Pregnancy-related deaths rise in the U.S.
By Amy Norton
NEW YORK | Thu Dec 2, 2010 4:29pm EST
NEW YORK (Reuters Health) - While it remains rare for a woman in the U.S. to die from pregnancy complications, the national rate of pregnancy-related deaths appears to be on the upswing, a new government study finds.
Researchers at the U.S. Centers for Disease Control and Prevention (CDC) found that between 1998 and 2005, the rate of pregnancy-related deaths was 14.5 per 100,000 live births. And while that rate is low, it is higher than what has been seen in the past few decades.
The researchers caution that the extent to which the rise reflects a true elevation in women's risk of dying is unclear. Recent changes in how causes of death are officially reported by states to the federal government may be at least partially responsible for the findings.
However, it is also possible that part of the increase is "real." According to the new data, deaths from chronic medical conditions that are exacerbated by pregnancy, including heart disease, appear to account for a growing number of pregnancy-related deaths.
In contrast, deaths from actual obstetric complications -- namely, hemorrhaging and pregnancy-related high blood pressure disorders -- are declining.
The absolute risk of a U.S. woman dying from pregnancy-related problems is still "very small," lead researcher Dr. Cynthia J. Berg, of the CDC's division of reproductive health, said in an interview.
But, she added, the new findings do underscore the importance of women "making sure they are in the best possible health before pregnancy."
All women, Berg said, should try to have a pre-pregnancy visit with their ob-gyn and, if needed, get their weight and any chronic medical conditions, like high blood pressure or diabetes, under control before becoming pregnant.
For their study, Berg and her colleagues looked at data on 4,693 pregnancy-related deaths reported to the CDC between 1998 and 2005. Pregnancy-related death was any death occurring during or within one year of pregnancy that was attributed to a pregnancy complication.
The researchers estimate that for that eight-year period, the national rate of pregnancy-related death was 14.5 for every 100,000 live births.
In contrast, in 1979, there were just under 11 maternal deaths per 100,000 live births in the U.S. -- a rate that fell to as far as 7.4 per 100,000 in 1986, before beginning a gradual increase.
In addition, the racial gap that has long been seen in pregnancy-related deaths shows no signs of narrowing. Between 1998 and 2005, the death rate among black women was 37.5 per 100,000 live births, versus 10.2 per 100,000 among white women and 13.4 per 100,000 for all other racial groups combined.
The reasons for the upward trend in the overall rate of pregnancy-related deaths are not certain, and more studies are needed to tease apart the contributing factors, Berg said.
One factor, according to the researchers, could be two technical changes in how causes of death are officially reported. In 1999, the U.S. adopted an updated system for coding causes of death -- one that allowed more deaths to be classified as "maternal."
Then in 2003, the standard death certificate was revised to include a "pregnancy checkbox," which increased the number of deaths that could be linked, in timing, to pregnancy.
However, recent years have seen not only a change in the rate of pregnancy-related deaths, but in the specific causes.
Berg explained that the proportion of deaths from "direct causes" -- obstetrical complications like hemorrhaging -- is going down, while the proportion attributed to indirect causes -- that is, medical conditions worsened by pregnancy -- is increasing.
Hemorrhaging, for example, accounted for just under 30 percent of pregnancy-related deaths between 1987 and 1990, but only 12 percent between 1998 and 2005. High blood pressure disorders (mainly pre-eclampsia and eclampsia) also accounted for about 12 percent of deaths in 1998-2005 -- down from around 18 percent in 1987-1990.
On the other hand, there was a sharp increase in the proportion of deaths attributed to heart problems. In the most recent time period, just over 12 percent of pregnancy-related deaths were attributed to "cardiovascular conditions," while just under 12 percent were attributed to cardiomyopathy, an enlargement of the heart.
In 1987-1990, only about five percent of deaths were linked to cardiomyopathy, and a smaller percentage to cardiovascular conditions.
This study cannot weed out the precise reasons for these patterns. But Berg pointed out that "our population is changing."
More women of childbearing age today are obese or have chronic health problems like high blood pressure and diabetes than in years past. So that could help explain the shifting pattern in the causes of pregnancy-related deaths, according to Berg.
The bottom line for women, she said, is that while the odds of dying from pregnancy-related problems remains quite low, it is important to go into pregnancy in the best possible health.
The CDC has information on pre-pregnancy health at www.cdc.gov/pregnancy.
SOURCE: link.reuters.com/vah38q Obstetrics & Gynecology, December 2010.
Pregnancy-Related Mortality in the United States, 1998 to 2005
Berg, Cynthia J.; Callaghan, William M.; Syverson, Carla; Henderson, Zsakeba
Obstetrics & Gynecology. 116(6):1302-1309, December 2010.
OBJECTIVE: To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes of these deaths.
METHODS: De-identified copies of death certificates for women who died during or within 1 year of pregnancy and matching birth or fetal death certificates for 1998 through 2005 were received by the Pregnancy Mortality Surveillance System from the 50 states, New York City, and Washington, DC. Causes of death and factors associated with them were identified, and pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated.
RESULTS: The aggregate pregnancy-related mortality ratio for the 8-year period was 14.5 per 100,000 live births, which is higher than any period in the previous 20 years of the Pregnancy Mortality Surveillance System. African-American women continued to have a three- to four-fold higher risk of pregnancy-related death. The proportion of deaths attributable to hemorrhage and hypertensive disorders declined from previous years, whereas the proportion from medical conditions, particularly cardiovascular, increased. Seven causes of death―hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions―each contributed 10% to 13% of deaths.
CONCLUSION: The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10thRevision, and the addition by states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality collaboratives have the potential to identify deaths, review the factors associated with them, and take action on the findings.
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