Classification of Pregnancy-Related Mortality based on Death Certificate versus Medical Chart Review...
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Transcript of Classification of Pregnancy-Related Mortality based on Death Certificate versus Medical Chart Review...
Classification of Pregnancy-Related
Mortality based on Death Certificate
versus Medical Chart Review Michigan, 1990-1998
Joanne G. Hogan, PhDBao-Ping Zhu, MD, MS
Division of Epidemiology ServicesCommunity Public Health Agency
Michigan Department of Community Health
Background
• U.S. maternal mortality among the highest in industrialized nations
• No decline since 1982• Statistics based on Death certificate
– ICD-9 630 - 676
• World Health Organization Definition• Death within 42 days of end of pregnancy• Due to complications of pregnancy• Chain of events initiated by pregnancy• Aggravation by physiologic or pharmacological effects
of pregnancy
Goal of Study
Improve Identification,
Classification and Knowledge
of Pregnancy-Related Deaths
Methods
Review medical charts and supporting documentation to compare
classifications
Death Certificate and
Michigan Maternal Mortality Study Medical Review Committee
Study Definition and Data Sources
Maternal death: – Death matched to live birth in previous 365
days– Death of woman while pregnant
Reporting sources for maternal deaths– Hospitals– Medical Examiners– Michigan Department of Community Health,
Division of Vital Records
Pregnancy-Associated and Related Mortality Ratio by Race, Death Certificate
NumberMortality Ratio
(/100,000 live births)
Pregnancy-Associated516 41.0 White 269 27.4 Black 228 92.8
Pregnancy-Related 90 7.1 (.ICD-9 630-376 on birth certificate-365 days)
White 33 3.4 Black 53 21.6
Black/White Ratio 6.4
Cases Reviewed
Number Percent
Selected for Review 232 44.9%
Reviewed 217 93.5%
No chart available 13 5.6%
Awaiting review 2 0.1%
Classified Pregnancy- 169 77.9%Related by MMMS Committee
Death Certificate Pregnancy-Related Cause Committee Reclassification
Pregnancy-Related - DC Total 90Selected for Review 86 95.5%
No chart/awaiting review 5 5.8%
DC/Committee Agreement 77 89.5%
Reclassified Unrelated 2 2.3%(1 Black, 1 Native American)
Reclassified Undetermined 2 2.3%(2 Black)
Characteristics of Reclassified CasesPregnancy-Related on Death Certificate
Death Certificate Cause Committee Cause
Abortion/spontaneous Ventricular fibrillationand induced (3) Cardiac arrest
Bacteremia
Obstetric air embolism (1) Pulmonary embolism
Characteristics of Reclassified CasesPregnancy-Related on Death Certificate
Number Number
Time of DeathNo Live Birth 3 >42 days 1
Autopsy Yes 3 No 1
Place of Death DOA/ER 3 Inpatient 1
Prenatal Care Yes 1 No 3(Native American 1) (Black 3)
Reclassification of Death CertificateNon-pregnancy-Related Cause
Number Percent
Total cases reviewed 217
Classified Pregnancy-Related by Committee 169 77.9%
Reclassified from Death Certificate by Committee as Pregnancy-Related 92 70.2%
Reclassified Cases - CauseNon-Pregnancy-Related on Death Certificate
No patterns for
Race Prenatal carePlace of Death Time to deathResidence Birth attendantEducation Birth placeBirth outcome Payment
sourceMedical risk factorsComplications of pregnancy
Characteristics of Reclassified CasesNon-Pregnancy-Related on Death Certificate
Percent of Death certificates coded as underlying cause
Reviewed Reclassified
Circulatory System 56.5% 56.2%
Respiratory System 12.3% 83.3%
Reclassification of remaining reviewed causes evenly distributed
Pregnancy-Related Mortality Ratio by RaceCommittee Review
NumberMortality Ratio
(/100,000 live births)
Total 169 13.4
White 73 7.4
Black 91 37.0
Black/White Ratio 5.0
Comparison of Black/White Ratio Committee Review and Death CertificatePregnancy-Related deaths, three-year running average
0
1
2
3
4
5
6
7
8
9
90-92 91-93 92-94 93-95 94-96 95-97 96-98
Bla
ck/W
hite
Rat
io
Death Certifi cate
Committee
Black/White Ratio by Age Group Committee Review and Death Certificate
0
2
4
6
8
10
12
14
<20 20-29 30-39
Age Group
Bla
ck/W
hite
Rat
io
Death Certifi cate
Committee
Time of Pregnancy-Related Death by RaceDeath Certificate
White
<=42
days
55%
>42 days
15%
No Live
Birth
30%
Black
No Live
Birth
40%
<=42
days
54%
>42 days
6%
Time of Pregnancy-Related Death by RaceCommittee Review
White
<=42
days
56%
No
Live
Birth
27%
>42
days
17%
Black
<=42
days
64%
>42
days
9%
No
Live
Birth
27%
Study Limitations
Inability to identify all cases
Small numbers of events for
analysis
Summary
Reclassification as pregnancy -related
• resulted in a decrease of the black/white discrepancy
• Increased identification of black and white women with circulatory system complications
• Decreased racial discrepancy for pregnancy-loss
Public Health Recommendations
Increase information to physicians about need to specify pregnancy on death certificate
Increase information to physicians and women at risk about cardiovascular compromise in pregnancy-related mortality