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MATERNAL MORBIDITY AND MORTALITY Elyse Watkins, DHSc, PA-C, DFAAPA
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Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Jul 31, 2020

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Page 1: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

MATERNAL MORBIDITY AND

MORTALITYElyse Watkins, DHSc, PA-C, DFAAPA

Page 2: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

What is a pregnancy-related death?

◦ The death of a woman during or within 1 year of

pregnancy

◦Caused by a pregnancy complication,

◦A chain of events initiated by pregnancy,

◦or the aggravation of an unrelated condition by the

physiologic effects of pregnancy.

Page 3: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

http://www.pphproject.org/maternal-morbidity-mortality.asp

Page 4: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one
Page 5: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Pregnancy-related mortality ratio increased from 7.2 deaths per 100,000 live births in 1987 to 17.8 deaths per 100,000 live births in 2009 in the United States.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/

Page 6: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Pregnancy-related mortality ratios are 3–4 times higher among black women than white women and for specific mortality causes (e.g., ectopic pregnancy), this gap appears to be even greater.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/

Page 7: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/

Page 8: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

A few interesting facts…

◦ In 2003 a pregnancy-related checkbox was

added to death certificates.

◦The higher mortality ratio in 2009 compared with

previous few years was due to the 2009 H1N1

influenza pandemic, which disproportionally

affected pregnant women.

◦Solution??

Page 9: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

More sobering statistics

◦ The United States has now a higher ratio than those

reported for most high-income countries and the

Islamic Republic of Iran, Libya and Turkey

◦ This is NOT due simply to changes in reporting!

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC50017

99/)

https://www.who.int/bulletin/volumes/93/3/14-148627/en/

Page 10: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Racial/ethnic differences

◦ Compared with white mothers, black women experienced

disproportionately high rates of death from cardiomyopathy,

thrombotic pulmonary embolism, and hypertensive disorders of

pregnancy

◦ American Indian/Alaskan Native women experienced

disproportionately high rates of death from hemorrhage and

hypertensive disorders

Page 11: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

MORBIDITY AND MORTALITY

CONFOUNDERS* *A confounder is a variable that influences both the dependent variable and

independent variable

Page 12: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Anemia◦ Of 515,270 women in a study population, 65,906 (12.8%) had anemia: 11.8%,

0.43%, and 0.02% had mild, moderate, and severe anemia, respectively.

◦ Categorization:

◦ No anemia (hemoglobin 11 g/dL or greater)

◦ Mild (9-10.9 g/dL)

◦ Moderate (7-8.9 g/dL)

◦ Severe (less than 7 g/dL)

◦ Anemic women experience:

◦ Longer hospitalization duration

◦ More antenatal admissions

◦ Higher rates of preeclampsia

◦ Higher rates of placenta previa

◦ Higher rates of cesarean delivery

https://www.ncbi.nlm.nih.gov/pubmed/31764734

Page 13: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Anemia

◦Also associated with:

◦Preterm birth

◦Small-for-gestational-age live births

◦Low 5-minute Apgar scores

◦Neonatal death

◦Perinatal death

Page 14: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Advanced maternal age

◦ AMA associated with:

◦ Higher prevalence of GDM, fetal aneuploidy, miscarriage,

placenta previa, cesarean delivery

◦ Increased risk of abruption, preterm delivery, low birth weight,

and perinatal mortality in women 40 years and older

◦ Morbidity and Mortality increased exponentially with maternal

age over 39 y, from OR = 1.2 (95% CI 1.2–1.3) among women

aged 35–39 y to OR = 5.4 (95% CI 2.4–12.5) among women aged

≥50 y

https://www.ncbi.nlm.nih.gov/pubmed/31770385

https://www.ncbi.nlm.nih.gov/pubmed/15863534

Page 15: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Advanced maternal age

◦ Adjusted rates of severe morbidity remained increased among

mothers ≥35 y

◦ Rates of amniotic fluid embolism (AOR = 8.0, 95% CI 2.7–23.7)

and obstetric shock (AOR = 2.9, 95% CI 1.3–6.6) among mothers

≥40 y

◦ Renal failure (AOR = 15.9, 95% CI 4.8–52.0), complications of

obstetric interventions (AOR = 4.7, 95% CI 2.3–9.5), and ICU

admission (AOR = 4.8, 95% CI 2.0–11.9) among those 45–49 y

https://www.ncbi.nlm.nih.gov/pubmed/15863534

Page 16: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Opioid use disorder

https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w

#F1_down

Page 17: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Prevalence of opioid use disorder per 1,000 delivery hospitalizations

https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w

#F1_down

Page 18: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Mental Health

◦Poor mental health may adversely impact pregnancy outcomes, maternal-infant bonding, maternal functioning, and infant health and development.

◦Among U.S. women with major depression, 89% have one or more chronic medical conditions (diabetes, obesity) or medical risk factors (smoking, binge or heavy drinking, physical inactivity).

◦What confounds mental health diagnosis and treatment?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880915/

Page 19: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

What are the core problems?

◦ Hospitals across the US generally lack a standard approach to

managing obstetric emergencies

◦ The complications of pregnancy and childbirth are often

identified too late

◦ Increasing number of women who present with chronic

conditions (hypertension, diabetes and obesity)

https://www.who.int/bulletin/volumes/93/3/14-148627/en/

Page 20: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

Core problems

◦ Only half of US states have maternal mortality review boards.

◦ Data that are collected are not systematically used to guide

changes that could reduce maternal mortality and morbidity.

https://www.who.int/bulletin/volumes/93/3/14-148627/en/

Page 21: Maternal Morbidity and Mortality...outcomes, maternal-infant bonding, maternal functioning, and infant health and development. Among U.S. women with major depression, 89% have one

What are potential solutions?

◦Let’s discuss!