INTRODUCTION :  In 1996, Florida initiated the Pregnancy-Associated Mortality Review (PAMR) process to improve surveillance and analysis of pregnancy-related mortality. PAMR uses the expanded definition of maternal mortality developed by the Centers for Disease Control and Prevention and the American College of Obstetrics and Gynecology: “…death of a woman, from any cause, while she is pregnant or within one year of termination of pregnancy, regardless of duration and site of the pregnancy.”

In the PAMR process, various methods are used to identify all deaths to women of reproductive age that may be pregnancy-associated. These deaths are then reviewed by a Department of Health nurse-physician team to make an initial categorization of the death as pregnancy-related, possibly pregnancy-related, or not pregnancy-related. All of the pregnancy-related deaths and a stratified, random sample of the possibly pregnancy-related and not pregnancy-related deaths are then reviewed by the PAMR team. The PAMR team is a multidisciplinary group of 31 professionals including physicians, nurses, nurse midwives, social workers, educators and researchers.

The PAMR process also includes case abstraction and review of the case abstracts by the PAMR review team. For more information about the PAMR process, please refer to “1999–2002 Florida Pregnancy-Associated Mortality Review (PAMR),” located at the following Web site: http://www.doh.state.fl.us/Family/mch/docs/pdf/PAMR99-02.pdf.

METHODS:  Pre-pregnancy height and weight data are collected in the PAMR process and are also collected for approximately 150,000 pregnant women annually on the Florida Healthy Start Prenatal Screening.  For this study, 215 pregnancy-related deaths that occurred in the period January 1999 through June 2006 were randomly matched to four prenatal screens, using marital status, age, and education as the matching criteria.  Conditional logistic regression was used to estimate the adjusted odds ratios for pregnancy-related mortality associated with black maternal race and four body mass index (BMI) categories (underweight – BMI < 18.5; overweight – BMI 25.0 to 29.9; obese – BMI 30.0 to 39.9; and morbidly obese – BMI 40.0+).  White maternal race and normal BMI (18.5 to 24.9) were used as the reference categories therefore the odds ratios for the maternal race and obesity factors are adjusted for associations between race and obesity.

RESULTS:  The pregnancy-related mortality adjusted odds ratio for women whose maternal race was black was 2.30 (95 percent confidence interval: 1.66 to 3.21). The adjusted odds ratios (with 95 percent confidence intervals in parentheses) for the underweight, overweight, obese, and morbidly obese categories were 1.82 (0.90 to 3.68), 1.69 (1.10 to 2.60), 2.62 (1.71 to 4.01), and 3.88 (2.17 to 6.92), respectively.  These were all statistically significant at the alpha 0.05 level except for the underweight category. 

CONCLUSION:  Increased risk of pregnancy-related death is significantly and substantially associated with black maternal race and high levels of BMI.  Encouraging women to achieve normal BMI before pregnancy may lower the risk of pregnancy complications and pregnancy-related death.  Further research is needed regarding the relationship between maternal race and obesity risk factors.

This research was conducted by Daniel Thompson, MPH, Angel Watson, MPH, RHIA, and Deborah Burch, RN, BS of the Florida Department of Health, Division of Family Health Services, Bureau of Family and Community Health.