In 1996, the Florida Department of Health initiated the Pregnancy-Associated Mortality Review (PAMR), to improve surveillance and analysis of pregnancy-related mortality. A pregnancy-related death is a death resulting from one of the following:
- complications of the pregnancy itself .
- the chain of events initiated by the pregnancy that led to death.
- aggravation of an unrelated condition by the physiologic or pharmacologic effects of the pregnancy that subsequently caused death.1
The Pregnancy-Associated Mortality Review (PAMR) is a case review process aimed at reducing Florida’s maternal mortality rate to the Healthy People 2010 objective of 3.3 deaths per 100,000 live births. The Project seeks to elucidate gaps in care, identify systemic service delivery problems, and recommend areas in which linkages between community resources can be improved to facilitate improvements in the system of care. The Project is loosely modeled after the National Fetal Infant Mortality Review (NFIMR) Project and borrows some concepts from the Centers for Disease Control and Prevention’s National Pregnancy Mortality Surveillance Project.
Why is the PAMR needed: Between 1985-1995, there was no systematic review of maternal deaths in Florida. In 1996, the PAMR Project began in Florida, using the CDC and American College of Obstetricians and Gynecologists’ expanded definition of maternal mortality to one of “pregnancy-associated deaths” that includes “death of a woman, from any cause, while she is pregnant or within 1 year of termination of pregnancy, regardless of duration and site of the pregnancy.” Using this definition, we found significant increases in the number of maternal deaths in Florida. The CDC and several other states have noted similar occurrences when the data were examined with similar methods. This means we may have been lulled into a false assumption that the rates of death have been low and therefore were not in need of scrutiny. It should be noted that these deaths may or may not be directly related to the pregnancy, but are associated with the pregnancy by time. The multidisciplinary case review process used by PAMR determines whether the death of each woman was directly related to the pregnancy or simply associated with the pregnancy by time.
How does PAMR work: After cases of maternal deaths are identified, they are sorted by a physician/nurse subcommittee and initially deemed pregnancy-related, possibly pregnancy-related, or not related. Cases are then selected for abstraction and review; all of the pregnancy-related and some of the possibly and not related are abstracted and reviewed each quarter. Upon completion of the abstraction, a multidisciplinary panel of health care practitioners and administrators from across the state assemble to review and analyze the reported de-identified findings. The multidisciplinary PAMR review team makes recommendations to organizations and groups who can best develop strategies to address the issues identified.
Data: In Florida, PAMR has shown that the pregnancy-related mortality ratio has remained fairly consistent ranging from 20.3 in 1999 to 23.0 in 2004. The Healthy People 2010 goal is to reduce maternal mortality to 3.3 maternal deaths per 100,000 live births. During 1999-2004, the PAMR team classified 234 cases as pregnancy-related deaths. The majority of the deaths (179; 76 percent) occurred during the postpartum period.
Many complications can occur in six to eight weeks or within one year following a pregnancy. The early postpartum period is critical to maternal survival. The American Academy of Pediatrics, American College of Obstetricians, and Gynecologists, and the American College of Nurse Midwives recommend that every postpartum woman should follow-up with her physician within four to six weeks after delivery or within 7-14 days after a cesarean delivery or complicated delivery.2
Of the 179 postpartum deaths, the number of days from date of live birth or fetal death was known for 160 cases. During this postpartum period, 139 (87 percent) were early postpartum deaths (0-42 days), and 21 (13 percent) were late postpartum deaths (43-365 days), as shown in Figure 2. The majority of these deaths occurred during the early postpartum period; within the recommended four to six week postpartum check-up. Sixty-five percent of the deaths occurred within two weeks of their live birth or fetal demise.
Of the 104 (65 percent) women dying during the first two weeks of their live birth or fetal demise, 30 percent were discharged and 70 percent were not discharged from the hospital. The leading causes of death were hypertension and embolism for those not discharged and cardiomyopathy, infection, and embolism for those discharged from the hospital.
Women who received no prenatal care were approximately eight times more likely to experience a postpartum pregnancy-related death. When compared to white women, black women were five times more likely to experience a postpartum pregnancy-related death. Additionally, women aged 35 and older (RR=2.9), who completed high school (RR=1.6), were unmarried (RR=1.2), were classified as overweight (RR=2.4) or obese I, II, or III, (RR= 4.1, 3.0, 7.4, respectively) were more likely to experience a postpartum pregnancy-related death.
Women significantly most at risk for a postpartum pregnancy-related death, from highest to lowest risk: received no prenatal care (CI:3.48,16.40), were classified as obese III (CI:4.24,12.89), of black race (CI:3.62,7.0), classified as obese I (CI:2.59,6.43), or obese II (CI:1.55,5.87), were aged 35 or older (CI:1.62,5.2), classified as overweight (CI:1.59,3.75), or had only a high school education (CI:1.13,2.18).
Florida’s pregnancy-related deaths have remained continually high. The research presented here is consistent with national research from the Maternal and Child Health Bureau which indicates women of black race, women aged 35 or older, and those who receive no prenatal care are at the highest risk for death from a pregnancy-related complication.3 Continued, ongoing monitoring of systems of care as well as further prevention research of cultural, health issues, and prevention programs are warranted.
Florida PAMR Committee Postpartum Recommendations:
Self-Empowerment – Systems must be in place to ensure the health needs of postpartum women are being met. Women and their families must know how to recognize the “danger signs,” where to access health care and what services are available.
Discharge Teaching – must be thorough, specific and education-level appropriate. Teaching should include information on the importance of seeking care for prolonged headache, shortness of breath, swelling, redness, warmth, or pain in lower extremities, chest pain, palpitations, and syncope. Teaching should also stress the importance of follow-up. Additionally, women with complex medical problems during delivery need to be carefully evaluated prior to discharge and may need longer hospital stays.
Emergency Personnel Training – to increase the awareness of potential cardio-respiratory complications in all postpartum women presenting to an emergency facility. Women presenting with cardio-respiratory symptoms require comprehensive evaluations.
Interconception Counseling – must be provided to all women concerning family planning, baby spacing, chronic illness, nutrition, exercise, and lifestyle habits.
For more information about the Pregnancy-Related Mortality Review (PRMR) or this study, please contact Deborah Burch, RN, BS, CPCE, Nursing Consultant/ PAMR Coordinator, at (850) 245-4465 or Deborah_Burch@doh.state.fl.us. The scientific portion of this report was prepared by Angel Watson, MPH, RHIA.
References:
1. Berg C, Danel I, Atrash H, Zane S, Barlett L. Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001.
2. Guidelines for Perinatal Care, Fifth Edition, 2002. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, page 159.
3. Women’s Health USA 2003: Maternal Mortality, Maternal and Child Health Bureau. Date accessed: 02/ 07/07. http://www.mchb.hrsa.gov/pages/page_55.htm.