Obesity and Maternal Death in Virginia, 1999-2004

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Maternal Mortality Review TeamVirginia Department of Health

Office of the Chief Medical Examiner

Victoria M. Kavanaugh, RN, PhDCoordinator

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Historical Perspective

Maternal death review dates to 1928 in Virginia.

Collaboration between the Medical Society of Virginia and Virginia Department of Health.

Early reviews focused on medical issues and natural deaths.

Lack of funding and support: review activities declined in 1990s.

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Historical Perspective (cont.)

Throughout the 1900’s, the maternal mortality rate declined significantly:

Principles of asepsis were institutedShift from home to hospital deliveries Institutional practice guidelines and guidelines defining

physician qualifications for hospital delivery privilegesUse of antibioticsSafer blood transfusionsBetter management of hypertensive disorders of

pregnancy

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Historical Perspective (cont.)

“Healthier Mothers and Babies” as measured by the decline in infant mortality and maternal mortality was considered to be one of the “Ten Great Public Health Achievements in the US, 1900-1999”*

*MMWR, April 2, 1999/48(12);241-243.

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Historical Perspective (cont.)

Since 1982, there has been no further decline in maternal mortality.

Maternal mortality rates rose during 2003, 2004, 2005 (possibly due at least in part to improved identification of cases).

1999 9.9

2000 9.8

2001 9.9

2002 8.9

2003 12.1

2004 13.1

2005 15.1

2006 13.3

2007 12.7

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Challenge for the 21st Century

Reduce the US maternal mortality rate to 11.4 per 100,000 live births by 2020.

US ranks 31st among other developed countries in maternal mortality. ( Virginia ranks 17th in the US.1)

US population has maternal mortality rates substantially lower in some racial/ethnic subgroups with no definable biologic reason to indicate an irreducible minimum has been reached.

1National Women’s Law Center Report Card, Maternal Mortality Rate, 1999-2004

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Virginia Maternal Mortality Review Team Purpose

understand the causes of maternal death.

educate colleagues and policymakers about these deaths and the need for changes.

recommend improvements for prevention.

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Team Values Public health approach

Emphasis on interventions and preventability

Multidisciplinary review

Confidentiality – Team members receive no identifying information

Retrospective review

Consensus decision-making

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Maternal Mortality Review Team Membership

Virginia Chapters of … American College of Nurse

Midwives American College of

Obstetricians and Gynecologists National Association of Social

Workers Association of Women’s Health,

Obstetric and Neonatal Nurses (AWHONN)

Medical Society of VirginiaRegional Perinatal CouncilsVirginia Hospital and Healthcare

AssociationVirginia Perinatal AssociationThe Virginia Sexual and Domestic

Violence Action AllianceVirginia Dietetic Association

Virginia Department of Health … Family Health Services Local Health Department Office of Chief Medical Examiner Vital Records Women’s and Infant’s Health

Virginia Department of Behavioral Health and Developmental Services

Virginia Department of Social Services

Virginia Department of Medical Assistance Services

Psychiatry

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Case Definition

Pregnancy-Associated Maternal Death:

All deaths of women occurring during pregnancy or within one year of termination of pregnancy.

Regardless of cause of death.Regardless of outcome of

pregnancy.

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Case Review - three primary questions

1. Was this death pregnancy related?

2. Was this death preventable?

3. What factors contributed to the death and what reasonable changes could have been made to alter the outcome?

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Preventable?

Preventable death is broadly defined as a death that may have been averted by one or more changes in:

clinical care facility infrastructurecommunitysystems response to patient factors

These determinations were made with the benefit of retrospective review and current clinical practice guidelines.

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Contributors to Death

As each case was reviewed, the Team identified factors within

those four categories that contributed to death in that

case.

After review of the first 4 years of cases, the Team looked at the findings and identified a major risk factor for pregnancy-associated death in Virginia:

Obesity

The Team published, “Obesity and Maternal Death in Virginia, 1999-2002” in March of 2009.

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Identification of Risk Factors for Maternal Death

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Increased risk for hypertension

Increased risk for Type 2 diabetes

Increased risk for heart disease

Increased risk for certain cancers (Nearly ½ of all endometrial or uterine cancers are believed to be caused by excess body fat.)

Increased risk for pregnancy complications such as pre-eclampsia which are associated with morbidity later in life

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The Problem of Obesity….

BMI Category

< 18.5Underweight

18.5 – 24.9 Normal weight

25.0-29.9Overweight

>30 Obese17

Measuring Obesity – Body Mass Index (BMI)

137 women died from natural causes while pregnant or within one year of a pregnancy in Virginia during the review period, 1999-2004.

102 (74.4%) of those cases had both height and prepregnancy weights listed in the record from which prenatal BMI was calculated and are included in this report.

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Identification of Cases (N=102)

Prepregnancy BMI ranged from 16.3 to 58.5

Average BMI was 29.96 (30.0 = Obese)

5 deaths were to underweight women32 deaths were to normal weight women24 deaths were to overweight women41 deaths were to obese women

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Prepregnancy BMI Among Women who Died within One Year of Pregnancy in Virginia,

1999-2004 (N=102)

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Percentage of Cases in Each BMI Category Among Women Who

Died

5% Underweight

31% Normal Weight

24% Overweight

40% Obese

Prepregnancy BMI Categories for a Sample of Women in the

United States, 2003

21CDC Pediatric and Pregnancy Nutrition Surveillance System, 2003 Pregnancy Nutrition surveillance, Nation.

12% Underweight

45% Normal Weight14%

Over-weight

29% Obese

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Chart Title

24% Overwt.

40% Obese

Women Who Died

14.5% Overwt.

28.5% Obese

All US Women

A Closer Look:

Prepregnancy BMI Category and Age of Women Who Died in

Virginia

  20-29 Years Old 30-39 Years Old

  # % # %

Underweight 1 2.3 4 6.8

Normal Weight 15 34.9 17 28.8

Overwt./obese 27 62.8 38 64.4

Total 43 100 59 100

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  White Black Asian Other

# % # % # % # %

Underweight 2 4.1 2 4.4 1 20.0 0 0

Normal wt. 15 30.6 13 28.9 3 60.0 1 33.3

Overwt./obese 32 65.3 30 66.7 1 20.0 2 66.6

Total 49 100 45 100 5 100 3 100

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Prepregnancy BMI Category by Race Among Women Who Died in Virginia

 

Total (Includes Asian and women of Other races) White Black

No. Ratio No. Ratio No. Ratio

Underweight 5 7.1

17 7.1 15 22.5Normal 32 12.2

Overweight 24 28.3

32 19.2 30 45.6Obese 41 24.6

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Estimated Maternal Mortality Ratio by BMI Category and Race in Virginia, 1999-2004

Estimates of maternal mortality ratios for each BMI category were calculated using percentages of women in each BMI category in the national sample of prepregnancy BMI categories.

Causes of Death by BMI Category

Underweight/Normal Weight

Cardiovascular Disorders = 11 (28.9%)

Infection = 5 (13.1%)

Hemorrhage and Exacerbation of Chronic Conditions = 4 each (10.5% each)

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Overweight/Obese

Cardiovascular Disorders = 20 (30.8%)

Cancer = 14 (21.5)

Pulmonary Embolism = 10 (15.4%)

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Mode of Delivery by BMI Category, and All Live Births

in Virginia, 2002

Normal Weight

Overweight Obese All Live Births0

1020304050607080

Vaginal Delivery Cesarean DeliveryOther PATD

Two women classified as overweight were pregnant at the time of death and died from cardiac disorders. There was one stillbirth.

Among the obese women, there was one miscarriage, one ectopic pregnancy and five losses due to the mother’s death.

Fetal losses resulted from the mother’s death due to pulmonary embolism, cancer, cardiac arrest or arrhythmia.

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Fetal and Infant Losses

38.4% had at least one miscarriage prior to the most recent pregnancy

23.1% had a previous pregnancy complication such as gestational hypertension, preeclampsia, p0st partum hemorrhage, hyperemesis gravidarum, preterm labor.

10.8% had gestational diabetes in this or a prior pregnancy

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Overweight and Obese Women Who Died (n=65)

35.4% died within one week of delivery with an additional 9.3% dying before six weeks post partum.

64.0% of the deaths of overweight and obese women were determined by the Maternal Mortality Review Team to be directly related to the pregnancy.

31.2% were thought to be preventable with reasonable systems changes. 30

Overweight and Obese Women Who Died (n=65)

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Maternal Mortality Review Team Recommendations to Address Obesity

• All providers should educate patients about the adverse physical effects of being overweight and obese especially during pregnancy.

• Providers of pregnancy-related services should promote the use of WIC by disseminating a description of the program and eligibility requirements to all pregnant women and new mothers.

All healthcare providers should be informed about the specialized level of care needed for obese pregnant patients. Emphasis should be placed on:

preconception counseling for all women on the risks associated with obesity and pregnancy;

identification of obesity as a diagnosis in and of itself requiring supplemental testing or consult for care. 32

Recommendations continued

All schools in Virginia should participate in the Governor’s Nutrition and Physical Activity Scorecard which provides incentives to schools for implementing research based best practices supporting proper nutrition and increased physical activity.

All employers should provide a health improvement program to employees which includes weight management strategies.

Third party payers should provide coverage for dietary counseling, education, and nutrition therapy for individuals with BMIs greater than 30.0.

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Recommendations continued…

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Program Contact

Victoria Kavanaugh, RN, PhDMaternal Mortality Review CoordinatorOffice of the Chief Medical Examiner

737 North 5th StreetRichmond, VA 23219

(804) 205-3853 (804) 786-0391 fax

Victoria.kavanaugh@vdh.virginia.gov

http://vdhweb/medexam/index.asp