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Ohio Maternal Health Data and Reports

Overview of Pregnancy-Related Deaths in Ohio

Maternal Mortality Definitions

Maternal mortality is commonly reported as trends in pregnancy-associated and pregnancy-related deaths. A pregnancy-associated death is defined as, “the death of a woman while pregnant or anytime within one year of pregnancy regardless of cause” (Pregnancy Mortality Surveillance System, 2019). A pregnancy-related death is a subcategory of pregnancy-associated deaths, and is defined as, “the death of a woman while pregnant or within one year of the end of a pregnancy–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” (Pregnancy Mortality Surveillance System, 2019). All pregnancy-related deaths are pregnancy associated, but not all pregnancy-associated deaths are pregnancy related. The figure below describes the relationship between pregnancy-associated and pregnancy-related deaths (Figure 1).        Figure 1. Maternal Mortality Definitions

What is the Difference Between Pregnancy-Related Death Data from CDC Pregnancy Mortality Surveillance System (PMSS) and Ohio Pregnancy-Associated Mortality Review (PAMR)?

The Centers for Disease Control and Prevention (CDC) Pregnancy Mortality Surveillance System (PMSS) is based only on vital statistics (e.g., birth certificate, death certificate, etc.) data submitted to the CDC by states. Medical epidemiologists review and analyze death records, linked birth records, and fetal death records if applicable, and additional available data from all 50 states, New York City, and Washington, DC.

Maternal Mortality Review Committees (MMRCs), like Ohio PAMR, access multiple sources of information beyond what is available in vital statistics records, such as medical records, social service records, etc. MMRCs have the potential to get the most detailed, complete data on maternal mortality that then supports their ability to make specific recommendations for prevention and to make determinations of pregnancy relatedness (Figure 1). The MMRC process for reviewing maternal deaths is the gold standard.

Thus, caution should be used when comparing pregnancy-related death data from MMRCs to data generated by PMSS. More information on the U.S. system can be found at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.

Pregnancy-Related Mortality Ratios in Ohio

Pregnancy-related mortality ratios (PRMR) are calculated as the number of pregnancy-related deaths divided by the total number of live births for a given time frame and are expressed per 100,000 live births.         Pregnancy-Related Mortality Ratio Example

The PRMR for Ohio has increased over time from 2008-18. The unit of measurement for PRMR is per 100,000 live births and was as follows: 10.8 in 2008, 23.5 in 2009, 15.8 in 2010, 18.1 in 2011, 14.5 in 2012, 11.5 in 2013, 10.8 in 2014, 15.8 in 2015, 11.6 in 2016, 29.2 in 2017, and 23.7 in 2018 (Figure 2).

Ohio PAMR currently has pregnancy-related mortality data for deaths that occurred from 2008-18. Please see page 74 of the Report on Pregnancy-Associated Deaths in Ohio, 2008-2016 for more information about the time intensive process required to generate this data.  Figure 2. Pregnancy-related mortality ratios have increased from 2008 to 2018 in Ohio.

Causes of Pregnancy-Related Mortality in Ohio, 2008-18

Figure 3 displays the underlying causes of pregnancy-related deaths in Ohio from 2008-18. The most common cause of death was mental health conditions (n=42), which includes deaths due to substance use disorder/overdose, depression, anxiety disorder, and other psychiatric conditions, followed by cardiovascular conditions  (n=36), infection (n=33), hemorrhage (n=26), pre-eclampsia and eclampsia (n=24), other/unknown causes, which includes deaths due to renal disease, anesthesia complications, autoimmune diseases, gastrointestinal diseases, metabolic/endocrine, neurologic conditions, pulmonary conditions, hematologic conditions, cancer, and unknown causes, cardiomyopathy (n=21), embolism (not amniotic fluid) (n=21), injury (n=13), amniotic fluid embolism (n=10), and cerebrovascular accident (n=9). Note that cardiomyopathy is a condition specific to the heart muscle and is separated from other cardiovascular and coronary conditions (Figure 3). Figure 3. Mental health conditions were the leading cause of pregnancy-related deaths in Ohio from 2008-2018.

Timing of Pregnancy-Related Mortality in Ohio, 2008-2018

Two-thirds (67%; n=173) of pregnancy-related deaths in Ohio from 2008-18 occurred during the postpartum period [up to 365 days after the end of pregnancy (Figure 4). The remaining 33% (n=85) of pregnancy-related deaths occurred while the decedent was pregnant (Figure 4)].   Figure 4. Most pregnancy-related deaths in Ohio from 2008-2018 occurred during the postpartum period.

Preventability of Pregnancy-Related Mortality in Ohio, 2008-18

After reviewing all available information for each pregnancy-related death, the PAMR committee determines whether each death was preventable. Between 2008-18, over half (61%) of all pregnancy-related deaths (n=193) were deemed preventable (Figure 5). Prior to 2012, the review process did not consistently determine chance to alter outcome, thus Figure 5 includes only those pregnancy-related deaths from 2008-18 for which preventability was determined.   Figure 5. Most pregnancy-related deaths that occurred in Ohio 2008-2018 were preventable.Visit the other tabs of the PAMR website to see how ODH is working to eliminate preventable pregnancy-related deaths in Ohio.

Data Reports and Special Topics Briefs

The Ohio Pregnancy-Associated Mortality Review (PAMR) was developed to identify and review pregnancy-associated deaths with the goal of developing interventions to reduce maternal mortality, particularly for pregnancy-related deaths. Below are reports associated with PAMR activities:

The purpose of the special topics reports are to supplement the statewide report, A Report on Pregnancy-Associated Deaths in Ohio 2008-2016, with additional information on leading causes of pregnancy-related deaths. Data in these reports summarize the findings of pregnancy-related deaths to Ohio residents during 2008-2016 that were identified by the Ohio Pregnancy-Associated Mortality Review (PAMR). Additional reports will be released throughout 2020.

Data in these profiles summarize the findings of pregnancy-associated deaths to Ohio Equity Institute (OEI) county residents during 2008-2016 that were identified by the Ohio Pregnancy-Associated Mortality Review (PAMR) and are intended to supplement the statewide report: A Report on Pregnancy-Associated Deaths in Ohio 2008-2016.

Other resources, data and reports:

Data Overview and Management

PAMR enters and stores all case data in Maternal Mortality Review Information Application (MMRIA), a comprehensive database provided by the Centers for Disease Control and Prevention (CDC) to all state maternal mortality review committees. MMRIA provides a system for case abstraction and logging committee decisions as well as providing data in a format ready for analysis. The national system gives a common language for maternal mortality review committees like PAMR across the country, allowing for comparisons among states and aggregation of data. Following beta-testing with CDC from 2014-2016, ODH fully adopted this system in 2017.

PAMR nurse abstractors enter information from a variety of sources into MMRIA, including:

  • maternal death certificate
  • autopsy report
  • birth certificate or fetal death certificate
  • prenatal records
  • mental health records
  • hospital records
  • emergency department visits
  • medical transport records (paramedics, emergency medical technicians)
  • law enforcement records

Abstractors synthesize information from all available sources to create a case narrative, a summary of the circumstances surrounding the death. Case summaries are reviewed by the interdisciplinary PAMR Board, as outlined in HB166 Section 3738.03, which completes the committee decisions form, a standardized documentation tool provided by CDC Review to Action, and captures the decisions of the committee, including pregnancy-relatedness, cause of death, preventability, contributing factors to the death, and recommendations that address contributing factors. After review, committee decisions form data are entered into MMRIA for analysis.

PAMR analyzes data extracted from MMRIA to identify themes, underlying risk factors, and gaps in care. The following variables are routinely analyzed to describe pregnancy-associated deaths:

  • age at death
  • race and ethnicity
  • education
  • insurance status
  • marital status
  • county type of maternal residence
  • timing of death in relation to pregnancy
  • causes of death.

Based on the analysis, PAMR makes recommendations for systems change to reduce maternal morbidity and preventable deaths, reduce disparities, and address health inequities.

Identification of Maternal Deaths/Quality Improvement for Vital Statistics

Identification of maternal deaths and accurately counting maternal deaths is the first step of the review process.  Ohio was one of four states invited to participate in a quality improvement collaborative by the CDC designed to identify solutions for improving accuracy of the pregnancy checkbox on death certificates. Monthly, the ODH Bureau of Vital Statistics staff performed a linkage between 2016 death certificates for women who died with a positive maternal checkbox and any live birth certificate or fetal death certificate issues within 365 days of each woman’s death. Women with a positive maternal checkbox should have a linkage and if so, would be a considered confirmed maternal death. If no linkage was identified, vital statistics staff queried local certifiers to either confirm (true positives) or disconfirm (false positives) pregnancy. If not confirmed, local certifiers were then asked to file an amended death certificate to correct any errors. Significantly more false negatives than false positives were identified. These certificates were successfully corrected. This on-going process leads to accurate state statistics for reporting maternal deaths to stakeholders and to national agencies and databases. From a PAMR standpoint, identification of false positives saves time for staff as they will not receive false positive records and spend unnecessary time requesting records for these cases. In addition, the pregnancy-associated death rate and number of cases for review will be available at least a year earlier.