January 2020 | Volume 69, Number 01 Contact: 971-673-1111 | [email protected] | www.healthoregon.org/cdsummary WHY ARE MOTHERS DYING IN OREGON? “Everyone always wants to say that it’s a review of national and state data, three maternal deaths, the expanded just about access to care and it’s just about and a discussion of recent legislation case-finding method found 13 potentially insurance, but that alone doesn’t explain it.” specific to the formation of Oregon’s pregnancy-associated deaths (Figure). – Dr. Elizabeth Howell on Serena Williams’ near-death childbirth MMRC. Only through case investigation can experience. New York Times, 2018 we determine which deaths were THE NUMBERS While calculated differently from pregnancy-associated but not causally The death of a mother during the U.S. PRMR, Oregon’s maternal related to pregnancy and which were pregnancy or childbirth is a tragic event death rate, measured by Oregon pregnancy-related (i.e. from a pregnancy that leaves a lasting impact on a family. Vital Statistics as the number of complication, a chain of events initiated In the United States, approximately maternal deaths per 100,000 live by pregnancy, or the aggravation of an 700 women die from pregnancy- births, is typically at or below the unrelated condition by the physiologic related complications annually; the overall U.S. rate. However, this may effects of pregnancy). Similarly, whether Centers for Disease Control and underestimate the true number of a particular death was preventable Prevention (CDC) estimates roughly can only be determined through case 1 maternal deaths in Oregon since 60% are preventable. The United it only includes specific cause of investigation. Both categories of deaths States’ pregnancy-related mortality death codes and/or an indication of will be analyzed by the Oregon MMRC ratio (PRMR) is higher than that pregnancy via a checkbox on death with the goal of identifying actionable of other industrialized nations at certificates. In response, the Oregon steps for prevention of future deaths. 17.2 deaths per 100,000 live births Health Authority (OHA) utilized an THE CAUSES during 2011–2015. The U.S. is the expanded case-finding method to Pregnancy-related deaths are a only industrialized nation where this identify all pregnancy-associated subset of pregnancy-associated deaths. ratio is increasing — along with a deaths since 2016. The process linked Pregnancy-associated deaths can continually widening disparity by race/ death certificates of all reproductive occur during pregnancy, at delivery, or ethnicity; black women experience age women with certificates of live up to one year postpartum. Causes of 3–4 times greater risk of pregnancy- 2 births or stillbirths taking place within death differ based upon the time period related death than white women. a year prior to the woman’s death. between pregnancy and death. In the For each pregnancy-related death, This process aims to identify all U.S. from 2011–2015, approximately approximately 50 mothers suffer “pregnancy-associated deaths”, i.e. one-third of pregnancy-related deaths from severe maternal morbidity– the death of a woman while pregnant occurred during pregnancy, one-third complications from pregnancy, labor, or within one year of pregnancy, within one week after delivery, and and delivery that bring the mother 3 regardless of the cause. one-third from one week to one year close to death. As Serena Williams’ In 2018, when the state vital postpartum.2 story shows, access to care alone is statistics’ reporting method noted Overall, “other cardiovascular not the problem. conditions” and “other non- To address the issue of maternal Figure. Comparison between number of cardiovascular medical conditions” mortality and severe morbidity, the maternal deaths and potentially pregnancy- associated deaths, Oregon, 2016–2018. caused the most pregnancy-related CDC has been building capacity deaths in the United States (Table, to start maternal mortality review verso).2 On the day of delivery, the committees (MMRCs), with the goal 30 25 leading cause of death was obstetric of understanding pathways leading to 20 emergencies, such as hemorrhage death or severe maternal morbidity and 15 and amniotic fluid embolisms. The stimulating preventive action. Oregon 10 Cases week following delivery, hemorrhage, has now joined 40 other states and 5 0 hypertensive disorders of pregnancy, jurisdictions in having an MMRC and 2016 2017 2018 and infections were the most common will start by reviewing 2018 deaths.4 Year causes of death. Between 6 weeks and This CD Summary includes resources Maternal Deaths 1 year postpartum, the leading cause of for providers and healthcare officials, Potentially associated-pregnancy deaths death was cardiomyopathy. health to characterize, intervene Table. Pregnancy-related deaths by cause of CONTRIBUTING FACTORS 2 Data from MMRCs from across the and reduce maternal mortality and death, United States; 2011–2015 country have detailed contributing morbidity in Oregon. Reducing Cause of Death Number of factors to pregnancy-related deaths pregnancy-associated deaths requires Deaths in their states. These include learning from each death as well as Amniotic fluid 173 (5.8%) improving women’s health by reducing system-level factors (inadequate embolism access to care, systemic racism and social inequities across the life span discrimination), community factors and ensuring quality care for pregnant Anesthesia 10 (0.3%) (unstable housing, intimate partner and postpartum women.2 complications Cardiomyopathy 307 (10.3%) violence), health facility factors WHAT CAN YOU DO? (limited experience with obstetric While conducting case reviews, Cerebrovascular 228 (7.6%) emergencies) and patient factors (lack OHA staff may call on providers to accidents 2 of knowledge of warning signs). send information in order to facilitate Hemorrhage 329 (11.0%) PREVENTION STRATEGIES case determinations. Throughout Hypertensive 212 (7.1%) In order to prevent and reduce the preconception, pregnancy, and disorders of pregnancy deaths associated with pregnancy, postpartum periods, providers and intervention must happen at patients can work together to optimally Infection 360 (12.0%) multiple stages, not just the period manage chronic health conditions Thrombotic pulmonary 281 (9.4%) of pregnancy through one year by helping patients understand their or other embolism postpartum. This requires connections central role in managing chronic Other cardiovascular 460 (15.4%) to upstream causes including conditions. Healthcare providers conditions evaluating social determinants of can communicate with patients Other non- 427 (14.3%) health and implementing effective about relevant warning signs during cardiovascular- strategies for prevention. The pregnancy and in the postpartum medical conditions California Pregnancy-Associated period through one year and use Unknown 203 (6.8%) Mortality Review Collaborative formed tools such as the electronic health in 2006. California has experienced a record to flag these warning signs Total 2,990 steady decline in maternal mortality, for intervention. Improving patient from 14 per 100,000 live births in 2008 education materials, offering home • California Maternal Quality Care to 7.3 per 100,000 live births in 2013. support services, and instituting Collaborative Toolkits: They focused on key components provider practice strategies for www.cmqcc.org/resources-tool-kits/ that included translating findings into coordinating with mental health and toolkits specific quality improvement initiatives substance use services can help • Mayo Clinic Labor and Delivery: to improve maternal care.5 Although address patient-level contributing Postpartum Care: these initiatives focus on hospital- factors. To help address some of www.mayoclinic.org/healthy-lifestyle/ labor-and-delivery/in-depth/postpar- system factors, California’s next these factors and link all families to tum-complications/art-20446702./ steps, including addressing social needed services, Oregon is phasing Accessed 13 Dec 2019. determinants of health, can further in universally offered home visiting. decrease mortality. Health systems and hospitals can REFERENCES 1. Centers for Disease Control and promote prevention practices by OREGON’S NEW MMRC LAW Prevention (CDC). Pregnancy-related During the 2018 legislative session, training non-obstetric providers, deaths. Available at: www.cdc.gov/ House Bill 4133 established the including those in emergency vitalsigns/maternal-deaths/index.html. departments, to elicit information Accessed 27 August 2019. Oregon MMRC. The multidisciplinary 2. Peterson EE, Davis NL, Goodman D et committee, made up of 15 Governor- about pregnancy within the past year al. Vital Signs: Pregnancy-related deaths, appointed members, includes a variety in patients to provide information that United States, 2011–2015, and strategies of stakeholders with different areas can help reduce missed or delayed for prevention, 13 States, 2013–2017. diagnoses. At end of the day, even one MMWR 2019;68:423–9. DOI: http://dx.doi. of expertise. Under OHA direction, org/10.15585/mmwr.mm6818e1. the committee is charged with the maternal death is one too many. 3. CDC. Severe Maternal Morbidity in study and review of information FOR MORE INFORMATION the U.S. Available at www.cdc.gov/ • Oregon Health Authority Maternal reproductivehealth/maternalinfanthealth/ relating to the incidence of maternal severematernalmorbidity.html. Accessed13 mortality and severe maternal Mortality Review