Pregnancy-Associated and Pregnancy-Related Death Rates
Ohio and U.S. Maternal Mortality Ratios, 2008-2017
Ohio data sources: Maternal Mortality Review Information Application (MMRIA) and Ohio Department of Health (ODH) Bureau of Vital Statistics
United States data source: Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System (PMSS)
Note: Caution should be used in comparing U.S. and Ohio ratios as surveillance methods differ. Both include women who died during pregnancy or within one year of pregnancy. However, in contrast to the Ohio Pregnancy-Associated Mortality Review process, the U.S. process is based entirely on vital statistics data submitted to the CDC by states; medically trained epidemiologists determine the cause and time of death related to the pregnancy. More information on the U.S. system can be found at the following website: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html.
The Ohio pregnancy-related mortality ratio for years of death 2008 to 2011 was 17.0, from 2012 to 2014 it was 12.2 deaths per 100,000 live births, and from 2015 to 2017 it was 18.8 deaths per 100,000 live births. The United States pregnancy-related mortality ratio for years of death 2008 to 2011 was 16.9, from 2012 to 2014 it was 17.0 deaths per 100,000 live births, and from 2015 to 2017 it was 17.1 deaths per 100,000 live births.
Leading Causes of Pregnancy-Related Deaths, Ohio 2008-2017
The leading causes of pregnancy-related death in Ohio from 2008 to 2017 were cardiovascular and coronary conditions at14 percent, infection at 13 percent, hemorrhage at 12 percent, mental health conditions at 11 percent, pre-eclampsia and eclampsia at 10 percent, cardiomyopathy at 9 percent, embolism at 9 percent, amniotic fluid embolism at 4 percent, and other at 18 percent. Other causes of death include cerebrovascular accidents, homicide, unintentional injury, malignancies, and blood disorders.
Snapshot of Ohio Pregnancy-Associated Deaths, 2008-2019*
From 2008 to 2017 there were 731 pregnancy-associated deaths in Ohio; 30 percent were pregnant at time of death, 20 percent were pregnant within 42 days of death, and 50 percent were pregnant within 43 to 365 days of death.
- 31% were determined to be pregnancy related.
- 60% were determined to be pregnancy-associated but not pregnancy-related.
- 59% of pregnancy-related deaths were deemed preventable.
Pregnancy-associated mortality ratios increased in 2015. The increase was primarily driven by an increase in unintentional overdose deaths, which doubled annually from 2014 to 2016. The 2017 pregnancy-related mortality ratio increased compared to preceding years. Contributing to this increase was the implementation of new criteria, adapted from the Utah Department of Health Perinatal Mortality Review, to determine the pregnancy-relatedness of unintentional overdose and suicide deaths, which focuses more on the possible aggravation of mental health conditions during pregnancy and in the postpartum year. Only a sample of 2015 to 2016 deaths were fully reviewed, if all 2015 to 2016 deaths were fully reviewed it is possible that the corresponding pregnancy-related mortality ratios for those year could be higher, however it is unlikely because the new criteria to determine pregnancy-relatedness were not implemented until 2017.
- Pregnancy-Associated Death: The death of a woman while pregnant or within one year of the end of pregnancy, regardless of the cause.
- Pregnancy-Related Death: A death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.
- Pregnancy-Associated, but not Pregnancy-Related Death: A death during pregnancy or within one year of the end of pregnancy from a cause that is not related to pregnancy.
- Pregnancy-associated but unable to determine pregnancy-relatedness: A death during pregnancy or within one year of then end of pregnancy from a cause that could not be determined as pregnancy-related or not pregnancy-related.
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.
- Pregnancy-Related Deaths due to Cardiovascular and Coronary Conditions and Cardiomyopathy in Ohio, 2008-2016.
- Pregnancy-Related Deaths due to Hemorrhage in Ohio, 2008-2016.
- Pregnancy-Related Deaths Due to Pre-eclampsia and Eclampsia in Ohio, 2008-2016.
- Pregnancy-Related Deaths Due to Embolism (not amniotic fluid) in Ohio, 2008-2016.
- Pregnancy-Related Deaths Due to Sepsis in Ohio, 2008-2016.
- Pregnancy-Related Deaths Due to Suicide in Ohio, 2008-2016.
- Pregnancy-Associated Deaths Due to Unintentional Overdose in Ohio, 2008-2016.
- Pregnancy-Associated Deaths with Intimate Partner Violence Contributing Factors in Ohio, 2008-2016.
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.
- Pregnancy-Associated Deaths in Butler County 2008-2016
- Pregnancy-Associated Deaths in Cuyahoga County 2008-2016
- Pregnancy-Associated Deaths in Franklin County 2008-2016
- Pregnancy-Associated Deaths in Hamilton County 2008-2016
- Pregnancy-Associated Deaths in Lucas County 2008-2016
- Pregnancy-Associated Deaths in Mahoning County 2008-2016
- Pregnancy-Associated Deaths in Montgomery County 2008-2016
- Pregnancy-Associated Deaths in Stark County 2008-2016
- Pregnancy-Associated Deaths in Summit County 2008-2016
Other resources, data and reports:
- Snapshot of Ohio Pregnancy Associated Deaths, 2008-2019*
- Snapshot of Racial Disparities in Pregnancy-Related Deaths in Ohio 2008-2016
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
- 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.