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WHO Collaborating Centre for Development of Midwifery Services and Education

Maternal Mortality in Puerto Rico Irene G. dela Torre, CNM, MS


Acknowledgement 

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.


SiVEMMa Committee 

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 

Data gathering

Analysis

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

SiVEMMa 

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 

Committee reviews


Table 1: Annual registered live births and ratios of pregnancy related deaths x 100,000 Vital Statistics vs. SiVEMMa, 2002 through 2007 Year

Total Births

Vital Statistics*

SiVEMMa**

Frequency

Frequency

†Ratio

†Ratio

2002

52,871

6

11.3

2003

50,803

8

15.7

2004

51,239

14

27.3

25

48.8

2005

50,687

6

11.8

9

17.8

2006

48,744

4

8.2

5

10.3

2007

46,736

12

25.7

18

38.5

301,080

50

16.6

83

27.6

TOTAL

11 15

Legend: † Pregnancy-related death ratio x 100,000 births. ** Preliminary SiVEMMa data for 2002 -2007. * Vital Statistics data revised by the PR

20.8 29.5


Results 

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


Next steps 

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.

Maternal mortality in puerto rico