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Pregnancy-Related Mortality -- Georgia, 1990-1992

Many pregnancy-related deaths are preventable. State-based surveillance is important for identifying such deaths and developing prevention strategies. Surveillance for pregnancy-related deaths based only on ascertainment through death certificates underestimates actual deaths (1-7). However, when this surveillance method has been supplemented by linking death certificates of reproductive-aged women to birth and fetal death records, ascertainment has increased 1%-153% (1,2,4,6,7). In 1994, the Division of Public Health, Georgia Department of Human Resources, assessed the completeness of reporting of pregnancy-related deaths during 1990-1992 by comparing current death-certificate-based surveillance with a supplemental method of linking women's death records and infants' birth records. This report characterizes the increase in the total number of pregnancy-related deaths identified and presents specific causes of pregnancy-related deaths in Georgia.

In this analysis, pregnancy-related deaths were defined as the immediate result of complications of pregnancy, events initiated by the pregnancy, or an exacerbation of an unrelated condition by the physiologic or pharmacologic effects of the pregnancy that occurred up to 1 year after giving birth or pregnancy termination (8). For both surveillance methods, deaths among women during pregnancy or post partum were first identified, then categorized by specific cause, and coded as pregnancy-related using the American College of Obstetricians and Gynecologists (ACOG) and CDC definitions. In Georgia, physicians, medical examiners, and coroners are required to indicate on the death certificate, regardless of cause of death, whether the decedent was pregnant at the time of death or had given birth within the preceding 90 days. For the current surveillance method, deaths during pregnancy or post partum were identified by manually reviewing each death certificate for this notation or for a cause of death related to the pregnancy or selected key words (e.g., cesarean delivery). For the record-linkage method, females were identified who died within 1 year of delivering a live-born infant by linking death certificates for females aged 10-49 years who died during 1990-1992 to birth records for 1989-1992. A probabalistic method was used to calculate the likelihood of a correct linkage based on use of the mother's first and last names and date of birth. All death and birth record matches identified by the linkage were manually reviewed. The pregnancy-related mortality ratio during 1990-1992 was calculated as the number of pregnancy-related deaths divided by the number of live births during the period.

During 1990-1992, a total of 210 deaths among women during pregnancy or post partum were identified by death-certificate review and record linkage. Of these, 73 (35%) were pregnancy-related, 65 (31%) resulted from a medical problem unrelated to the pregnancy, and 72 (34%) resulted from injuries Table_1. Of the 135 additional deaths identified by record linkage, 118 (87%) were caused by injuries and medical problems unrelated to pregnancy Table_1. Although 35 (26%) of the 135 deaths occurred within 90 days of giving birth or pregnancy termination (i.e., the specified time in Georgia for indicating a recent pregnancy on the death certificate), this information was not indicated on the death certificate.

As a result of record linkage, the pregnancy-related maternal mortality ratio during 1990-1992 increased 30%, from 16.8 deaths per 100,000 live births (based only on death-certificate review) to 21.9 per 100,000 (based on combined death-certificate review and record linkage).

The three leading causes of pregnancy-related death -- hemorrhage, embolism, and infection -- were the same for deaths identified by the current surveillance method and the combined methods Table_2. Compared with the current surveillance method, record linkage resulted in increased case ascertainment for all but two specific causes of death (pregnancy-induced hypertension and anesthesia complications). The largest percentage increase in pregnancy-related deaths (200%) was for cardiomyopathy. Reported by: V Floyd, MD, C Hadley, MN, Family Health Br; M Lavoie, MA, Center for Health Information; Office of Perinatal Epidemiology, Epidemiology and Prevention Br; K Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of Human Resources. Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: In Georgia, ascertainment of pregnancy-related deaths improved substantially when death certificates were linked to birth records -- a result also documented in other states (2,4,6). However, compared with other states, the percentage increase in pregnancy-related deaths in Georgia was lower. This finding may reflect more complete death-certificate-based ascertainment in Georgia and the linkage of live-birth records only instead of both fetal death and live-birth records. The variation among states in the percentage of additional pregnancy-related deaths identified by linked records (1%-153%) also may be associated with such factors as differences in definitions of maternal death, variables used to match records, and methods used to link records.

A year 2000 national health objective is to reduce the maternal mortality rate to no more than 3.3 deaths per 100,000 live births (objective 14.3). The findings in this report indicate that the pregnancy-related mortality ratio in Georgia is higher than previously estimated (9) and that efforts must be intensified to attain the objective. State health departments should enhance ascertainment of pregnancy-related deaths through linkage of birth and fetal death records to death records of reproductive-aged women to more accurately track pregnancy-related mortality.

References

  1. Allen MH, Chavkin W, Marinoff J. Ascertainment of maternal deaths in New York City. Am J Public Health 1991;81:380-2.

  2. CDC. Misclassification of maternal deaths -- Washington state. MMWR 1986;35:621-3.

  3. Speckhard ME, Comas-Urrutia AC, Rigau-Perez J, Adamsons K. Intensive surveillance of pregnancy-related deaths, Puerto Rico, 1978-1979. Bol Asoc Med P R 1985;77:508-13.

  4. CDC. Enhanced maternal mortality surveillance -- North Carolina, 1988 and 1989. MMWR 1991; 40:469-71.

  5. Comas A, Navarro A, Conde J, Blasini I, Adamsons K. Misreporting of maternal mortality in Puerto Rico. Bol Asoc Med P R 1990;82:343-

  6. Dye TD, Gordon H, Held B, Tolliver NJ, Holmes AP. Retrospective maternal mortality case ascertainment in West Virginia, 1985 to 1989. Am J Obstet Gynecol 1992;167:72-6.

  7. Rubin G, McCarthy B, Shelton J, Rochat RW, Terry J. The risk of childbearing re-evaluated. Am J Public Health 1981;71:712-6.

  8. CDC. National pregnancy mortality surveillance coding manual. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992.

  9. Ledbetter JG, Galvin VG. Healthy Georgians 2000. Atlanta: Georgia Department of Human Resources, Division of Public Health, Center for Health Information, October 1993.



Table_1
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TABLE 1. Number and percentage of deaths among women during pregnancy or
postpartum, by cause of death and surveillance method -- Georgia, 1990--1992
============================================================================
                                               Death certificate review
                            Death certificate     and record linkage
                               review only           record linkage
                            -----------------  -------------------------
Cause of death                No.       (%)          No.       (%)
----------------------------------------------------------------------------
Pregnancy-related *           56      ( 74.7)        73      ( 34.7)
Medical problem
  unrelated to pregnancy       6      (  8.0)        65      ( 31.0)
Injury                        13      ( 17.3)        72      ( 34.3)

Total                         75      (100.0)       210      (100.0)
----------------------------------------------------------------------------
* Defined by the American College of Obstetricians and Gynecologists and CDC
  as the immediate result of complications of pregnancy, events initiated by
  the pregnancy, or an exacerbation of an unrelated condition by the
  physiologic or pharmacologic effects of the pregnancy.
============================================================================

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Table_2
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Number and percentage of pregnancy-related deaths *, by cause of death
and surveillance method -- Georgia, 1990-1992
===============================================================================
                    Death certificate             Death certificate review
                       review only                   and record linkage
                    ------------------            -------------------------
Cause of Death        No.       (%)                    No.         (%)
-------------------------------------------------------------------------------
Hemorrhage            16      ( 28.6)                  17        ( 23.3)
Embolism              12      ( 21.4)                  16        ( 21.9)
Infection              6      ( 10.7)                   8        ( 11.0)
Pregnancy-induced
  hypertension         4      (  7.1)                   4        (  5.5)
Pulmonary
  problems             4      (  7.1)                   6        (  8.2)
Anesthesia
  complications        3      (  5.4)                   3        (  4.1)
Cardiovascular
  problems +           2      (  3.6)                   3        ( 12.3)
Cardiomyopathy         2      (  3.6)                   6        (  8.2)
Other causes           7      ( 12.5)                  10        ( 13.7)

Total                 56      (100.0)                  73        (100.0)
-------------------------------------------------------------------------------
* Defined by the American College of Obstetricians and Gynecologists as the
  immediate result of complications of pregnancy, events initiated by the
  pregnancy, or an exacerbation of an unrelated condition by the physiologic
  or pharmacologic effects of the pregnancy.
+ Excludes cardiomyopathy.
===============================================================================

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