Maternal Mortality

Examination of Years 2012-2016

 CODING OF PREGNANCY-RELATED DEATHS
Indicator ICD-10 Codes Pregnancy Checkbox
Maternal Death All O-Codes (Pregnancy, childbirth and the “Pregnant at Time of Death”
A maternal death is defined by the CDC and WHO as “a death of a puerperium) except O-96 and O97; A34 “Pregnant within 42 days of death”
woman while pregnant or within 42 days of termination of (Obstetric Tetanus)
pregnancy, irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes” (Alkema
et al, 2017).

Pregnancy-Related Death O96 (Death from any obstetric cause “Pregnant 43 days to one year of death”
The CDC defines a pregnancy-related death as “a death of a woman occurring more than 42 days but less than
while pregnant or within one year of the end of a pregnancy— one year after delivery);
regardless of the outcome, duration or site of the pregnancy–from
any cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes” (CDC).

Pregnancy-Associated Death Any code “Pregnant at Time of Death”

A death of a woman during pregnancy or within one year of the end “Pregnant within 42 days of death”
of pregnancy irrespective of cause “Pregnant 43 days to one year of death”

References: Alkema, Leontine et al. 2015. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic
analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet, Volume 387, Issue 10017, 462 – 474. CDC,
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html . Indicators are based on Vital Records data with no case review.
PREGNANCY CHECKBOX ON DEATH
CERTIFICATE
2012-2016 DC PREGNANCY-RELATED DEATHS

Pregnant 43
days to 1
year before
Pregnant at death, n=4
time of
death, n=8

Pregnant
within 42
days of
death, n=6
 PREGNANCY-RELATED MORTALITY,
DISTRICT OF COLUMBIA
Number of DC-Resident Maternal and Pregnancy-Related Deaths by Year, 2012-2016

3
0
5
3 3 1
2
1
2012 2013 2014 2015 2016
Maternal Deaths Additional Pregnancy-Related Deaths

Data Source: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health.
A maternal death is a death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
A death of a woman between 43 days to one year of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes is presented here as an additional
pregnancy-related death. Together, the two categories constitute pregnancy-related deaths.
 PREGNANCY-RELATED MORTALITY,
DISTRICT OF COLUMBIA
Number of DC-Resident Maternal and Pregnancy-Related Deaths by Ward, 2012-2016

1 1

4 4
1
2 2
1 1 1

Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 Missing

Maternal Deaths Additional Pregnancy-Related Deaths

Data Source: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health.
 PREGNANCY-RELATED MORTALITY,
DISTRICT OF COLUMBIA
Number of DC-Resident Maternal and Pregnancy-
Related Deaths by Race and Ethnicity, 2012-2016

13
1

Non-Hispanic Black Hispanic

Maternal Deaths Additional Pregnancy-Related Deaths

Data Source: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health.
 MATERNAL AND PREGNANCY-RELATED
MORTALITY, DISTRICT OF COLUMBIA
Maternal and Pregnancy-Related Mortality Rates among District of Columbia Residents and
US Total Population, 2012-2016
Rate Per 100,000 Live Births

70.0
60.0
50.0
37.8
40.0
29.4 28.0
30.0 21.2
20.0
10.0
0.0
Maternal Mortality Rate Pregnancy-Related Mortality Rate
District of Columbia United States
The maternal mortality rate is the number of DC-resident maternal deaths per calendar year divided by the total number of live births to residents. The value is multiplied by 100,000 to present a rate per 100,000
live births. Similarly, the pregnancy-related mortality rate is the number of pregnancy-related deaths per calendar year divided by the total number of live births during the calendar. 95% Confidence Intervals
estimated using a Poisson distribution are shown in blue.
Data Sources: For DC: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health. US Natality Data: United States Department of Health and
Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data 2007-2016, on CDC WONDER Online
Database; US Mortality Data: CDC, NCHS. Underlying Cause of Death 1999-2016 on CDC WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016, as
compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
 DISTRIBUTION OF UNDERLYING CAUSES OF DEATH AMONG DC-
RESIDENT MATERNAL DEATHS, 2012-2016

Underlying Cause N Deaths

Other specified pregnancy-related conditions 3
Complications of the puerperium, not elsewhere classified -- Cardiomyopathy in the puerperium 2
Complication of labor and delivery, unspecified 1
Diseases of the respiratory system complicating pregnancy, childbirth and the puerperium 1
Ectopic pregnancy, unspecified 1
Other complications of obstetric surgery and procedures 1
Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium 1
Phlebitis and thrombophlebitis of other and unspecified deep vessels of lower extremities 1
Pre-existing hypertensive heart disease complicating pregnancy, childbirth and the puerper 1
Premature separation of placenta, unspecified 1
Rupture of uterus during labour as occurring before onset of labour 1

Data Source: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health.
 DISTRIBUTION OF UNDERLYING CAUSES OF DEATH AMONG DC-RESIDENT
DEATHS TO WOMEN PREGNANT WITHIN A YEAR OF DEATH WHO WERE
NOT CAPTURED AS A PREGNANCY-RELATED DEATH, 2012-2016
Underlying Cause Frequency
Person injured in motor-vehicle accident, traffic 3
Assault 2
Malignant neoplasm of breast 2
Accidental poisoning 1

Data Source: 2012-2016 D.C. Birth and Death Data, Vital Records Division, Center for Policy Planning and Evaluation, D.C. Department of Health.
PREGNANCY/BIRTH CHARACTERISTICS
2012-2016 DC PREGNANCY-RELATED DEATHS

Among 18 pregnancy-related deaths, we identified:

• 7 birth records
o 2 maternal deaths occurred within 1 week of the newborn’s birth; 1 maternal death
occurred 8-42 days after the birth; 4 maternal deaths occurred between 43-364 days
o Route - 3 were delivered by cesarean section; 4 were delivered spontaneously
o Labor augmentation – 3 mothers had their labor augmented while 4 did not
o Birth outcomes – 1 birth were classified as preterm; 2 were classified at low birthweight
o Smoking status – 1 mother smoked at least one cigarette prior to pregnancy and during
pregnancy; 1 additional mother smoked at least one cigarette during pregnancy
o Pre-pregnancy weight – 3 mothers were classified as overweight; 4 mothers were
classified as obese
o Number of prenatal visits – 7 decedents attended 13 or fewer prenatal visits
o 5 decedents received WIC; 2 decedents did not receive WIC
PREGNANCY CHARACTERISTICS
2012-2016 DC PREGNANCY-RELATED DEATHS

Among 18 pregnancy-related deaths, we identified:

• 2 fetal death records
o Both maternal deaths occurred within 1 week of the fetal death
o Route – 1 woman delivered spontaneously and 1 was delivered via cesarean section
o Smoking status – 1 mother smoked at least one cigarette prior to pregnancy
o Pre-pregnancy weight – 1 woman was classified as overweight prior to pregnancy; 1
woman was classified as obese prior to pregnancy
BEYOND MORTALITY
EXAMINATION OF DELIVERIES WITH SEVERE COMPLICATIONS

• Given DC’s small population size and the rarity of maternal death, it is
difficult to examine patterns in MMR and challenging to identify populations
at higher risk by examining the mortality data alone

• Annual hospital discharge data provides information on all women who

experienced severe maternal morbidity during hospital-based deliveries

• The larger N  more stable trend over time, and provides more flexibility to
examine patterns by subgroups
SEVERE MATERNAL MORBIDITY, DEFINED
• Severe Maternal Morbidity includes unexpected outcomes of labor and delivery that result in significant short-
or long-term consequences to a woman’s health. The definition includes the following 21 specific morbidities:

– Acute myocardial infarction – Severe anesthesia complications

– Acute renal failure – Sepsis
– Adult respiratory distress syndrome
– Shock
– Amniotic fluid embolism
– Aneurysm – Sickle cell disease with crisis
– Cardiac arrest/ventricular fibrillation – Air and thrombotic embolism
– Disseminated intravascular coagulation – Blood transfusion
– Eclampsia – Conversion of cardiac rhythm
– Heart failure/arrest during surgery or procedure
– Hysterectomy
– Puerperal cerebrovascular disorders
– Pulmonary edema/acute heart failure – Temporary tracheostomy
– Ventilation

Source: CDC, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

 SEVERE MATERNAL MORBIDITY
NUMBER OF SEVERE MATERNAL MORBIDITIES EXPERIENCED BY DC-RESIDENTS
DELIVERING BIRTH AT DC HOSPITALS BY TYPE OF MORBIDITY, 2012-2016

660

111
52 46 38 33 31 25 18 13 12 9 6 4 3 1 1 1

Data Source: Hospital Discharge Data for 2012-2016, DC Hospital Association. Compiled by State Health Planning and Development Agency (SHPDA), Center for Policy,
Planning and Evaluation, DC Department of Health. Numbers represent instances of maternal morbidity during delivery-hospital stays; women with multiple severe
morbidities are counted multiple times in this chart. Preliminary analysis as of 3/27/2018. Two women who died during the hospital stay are excluded to reduce double
counting between mortality and morbidity analyses.
 SEVERE MATERNAL MORBIDITY
NUMBER OF DC-RESIDENTS WITH SEVERE MATERNAL MORBIDITIES WHILE
DELIVERING BIRTH AT DC HOSPITALS BY YEAR, 2012-2016
250
N. Deliveries with Severe

200
Morbidity

150
128
109 107
132 85
100

50
71 68 70 74
46
0
2012 2013 2014 2015 2016

Any severe morbidity excluding Blood Transfusion Only Blood Transfusion Only

Data Source: Hospital Discharge Data for 2012-2016, DC Hospital Association. Compiled by State Health Planning and Development Agency (SHPDA), Center for
Policy, Planning and Evaluation, DC Department of Health. International Classification of Diseases (ICD) diagnosis and procedure codes were used to identify
severe maternal morbidities occurring during delivery hospital stays. Preliminary analysis as of 3/27/2018. Two women who died during the hospital stay are
excluded to reduce double counting between mortality and morbidity analyses.
 SEVERE MATERNAL MORBIDITY
TREND IN RATE OF SEVERE MATERNAL MORBIDITY AMONG DC-RESIDENT
HOSPITAL-BASED DELIVERIES, 2012-2016

250.0
SMM Per 10,000 Deliveries

200.0

150.0

100.0

50.0

0.0
2012 2013 2014 2015 2016

Any severe morbidity Any severe morbidy excluding blood transfusion only Blood transfusion only

Data Source: Hospital Discharge Data for 2012-2016, DC Hospital Association. Compiled by State Health Planning and Development Agency (SHPDA), Center
for Policy, Planning and Evaluation, DC Department of Health. Preliminary analysis as of 3/27/2018. Two women who died during the hospital stay are
excluded to reduce double counting between mortality and morbidity analyses.