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Maternal MortalityInternationalUnited StatesWashington State
Thomas R. Easterling, MDProfessor
Maternal-Fetal MedicineUniversity of Washington
Seattle, WA
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Georgia
Ivory CoastNigeriaCameroon
NamibiaBotswanaSouth AfricaSwazilandZimbabweMozambiqueMalawi
Georgia
Afghanistan
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Hemorrhage
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
HypertensionIndiaMMR 323≤ 10%
MexicoMMR 5720-30%
ColumbiaMMR 76
≥30%
ChileMMR 4120-30%
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
AbortionHypertension
Hemorrhage
Hemorrhage
Hypertension
Hemorrhage
Hypertension
Hypertension
Hemorrhage
Embolism
Embolism
Embolism
Africa - South Asia• MMR 300-600/100,000• 9% Hypertension
Latin America - Caribbean• MMR 50-100/100,000• 25% Hypertension
Canada• MMR 6.1/100,000• 14% Hypertension
Netherlands• MMR 8.8/100,000• 39% Hypertension
Latin America-Caribbean
Africa Asia
Developed Countries
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Delay in Diagnosis• Asymptomatic until severe• Technology required• Skilled operator
Delay Reaching Care• Roads• Access to vehicles• Social customs
Delay Appropriate Care• MgSO4• Blood pressure control• Delivery
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Lucknow Nagpur VelloreDeliveries 4652 9600 8702MMR 319 376Booked 3.2% 65% 100%Eclampsia Rate 5.4% 2.6% 0.6%Case-Fatality Rate 14.7% 8.1%* 6.1%
Treatment of Preeclampsia Low Resource Settings
Lucknow
Vellore
Nagpur
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Eclampsia Rate /10,000 births
High-income Countries Low-income Countries
>10Xreduction
minimalreduction
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Eclampsia Case Fatality Rate (%)
High-income Countries Low-income Countries
>10Xreduction minimal
reduction
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Perinatal Advisory CommitteeMaternal Mortality Subcommittee
• Thomas Benedetti• Sherilynn Casey
(2004)• Kathy Chapman• Jane Dimer• Thomas Easterling• Leslee Goetz• Ann Lima• Nancy O’Brien Abel
• Dale Reisner• Melissa Schiff• Polly Taylor• Danae Steele (2001)• Carla Syverson• Cathy Wasserman• Jeanette Zaichkin (2001)
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Introduction
• Concerns were raised in late 1990s about maternal mortality in WA and whether it was increasing.
• Death certificates at that time were known to undercount maternal deaths.
• Perinatal Advisory Committee convened a subcommittee to explore maternal mortality surveillance in 1999.
• Initial findings presented in 2001 and again in 2004, but methodology was incomplete.
• Ascertainment methodology now complete for 1990-2005.
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Definitions
• A Pregnancy-Associated Death is the death of a woman while pregnant or within a year of delivery or termination of pregnancy from anycause.
• A Pregnancy-Related Death is the death of a woman while pregnant or within a year of delivery or termination of pregnancy from any cause related to or aggravated by pregnancy or its management.
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Pregnancy-Related Mortality in Washington
0.02.04.06.08.0
10.012.014.016.0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Deat
hs p
er 1
00,0
00 L
iveb
irths
3 Year Maternal Mortality Ratio Maternal Mortality Ratio
On Average 7 deaths reported per year
Maternal Mortality Ratio – 8.3 deaths per 100,000 live births
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Pregnancy-Related Deaths by CauseWashington, 1990-2005
MMR 7-8/100,000
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Preventability of Pregnancy-Related DeathsWashington, 1990-2005
Cause of DeathTotal
DeathsPreventable
Deaths
Possibly Preventable
Deaths
Not Preventable
DeathsInfection 19 1 16 2Cardiac/Cardiovascular 19 2 8 9Deep Vein Thrombosis 13 0 2 11Amniotic Fluid Embolism 12 1 2 9OB Hemorrhage 12 5 6 1Hypertension 9 9 0 0CNS/CVA 7 0 1 6Anesthesia 2 2 0 0Other Cause 9 2 5 2Don't Know 3 0 3 0Total 105 22 43 40
Pregnancy-Related Mortality Ratio = = 8.3 per 100,000 livebirths105
1,272,309
If remove 22 preventable deaths =
If remove 65 preventable and possibly preventable deaths
831,272,309 = 6.5 per 100,000 livebirths
=40
1,272,309 = 3.1 per 100,000 livebirths
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Maternal MortalityWashington State
2009-2012preliminary analysis
Births 350,306
Minimum MaximumPregnancy Related Deaths 32 47MMR/1000,000 live births 9.1 10.6
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Washington
1990 to2005
2009 to2012
7-8 9.1
Washington State
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Maternal MortalityWashington State
2009-2012preliminary analysis
Births 350,306
AFE CNS CV Arryth CM MI pHTNN 1 3 14 2 7 2 1MMR 0.29 0.86 4.0 0.57 2.0 0.57 0.29/year 0.25 0.75 3.5 0.5 1.75 0.5 0.25
Hem Ectopic Inf H1N1 PreE PEN 3 4 1 2 2 3MMR 0.86 1.14 0.29 0.57 0.57 0.86/year 0.74 1.0 0.25 0.5 0.5 0.75
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015
Hemorrhage*
9.4%0.75/yr
Hypertension9.4%
0.75/yr
Infection*3.1%
0.25/yr
AFE3.1%
0.25/yr
Pulm Emb9.4%
0.75/yr
CM22%%1.75/yr
CardioVasc44%
3.5/yr
Washington State 2009-2012CVA9.4%
0.75/yr
Presented at the Washington State Hospital Association – Safe Deliveries Safe Table – Feb. 10, 2015