WHO Collaborating Centre for Development of Midwifery Services and Education
Maternal Mortality in Puerto Rico Irene G. dela Torre, CNM, MS
I gratefully acknowledge Sixto Merced RolĂłn, a health system evaluator in the PR Department of Health, and coordinator of the SiVEMMa committee for providing information used for this presentation.
Invited in 2005 by the Secretary of Health
Members: multidisciplinary team of 16 health professionals ( MD, CNM, RN, pathologist (medical examiner) epidemiologists, social worker, demographer, plus others)
Members sign confidentiality statement
Legal immunity for committee members
Meets every 2-3 months to discuss cases
Makes evidence-based recommendations – priority for pregnancy-related causes
SiVEMMa ( SISTEMA DE Vigilencia Epidemiologica de mortalidad Materna)
Objective: To establish guidelines for preventive activities directed at reducing the maternal mortality in Puerto Rico by means of
Interpretation of data
Dissemination of information
Formulation of evidence-based recommendations
Methods: electronic linkage of deaths, births and stillbirth files ; review of hospital medical record, prenatal record, death certificate and autopsy record. Interview of providers and family members ( not a strict “oral autopsy”- more to complement information not available on medical records)
WHY a Better Method Vital Statistics
Review of ICD-10 Code: Cause(0-99)
Review of ICD-10 Code: Cause(099)
Linkage of electronic data
( maternal, fetal and stillbirth)
Review of death, birth and stillbirth certificates
Review of autopsy reports
Review of medical records
Table 1: Annual registered live births and ratios of pregnancy related deaths x 100,000 Vital Statistics vs. SiVEMMa, 2002 through 2007 Year
Legend: † Pregnancy-related death ratio x 100,000 births. ** Preliminary SiVEMMa data for 2002 -2007. * Vital Statistics data revised by the PR
During the period 2002-2007, SiVEMMa identified 83 pregnancy related death cases (27.6 per 100,000 live births).
Leading causes were pre-eclampsia and eclampsia (24%), emboli (20%), and postpartum bleeding (8%). Findings suggests that the risk of death related to pregnancy is higher as women become older.
Conclusions: For 2002-2007 period, SiVEMMa identified 49.6% more cases of maternal death as compared to Vital Statistics ( 83 vs 50, respectively). The leading causes are related to pregnancy-induced hypertension disorders.
Graphic 1: Specific causes of deaths, maternal mortality, 2002 to 2007
Pulmonary embolism without mention of acute cor pulmonale; 11%
Eclampsia, unspecified as to time period; 8%
Preeclampsia, unspecified; 6% Others; 39%
% .4 ed i fi ec sp un 4% y, nc athy na y op eg i om pr card pi c te d y to Di l a pre gnanc Ec me llitus Diabe te s 4% disorders in pregnancy 2% CLiver Caarrdiomyopath d y , i o u n m s p e cified Am yopa th 2% y pu nio e t i r c p e fl rium u i d 2% em b o l ism 2%
Disease circulatory system complicating pregnancy Se p t 5% i ce m O th i a un In e r d spe c t ra i se i fi e d ase ce 4% re com br pl . al p re he g. 4 m % or rh ag e 4%
Recommendations by SiVEMMa
Training of emergency room personnel about management of pregnancy
Review the findings on the vital statistics
Revise box # 21 on the death certificate
To include YES or NO if dead person was pregnant within the last year
A legislative project to protect the information of SiVEMMa
Maternal mortality is a reportable condition
Why Surveillance? Why Midwives and nurses?
Most maternal deaths are preventable through improved quality of care
To improve quality, must know what is currently happening
Maternal surveillance data tell what is happening and points how to improve
Midwives and nurse are well positioned to collect, analyze and use data to improve quality of care
Understand better how midwives and nurses participate in surveillance in the region.
Learn from PAHO ( what is available re: assessment of current surveillance system)
Identify gaps in knowledge and/or practice related to surveillance
Virtual forum to plan strategy – academic as well as practice interventions
Develop a pilot midwife and nurse specific surveillance training materials
Continuing education provided to health care providers in emergency rooms on identification, management of common maternal morbidity/ mortality
Recommend to medical/midwifery/nursing schools to improve documentations in patients records.