of blood disorders in public health. We propose a national, comprehensive, organized, coordinated, institutionalized, sustainable public health response to blood disorders based on the three core functions and the ten essential services of public health. Immediate action needs to be taken to improve surveillance and monitoring, increase public and provider awareness, increase the use of evidence-based practices, and enhance epidemiologic research on the causes, prevention, and treatment of conditions resulting in adverse outcomes.

Recommendations to Improve Preconception Health and Health Care: Strategies for Implementation

Promoting preconception health and health care is widely accepted as a useful prevention strategy to lessen adverse maternal and infant health outcomes. There remains, however, a lack of national standards of practice or a comprehensive agenda to ensure that all women of childbearing age receive appropriate services that will enable them to achieve optimal health before any pregnancy. To address this need, the Centers for Disease Control and Prevention (CDC) launched the Preconception Health and Health Care Initiative, which aims to improve the health of women before pregnancy. In 2005, the CDC sponsored the first National Summit on Preconception Care, bringing together over 400 participants to share their expertise and information about various activities currently underway. In conjunction with the National Summit, a Select Panel on Preconception Care, a group of experts and representatives of 35 national organizations and 22 CDC programs, was convened. Based on the literature, presentations made at the National Summit, and deliberations during the Select Panel meeting, the recommendations to improve Preconception Health and Health Care--United States were developed. In order to move the recommendations from paper to practice, the Select Panel was convened to develop strategies to implement the recommendations across three areas: clinical practice, consumer roles, and public health practice. Future plans include developing a research agenda, supporting existing and new research activities, and developing policy and financing initiatives that will advance the practice of preconception health and health care. In addition, a Second National Summit is being planned. This paper describes current and future activities to implement the recommendations.

Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care

This report provides recommendations to improve both preconception health and care. The goal of these recommendations is to improve the health of women and couples, before conception of a first or subsequent pregnancy. Since the early 1990s, guidelines have recommended preconception care, and reviews of previous studies have assessed the evidence for interventions and documented the evidence for specific interventions. CDC has developed these recommendations based on a review of published research and the opinions of specialists from the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. The 10 recommendations in this report are based on preconception health care for the U.S. population and are aimed at achieving four goals to 1) improve the knowledge and attitudes and behaviors of men and women related to preconception health; 2) assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health; 3) reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children; and 4) reduce the disparities in adverse pregnancy outcomes. The recommendations focus on changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps and, when implemented, can yield results within 2-5 years. Based on implementation of the recommendations, improvements in access to care, continuity of care, risk screening, appropriate delivery of interventions, and changes in health behaviors of men and women of childbearing age are expected to occur. The implementation of these recommendations will help achieve Healthy People 2010 objectives. The recommendations and action steps are a strategic plan that can be used by persons, communities, public health and clinical providers, and governments to improve the health of women, their children, and their families. Improving preconception health among the approximately 62 million women of childbearing age will require multistrategic, action-oriented initiatives.

Risk Factors for Legal Induced Abortion–Related Mortality in the United States

OBJECTIVE

To assess risk factors for legal induced abortion-related deaths.

METHODS

This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates.

RESULTS

During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation.

CONCLUSION

Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths.

LEVEL OF EVIDENCE

II-2

Pregnancy-related mortality from preeclampsia and eclampsia

OBJECTIVE

To examine the role of preeclampsia and eclampsia in pregnancy-related mortality.

METHODS

We used data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to examine pregnancy-related deaths from preeclampsia and eclampsia from 1979 to 1992. The pregnancy-related mortality ratio for preeclampsia-eclampsia was defined as the number of deaths from preeclampsia and eclampsia per 100,000 live births. Case-fatality rates for 1988-1992 were calculated for preeclampsia and eclampsia deaths per 10,000 cases during the delivery hospitalization, using the National Hospital Discharge Survey.

RESULTS

Of 4024 pregnancy-related deaths at 20 weeks' or more gestation in 1979-1992, 790 were due to preeclampsia or eclampsia (1.5 deaths/100,000 live births). Mortality from preeclampsia and eclampsia increased with increasing maternal age. The highest risk of death was at gestational age 20-28 weeks and after the first live birth. Black women were 3.1 times more likely to die from preeclampsia or eclampsia as white women. Women who had received no prenatal care had a higher risk of death from preeclampsia or eclampsia than women who had received any level of prenatal care. The overall preeclampsia-eclampsia case-fatality rate was 6.4 per 10,000 cases at delivery, and was twice as high for black women as for white women.

CONCLUSION

The continuing racial disparity in mortality from preeclampsia and eclampsia emphasizes the need to identify those differences that contribute to excess mortality among black women, and to develop specific interventions to reduce mortality from preeclampsia and eclampsia among all women.

Racial disparity in pregnancy-related mortality associated with livebirth: can established risk factors explain it?

The authors conducted a nested case-control study to determine whether the fourfold increased risk of pregnancy-related mortality for US Black women compared with White women can be explained by racial differences in sociodemographic and reproductive factors. Cases were derived from a national surveillance database of pregnancy-related deaths and were restricted to White women (n = 840) and Black women (n = 448) whose pregnancies resulted in a livebirth and who died of a pregnancy-related cause between 1979 and 1986. Controls were derived from national natality data and were randomly selected White women and Black women who delivered live infants and did not die from a pregnancy-related cause (n = 5,437). Simultaneous adjustment for risk factors by using logistic regression did not explain the racial gap in pregnancy-related mortality. The largest racial disparity occurred among women with the lowest risk of pregnancy-related death: those of low to moderate parity who delivered normal-birth-weight babies (adjusted odds ratio = 3.53, 95% confidence interval: 2.9, 4.4). In contrast, no racial disparity was found among women with the highest risk of pregnancy-related death: high-parity women who delivered low-birth-weight babies. These findings indicate that reproductive health care professionals need to develop strategies to reduce pregnancy-related deaths among both high- and low-risk Black women.

Maternal mortality surveillance and maternal death reviews in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on maternal mortality surveillance systems and death review activities in the Region. Data were collected by questionnaire completed by ministry of health personnel. The findings show that 13 countries require official reporting of deaths of women of reproductive age. Most of the countries conduct maternal death reviews although only 8 have surveillance systems. Other areas investigated were the sources of information on maternal deaths, types of data collected, how the data are analysed and how such data are used. There is a need to strengthen information systems on maternal mortality in the Region in order to guide decision-makers in the planning and evaluation of maternal health programmes.

Family planning services and programmes in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves.

Are interpregnancy intervals between consecutive live births among black women associated with infant birth weight?

OBJECTIVES

The purpose of this study was to determine whether the length of interpregnancy intervals between consecutive live births among Black women had any significant effect on mean birth weight as had previously been reported in another study.

DESIGN

We examined a sample (1,048 women, 66% of study participants) from a study of non-Hispanic Black women whose infants were born at a large, inner-city, public hospital in Georgia from October 1988 through August 1990. Data were evaluated for the 494 women whose current and immediately previous pregnancies ended in the birth of a live infant weighing 500 grams or more.

METHODS

Linear regression and analysis of covariance models were developed.

RESULTS

The median interpregnancy interval was 15 months (range 1 to 207 months), with 19 (4%) of the women having intervals of less than 3 months. After adjustment for parity, gestational age (in weeks), and smoking status, the mean birth weight associated with an interpregnancy interval of three or more months was 3,106 grams, 215 grams greater than that for an interval of less than three months (P = .06).

CONCLUSIONS

Although longer birth spacing has been associated with certain positive social and health effects, the population attributable effect on infant birth weight may not be very significant.

Pregnancy-related mortality in Hispanic women in the United States

OBJECTIVE

To examine pregnancy-related mortality among Hispanic women in the United States.

METHODS

We used data from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System to examine all reported pregnancy-related deaths (deaths during or within 1 year of pregnancy that were caused by pregnancy, its complications, or treatment) in states that reported Hispanic origin for 1979-1992. The pregnancy-related mortality ratio was defined as the number of pregnancy-related deaths per 100,000 live births.

RESULTS

For the 14-year period, the overall pregnancy-related mortality ratio was 10.3 deaths per 100,000 live births for Hispanic women, 6.0 for non-Hispanic white women, and 25.1 for black women. In Hispanic subgroups, the pregnancy-related mortality ratio was 9.7 for Mexican women and ranged from 7.8 for Cuban women to 13.4 for Puerto Rican women. Pregnancy-induced hypertension was the leading cause of pregnancy-related death for Hispanic women overall.

CONCLUSION

Pregnancy-related mortality ratios for Hispanic women were higher than those for non-Hispanic white women, but markedly lower than those for black women. The similarity in socioeconomic status between Hispanic and black women was not an indicator of similar health outcomes. Prevention of pregnancy-related deaths in Hispanic women should include investigation of medical and nonmedical factors and consider the heterogeneity of the Hispanic population.

Pregnancy-related mortality in the United States due to hemorrhage: 1979-1992

OBJECTIVE

To study trends and examine risk factors for pregnancy-related mortality due to hemorrhage.

METHODS

We analyzed pregnancy-related deaths from 1979-1992 from the National Pregnancy Mortality Surveillance System of the Centers for Disease Control and Prevention. Live-birth data used to calculate mortality ratios were obtained from published vital statistics. Deaths due to ectopic pregnancies were excluded.

RESULTS

There were 763 pregnancy-related deaths from hemorrhage associated with intrauterine pregnancies, a ratio of 1.4 deaths per 100,000 live births. The pregnancy-related mortality ratio was higher for black women and those of other races than white women. The risk of pregnancy-related mortality increased with age. Abruptio placentae was the overall leading cause of pregnancy-related death due to hemorrhage. Leading causes of death differed by race, age group, and pregnancy outcome.

CONCLUSION

Hemorrhage is the leading cause of pregnancy-related death in the United States. Black women have three times the risk of death of white women. In-depth investigations are needed to ascertain the risk factors associated with those deaths.

Spontaneous abortion-related deaths among women in the United States--1981-1991

OBJECTIVE

To examine trends in spontaneous abortion-related mortality and risk factors for these deaths from 1981 through 1991.

METHODS

We used national data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to identify deaths due to spontaneous abortion (less than 20 weeks' gestation). Case-fatality rates were defined as the number of spontaneous abortion-related deaths per 100,000 spontaneous abortions. We calculated annual case-fatality rates as well as risk ratios by maternal age, race, and gestational age.

RESULTS

During 1981-1991, a total of 62 spontaneous abortion-related deaths were reported to the Pregnancy Mortality Surveillance System. The overall case fatality rate was 0.7 per 100,000 spontaneous abortions. Maternal age 35 years and older (risk ratio [RR] 1.7, 95% confidence interval [CI] 0.9-3.0), maternal race other than white (RR 3.8, 95% CI 2.2-5.9), and gestational age over 12 weeks (RR 8.0, 95% CI 4.2-11.9) were risk factors for death due to spontaneous abortion. Of the 62 deaths, 59% were caused by infection, 18% by hemorrhage, 13% by embolism, 5% from complications of anesthesia, and 5% by other causes. Disseminated intravascular coagulation (DIC) was an associated condition among half of those deaths for which it was not the primary cause of death.

CONCLUSION

Women 35 years of age and older, of races other than white, and in the second trimester of pregnancy age are at increased risk of death from spontaneous abortion. In addition, DIC complicates many spontaneous abortion cases that end in death. Because spontaneous abortion is a common outcome of pregnancy, continued monitoring of spontaneous abortion-related deaths is recommended.

Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991

The authors estimated the number of clinically recognized pregnancies that occurred annually from 1981 to 1991 in the United States by type of outcome and by race. Estimates of the numbers of livebirths, induced abortions, ectopic pregnancies, and fetal deaths were obtained by using data from the Centers for Disease Control and Prevention in Atlanta, Georgia. The number of spontaneous abortions was estimated by using previously published, age-specific rates. More than 67 million pregnancies occurred during the study period. Overall, 62.5% of these pregnancies resulted in livebirths, 21.9% in legal induced abortions, 13.8% in spontaneous abortions, 1.3% in ectopic pregnancies, and 0.5% in fetal deaths. These data can be used to provide denominators for the calculation of a variety of pregnancy outcome-specific rates.

Postneonatal mortality surveillance--United States, 1980-1994

PROBLEM/CONDITION

This report contains public health surveillance data that describe trends in postneonatal mortality (PNM) and that update information published in 1991.

REPORTING PERIOD COVERED

1980-1994.

DESCRIPTION OF SYSTEM

National death certificate data characterizing PNM were reported by hospital physicians, coroners, and medical examiners. Data for 1980-1994 were compiled by the National Center for Health Statistics (NCHS) and obtained from NCHS public-use mortality tapes.

RESULTS

The PNM rate per 1,000 live births declined 29.8% from 4.1 in 1980 to 2.9 in 1994 (31.7% decline among white infants and 25.8% among black). Most of the decline resulted from reduced mortality from infections and sudden infant death syndrome (SIDS). The PNM ratio between blacks and whites remained steady at approximately 2.1 during 1982-1988 and gradually increased to 2.4 by 1994 [corrected]. Autopsy rates for cases of SIDS increased from 82% to approximately 95% and did not differ among black infants and white infants. The decline of PNM rates for birth defects was greater for white infants than for black infants. The racial gap in PNM rates widened regionally during the study period, except in the South and the Northeast where ratios remained stable. In 1994, the largest gap persisted in the north-central region followed by the West and Northeast.

INTERPRETATION

In 1994 as in 1980, PNM remained an important contributor to infant mortality, but nearly half of these deaths are caused by potentially preventable causes such as SIDS, infections, and injuries. The use of interventions for SIDS, birth defects, infections, and injuries can help reduce PNM and narrow the associated racial gap.

ACTIONS TAKEN

This surveillance information, which will be distributed to administrators of state maternal and child health programs and to community-based organizations nationwide, will be useful in planning infant mortality reduction programs and to target PNM prevention efforts.

Cigarette smoking as a risk factor for ectopic pregnancy

OBJECTIVE

Our purpose was to assess the risk of ectopic pregnancy among women who smoke cigarettes.

STUDY DESIGN

We used data from a case-control study of ectopic pregnancy conducted from October 1988 to August 1990 at an inner-city hospital in Georgia. Cases were 196 non-Hispanic black women with a surgically confirmed ectopic pregnancy. Controls were non-Hispanic black women who had delivered either a live or a stillborn infant weighing at least 500 gm (n = 882) or who were pregnant and seeking an induced abortion (n = 237).

RESULTS

After we adjusted for parity, douching history, history of infertility, and age, the odds ratio for ectopic pregnancy was 1.9 (95% confidence interval 1.4 to 2.7) for women who smoked during the periconception period compared with women who did not smoke at that time. After stratification by the amount of daily smoking during the periconception period, the odds ratio rose from 1.6 (95% confidence interval 0.9 to 2.9) for women who smoked 1 to 5 cigarettes to 1.7 (95% confidence interval 1.1 to 2.8) for women who smoked 6 to 10 cigarettes to 2.3 (95% confidence interval 1.3 to 4.0) for women who smoked 11 to 20 cigarettes, and to 3.5 (95% confidence interval 1.4 to 8.6) for women who smoked >20 cigarettes per day.

CONCLUSION

In this inner-city population, cigarette smoking was an independent, dose-related risk factor for ectopic pregnancy among black women. The public health and medical care communities should inform the public of this additional risk associated with cigarette smoking and intensify intervention strategies to reduce cigarette smoking among women of reproductive age.

Pregnancy-related mortality surveillance--United States, 1987-1990

PROBLEM/CONDITION

The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 maternal deaths per 100,000 live births among black women; as of 1990, these goals had not been met. In addition, race-specific differences between black women and white women persist in the risk for pregnancy-related death.

REPORTING PERIOD COVERED

This report summarizes surveillance data for pregnancy-related deaths in the United States for 1987-1990.

DESCRIPTION OF SYSTEM

The National Pregnancy Mortality Surveillance System was initiated in 1988 by CDC in collaboration with the CDC/American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provided CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death records) of all identified pregnancy-related deaths.

RESULTS

During 1987-1990, 1,459 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 9.2 deaths per 100,000 live births. The pregnancy-related mortality ratio for black women was consistently higher than for white women for every risk factor examined by race. The disparity between pregnancy-related mortality ratios for black women and white women increased from 3.4 times greater in 1987 to 4.1 times greater in 1990. Older women, particularly women aged > or =35 years, were at increased risk for pregnancy-related death. The gestational age-adjusted risk for pregnancy-related death was 7.7 times higher for women who received no prenatal care than for women who received "adequate" prenatal care. The distribution of the causes of death differed depending on the pregnancy outcome; for women who died following a live birth (i.e., 55% of the deaths), the leading causes of death were pregnancy-induced hypertension complications, pulmonary embolism, and hemorrhage.

INTERPRETATION

Pregnancy-related mortality ratios for black women continued, as noted in previously published surveillance reports, to be three to four times higher than those for white women. The risk factors evaluated in this analysis confirmed the disparity in pregnancy-related mortality between white women and black women, but the reason(s) for this difference could not be determined from the available information.

ACTIONS TAKEN

Continued surveillance and additional studies should be conducted to assess the magnitude of pregnancy-related mortality, to identify those differences that contribute to the continuing race-specific disparity in pregnancy-related mortality, and to provide information that policy makers can use to develop effective strategies to prevent pregnancy-related mortality for all women.

Hospitalizations for severe complications of pregnancy, 1987-1992

OBJECTIVE

To compute ratios of severe pregnancy complications (the number of hospitalizations for pregnancy complications per 100 deliveries) and to examine factors associated with their prevalence.

METHODS

Using population-based California hospital discharge data to estimate hospitalization ratios of pregnancy complications during 1987-1992, we defined cases by preselected pregnancy complication codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, excluding induced abortions and delivery-associated complications. All hospital deliveries of liveborn or stillborn infants were included in our denominator. We examined ratios by age, race-ethnicity, payment source, total hospitalization charges, and length of hospital stay.

RESULTS

There were 833,264 hospitalizations for pregnancy complications in California (25 complications per 100 deliveries), which included admissions for preterm labor (33%), genitourinary infection (16%), and pregnancy-induced hypertension (15%). Age-specific ratios were highest for women 14 years old and younger (38 per 100 deliveries) and lowest for women 25-29 years old (23 per 100 deliveries). Ratios of complications varied by race-ethnicity; black women had the highest (42 per 100 deliveries), and Asian-Pacific Islander women had the lowest (21 per 100 deliveries). Ratios were unaffected by payment source. In 1987, Medicaid charges were $118 million for 33% of the number of total hospitalizations for complications. In 1992, such Medicaid hospitalizations accounted for $356 million (49%) of the $734 million in total charges and for 183,295 (45%) of the 409,000 total hospital days.

CONCLUSION

Our results showed disparities in ratios of severe complications of pregnancy by age and race-ethnicity as well as a shift of financial burden to Medicaid. These findings suggest that such complications may be reduced by identifying risk factors and targeting high-risk groups.

Vaginal douching and the risk of ectopic pregnancy among black women

OBJECTIVE

Our goal was to determine whether vaginal douching was associated with ectopic pregnancy among black women and whether specific douching behaviors were associated with differences in risk.

STUDY DESIGN

We analyzed data from a case-control study of ectopic pregnancy conducted between October 1988 and August 1990 at a major public hospital in Atlanta, Georgia. Case subjects were 197 black women with surgically confirmed ectopic pregnancies; the control group included 882 black women who were delivered of live or stillborn infants and 237 black women who were seeking to terminate a pregnancy.

RESULTS

The adjusted odds ratio for ectopic pregnancy associated with ever having douched was 3.8 (95% confidence interval 1.6 to 8.9). The risk increased with increasing number of years of douching at least once per month. No douching behavior was found to be without risk; even women who douched for routine cleanliness were at increased risk of ectopic pregnancy.

CONCLUSIONS

Vaginal douching is a modifiable behavior that may greatly increase a woman's risk of ectopic pregnancy.

The relation between induced abortion and ectopic pregnancy

OBJECTIVE

To determine whether having had one or more induced abortions increases a woman's risk of having an ectopic pregnancy.

METHODS

We conducted a case-control study of all women admitted to a major metropolitan hospital in Georgia with a surgical diagnosis of ectopic pregnancy during the period of October 1988 to August 1990. Controls were randomly selected from women seeking an induced abortion or delivering an infant at the same hospital. After exclusions, this analysis included 182 cases and 1056 controls. Stratified analysis and unconditional logistic regression were used to control for confounding and to estimate the relative risks.

RESULTS

Approximately 90% of cases and controls were non-Hispanic, black women; 34% of the cases and 36% of the controls reported a history of induced abortion. The crude odds ratio for having an ectopic pregnancy associated with a history of induced abortion was 0.9 (95% confidence interval 0.6, 1.3). The odds ratio remained the same after adjusting for selected confounding variables and stratifying by the number of induced abortions, gestational age at the time of abortion, place where the abortion was performed, and the woman's report of medical complications of the abortion.

CONCLUSION

We found no evidence that having one or more induced abortions increases a woman's risk of having an ectopic pregnancy.

Increasing incidence of ectopic pregnancy in one Norwegian county--a population based study, 1970-1993

OBJECTIVE

To estimate time trends related to ectopic pregnancy while considering the contribution of repeat ectopic pregnancy and changing treatment for infertile couples over the past 24 years.

METHODS

Population based incidence data on ectopic pregnancy were collected from the only two hospitals in one Norwegian county from 1970 through 1993. Cases were identified through hospital discharge registries and all medical records were reviewed. Only females, aged 15-44 years, living permanently in the county and having a histologically verified ectopic pregnancy were eligible for the study. Data were analyzed in 5-year periods and 5-year age-groups.

RESULTS

The incidence of ectopic pregnancy (per 1,000 woman-years) increased fourfold from the first to the last period. When we restricted the analyses to women with no previous ectopic pregnancy and no previous infertility surgery or treatment, we observed a linear threefold increase in the number of ectopic pregnancies.

CONCLUSIONS

Repeat ectopic pregnancy and increased infertility treatment in the late 1970s and early 1980s might explain at most 25% of the increase in the incidence of ectopic pregnancy. After 1985, assisted reproduction might contribute to 4-5% of ectopic pregnancies diagnosed. The introduction of laparoscopy might explain some of this increase in the 1970s; however, we doubt that the introduction of more sensitive pregnancy tests or vaginal ultrasound in the 1980s contributed to the observed increase in ectopic pregnancy.

Evaluation of induced abortion as a risk factor for ectopic pregnancy. A case-control study

OBJECTIVE

To assess the risk of ectopic pregnancy after one or more induced abortions.

DESIGN

Population-based case-control study.

METHODS

We studied all women who had a histologically verified ectopic pregnancy in one Norwegian county between January 1, 1987, and December 31, 1990. We identified population-based control sets of women among participants in the second Norwegian fertility study (1988-1989). Gravida women 20-39 years of age, who were not using contraceptives and had become spontaneously pregnant, were eligible for analysis. The final analyses included 174 women with ectopic pregnancy, 115 pregnant control women and 227 nonpregnant control women.

STATISTICAL METHODS

Chi-square test and unconditional logistic regression.

RESULTS

Fifty-three (30.5%) of women with ectopic pregnancy, 18 (15.7%) of pregnant control women and 51 (22.5%) of nonpregnant control women had had one or more previous induced abortions. The adjusted odds ratio of ectopic pregnancy among women with one previous induced abortion was 1.3 (95% confidence interval; 0.9 to 1.8) and 1.2 (95% CI; 0.8 to 1.7) compared with pregnant and nonpregnant control women, respectively. Among women who had two or more induced abortions, the adjusted odds ratio of ectopic pregnancy was 0.2 (95% CI; 0.04 to 0.9) compared with pregnant control women and 1.8 (95% CI; 0.4 to 7.8) compared with nonpregnant control women. When we used the outcome of the most recent pregnancy, birth as reference, we found no association between an outcome of induced abortion and subsequent ectopic pregnancy regardless of whether the control women were pregnant.

CONCLUSION

We found no association between induced abortion and subsequent ectopic pregnancy. Women who had induced abortions were characterized as having several other risk factors for ectopic pregnancy.

Pregnancy-related mortality in the United States, 1987-1990

OBJECTIVE

To use data from the Centers for Disease Control and Prevention's (CDC) Pregnancy-Related Mortality Surveillance System to examine trends in pregnancy-related mortality and risk factors for pregnancy-related death.

METHODS

In collaboration with ACOG and state health departments, the Pregnancy-Related Mortality Surveillance System has collected information on all deaths caused by pregnancy since 1979. Multiple data sources were used, including national death files, state health departments, maternal mortality review committees, individuals, and the media. As part of the initiation of the Pregnancy-Related Mortality Surveillance System in 1987, CDC staff contacted state health department personnel and encouraged them to identify and report pregnancy-related deaths. Data were reviewed and coded by experienced clinicians. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated.

RESULTS

After decreasing annually after 1979, the reported pregnancy-related mortality ratio increased from 7.2 in 1987 to 10.0 in 1990. This increase occurred among women of all races. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live-birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy-related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. During the periods 1979-1986 and 1987-1990, the cause-specific pregnancy-related mortality ratios decreased for deaths due to hemorrhage and anesthesia, whereas pregnancy-related mortality ratios due to cardiomyopathy and infection increased. The leading causes of death varied according to the outcome of the pregnancy.

CONCLUSION

Increased efforts to identify pregnancy-related deaths have contributed to an increase in the reported pregnancy-related mortality ratio. More than half of such deaths, however, are probably still unreported. Adequate surveillance of pregnancy-related mortality and morbidity is necessary for interpreting trends, identifying high-risk groups, and developing effective interventions.

Previous cesarean delivery and the risk of ectopic pregnancy

OBJECTIVE

To determine whether previous cesarean delivery is an independent risk factor for ectopic pregnancy.

METHODS

We analyzed data collected between October 1988 and August 1990 from a case-control study of ectopic pregnancy among parous, black, non-Hispanic women, 18-44 years old, at a major metropolitan hospital in Georgia. Cases were 138 women with confirmed ectopic pregnancy; controls were 842 women either seeking abortion or delivering an infant. Unconditional logistic regression was used to estimate the relative risk while controlling for the effects of potential confounders selected a priori.

RESULTS

Adjusted for age, parity, marital status, history of pelvic inflammatory disease, infertility, douching, and smoking, the odds ratio was 0.6 (95% confidence interval 0.4-1.1), indicating no significant association.

CONCLUSION

We found no evidence of an increased risk of ectopic pregnancy related to previous cesarean delivery.

Maternal mortality in developed countries: not just a concern of the past

OBJECTIVE

To review the activities in selected developed countries for strategies to identify maternal deaths, the impact of these strategies on underreporting, and the information needed to understand the events leading to death.

DATA SOURCES

We reviewed the literature from the United States, Europe, and Australia for publications dealing with maternal death identification and investigation from 1980 to April 1995. We also obtained information directly from researchers involved in major maternal mortality studies.

METHODS OF STUDY SELECTION

We included all 31 reports (from 14 countries) that discussed methods to improve the ascertainment of maternal deaths beyond the routine use of vital registration. Because of the nature of the subject matter, almost all reports relied on descriptive epidemiology.

DATA EXTRACTION AND SYNTHESIS

We found that a variety of methods can be used to improve the ascertainment of maternal deaths, including linkage of birth and fetal death certificates, check-boxes on death certificates, periodic review of deaths of reproductive-age women, and ongoing birth registries and medical audits. Information from a variety of sources is also needed to understand the events leading to death.

CONCLUSION

The numbers of deaths due to pregnancy and its complications are underestimated in most developed countries. Improved ascertainment of maternal death is needed to determine the magnitude of the problem and to assess trends and identify risk groups, allowing development of appropriate and effective strategies to prevent the morbidity and mortality associated with pregnancy.

Abortion mortality, United States, 1972 through 1987

OBJECTIVE

The aim of our study was to describe risk factors for legal abortion mortality and the characteristics of women who died of legal abortion complications for the period 1972 through 1987.

STUDY DESIGN

We reviewed abortion mortality surveillance data collected by the Division of Reproductive Health, Centers for Disease Control and Prevention, and calculated rates by various demographic and reproductive health variables using the Center for Disease Control and Prevention's abortion surveillance data as denominators. Rates are reported as legal abortion deaths per 100,000 abortions.

RESULTS

Between 1972 and 1987, 240 women died as a result of legal induced abortions. The case-fatality rate decreased 90% over time, from 4.1 deaths per 100,000 abortions in 1972 to 0.4 in 1987. Women > or = 40 years old had three times the risk of death as teenagers (relative risk 3.0, 95% confidence interval 1.5 to 6.0), and black women and those of other minority races had 2.5 times the risk of white women (relative risk 2.5, 95% confidence interval 1.9 to 3.2). Abortions at > or = 16 weeks were associated with a risk of death almost 15 times the risk of death from procedures at < or = 12 weeks' gestation. Women undergoing currettage procedures for abortion had a significantly lower risk of death than women undergoing other procedures. Whereas before 1977 infection and hemorrhage were the leading causes of death, during 1977 through 1982 anesthesia complications emerged as one of the leading causes of death and since 1983 have become the most frequent cause.

CONCLUSIONS

Although legal induced abortion-related deaths are rare events, our findings suggest that more rigorous efforts are needed to increase the safety of anesthetic methods and anesthetic agents used for abortions and that efforts are still necessary to monitor serious complications of abortion aimed at further reducing risks of death associated with the procedure.