Maternal Mortality Review Team
Virginia Department of Health
Office of the Chief Medical Examiner
Victoria M. Kavanaugh, RN, PhD
Coordinator
1
 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.
2
 Throughout the 1900’s, the maternal mortality rate
declined significantly:
 Principles of asepsis were instituted
 Shift from home to hospital deliveries
 Institutional practice guidelines and guidelines defining physician
qualifications for hospital delivery privileges
 Use of antibiotics
 Safer blood transfusions
 Better management of hypertensive disorders of pregnancy
3
“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.
4
1999
9.9
2000
9.8
been no further decline
in maternal mortality.
2001
9.9
2002
8.9
 Maternal mortality rates
2003
12.1
rose during 2003, 2004,
2005 (possibly due at
least in part to improved
identification of cases).
2004
13.1
2005
15.1
2006
13.3
2007
12.7
 Since 1982, there has
5
 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
6
 understand the causes of maternal death.
 educate colleagues and policymakers about
these deaths and the need for changes.
 recommend improvements for prevention.
7
 Public health approach
 Emphasis on interventions and preventability
 Multidisciplinary review
 Confidentiality – Team members receive no
identifying information
 Retrospective review
 Consensus decision-making
8
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 Virginia
Regional Perinatal Councils
Virginia Hospital and Healthcare
Association
Virginia Perinatal Association
The Virginia Sexual and Domestic
Violence Action Alliance
Virginia 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
9
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.
10
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?
11
Preventable death is broadly defined as a death
that may have been averted by one or more
changes in:
clinical care
facility infrastructure
community
systems response to patient factors
These determinations were made with the benefit
of retrospective review and current clinical
practice guidelines.
12
As each case was reviewed, the Team
identified factors within those four
categories that contributed to death
in that case.
13
 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.
14
15
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
16
BMI
 < 18.5
 18.5 – 24.9
 25.0-29.9
 >30
Category
Underweight
Normal weight
Overweight
Obese
17
 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.
18
 Prepregnancy BMI ranged from 16.3 to 58.5
 Average BMI was 29.96 (30.0 = Obese)
 5 deaths were to underweight women
 32 deaths were to normal weight women
 24 deaths were to overweight women
 41 deaths were to obese women
19
5%
Underweight
31% Normal
Weight
40% Obese
24%
Overweight
20
12%
Underweight
29% Obese
14%
Overweight
CDC Pediatric and Pregnancy Nutrition Surveillance System, 2003 Pregnancy Nutrition surveillance, Nation.
45% Normal
Weight
21
A Closer Look:
Women Who Died
All US Women
14.5%
43%
24%
Overwt.
Overwt.
28.5%
Obese
64%
40%
Obese
22
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
43
100
59
100
Total
23
Prepregnancy BMI Category by
Race Among Women Who Died in
Virginia
White
Underweight
Normal wt.
Overwt./obese
Total
Black
Asian
Other
#
2
15
%
4.1
30.6
#
2
13
%
4.4
28.9
#
1
3
% # %
20.0 0
0
60.0 1 33.3
32
49
65.3
100
30
45
66.7
100
1
5
20.0 2 66.6
100 3 100
24
Estimated Maternal Mortality Ratio
by BMI Category and Race in
Virginia, 1999-2004
Total
(Includes Asian and women of Other
races)
No.
Ratio
Underweight
5
7.1
Normal
32
12.2
Overweight
24
28.3
Obese
41
24.6
White
Black
No.
Ratio
No.
Ratio
17
7.1
15
22.5
32
19.2
30
45.6
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.
25
Underweight/Normal
Weight

Cardiovascular Disorders = 11
(28.9%)

Infection = 5 (13.1%)

Hemorrhage and
Exacerbation of Chronic
Conditions = 4 each (10.5%
each)
Overweight/Obese
 Cardiovascular Disorders = 20
(30.8%)
 Cancer = 14 (21.5)
 Pulmonary Embolism = 10
(15.4%)
26
80
70
60
50
40
30
20
10
0
Normal Weight
Overweight
Vaginal Delivery
Obese
Cesarean Delivery
All Live Births
Other
PATD
27

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.
28
 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
29
 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
•
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.
31
 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

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.
33
Victoria Kavanaugh, RN, PhD
Maternal Mortality Review Coordinator
Office of the Chief Medical Examiner
737 North 5th Street
Richmond, VA 23219
(804) 205-3853
(804) 786-0391 fax
Victoria.kavanaugh@vdh.virginia.gov
http://vdhweb/medexam/index.asp
34