Georgia epidemiology report, Vol. 18, no. 10 (Oct. 2002)

October 2002

volume 18 number 10

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer
Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H.
Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
Georgia Department of Human Resources
Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517
Please send comments to: Gaepinfo@dhr.state.ga.us
The Georgia Epidemiology Report is a publication of the Epidemiology Branch,
Division of Public Health, Georgia Department of Human Resources

Enhanced Pregnancy-related Mortality
Surveillance:
Identification of Pregnancy-related Deaths Using
Non-pregnancy ICD-10 Codes, Georgia, 1999
Introduction The Healthy People 2010 Objective for maternal mortality is 3.3 deaths per 100,000 live births1 with a 1998 baseline rate of 7.1 which has remained stable over the past twenty years2. Gaps between subpopulations defined by race and ethnicity, such as the four-fold increased pregnancy-related mortality ratio for black women than white women and a 1.7 increased ratio for Hispanic women than for white women,1,3 indicate opportunities to prevent pregnancy-related deaths. Demographically, the population in Georgia includes a significant proportion of births and pregnancies to women in these higher risk populations. In Georgia in 1998 the maternal mortality ratio was 7.4 deaths per 100,000 births4. Approximately one-third of births occurred to black women and 3% to Hispanic women with Georgia experiencing a rapidly expanding Hispanic population. The prevention of pregnancy-related deaths in Georgia, as elsewhere, requires accurate information to inform programs, prevent deaths and reduce the gaps.
The measurement of the magnitude of pregnancy-related deaths (Definitions, Box 1) and the interventions to reduce such deaths must be based on thorough case-identification and accurate assessment of the reasons for these deaths. Therefore, it is important to identify all deaths so that selection bias is eliminated. Routine surveillance that uses the pregnancy chapter ICD codes reported on death certificates underreports maternal deaths due to misclassification of maternal deaths as deaths due to other causes5. The need for multiple sources in pregnancy-related death case identification has been demonstrated in other studies.6,7,8 Another common method to identify pregnancy-related deaths is the linkage of death certificates among women of reproductive age with birth certificates and fetal death certificates.6 However, this method does not capture all pregnancyassociated deaths either since deaths secondary to ectopic pregnancy, abortion or molar pregnancy, as well as deaths to women prior to delivery, would be missed.7 Another method to identify pregnancyrelated deaths is the inclusion of a check box on the death certificate.8 The usefulness of medical examiner records has been identified as well.7 In an attempt to identify additional pregnancy-related deaths, another method has been suggested - the manual review of death certificates among women of reproductive age for indication of pregnancy. 9,10 Since this proposed method has not been assessed, and since in Georgia this is not practical on a routine surveillance basis given that approximately 3,000 deaths occur annually to women of reproductive age, we assessed a modified version of the proposed method. Selective death certificates were reviewed among deaths to women of reproductive age. This assessment is important for health departments that must assign their limited resources in effective ways.
Box 1. Definitions8
Pregnancy Related Death: Death of a woman while pregnant or within 1 year of termination of pregnancy, irrespective of the duration and site of the pregnancy from any cause related to or aggravated by her pregnancy or its management, but not from accidental or incidental causes.
Pregnancy Associated Death: Death of a woman while pregnant or within 1 year of termination of pregnancy, irrespective of cause.

Methods
We reviewed selected death certificates among women of reproductive age (10-49 years) which had ICD-10 codes that were outside the traditional coding range from the pregnancy chapter, O00-O99, but could plausibly be a pregnancy-related death (Table 1). The specific ICD-10 codes were selected based on conditions identified as having the potential to be associated with a pregnancy-related death. For example, deaths of WRA from cerebral vascular accident or shock. The list of non-pregnancy codes was selected based on the literature, other states' findings, advice from a local obstetrician and clinically experienced epidemiologists from the Centers for Disease Control, Division of Reproductive Health.

epidemiologists. Certificates that had one of the selected keywords anywhere on the certificate were considered to be a possible pregnancy-related death. Medical records of potential cases of pregnancy-related deaths were reviewed to determine the existence of a pregnancy.
Results In 1999, 2,666 Georgia resident women of reproductive age died. Among these deaths were 864 with the selected non-pregnancy ICD-10 codes, of which 28 were excluded because they also had a pregnancy on the certificate or the certificate had linked with a live birth or fetal death in the previous year. Therefore, a subset of 836 certificates remained among which 14 deaths

Table 1. ICD-10 codes used to select death certificates and number of deaths and potential pregnancy-related cases by ICD-10 code

ICD 10 Code
A40-A41 E10-E14 D58-D57 D62-D64 D65-D69
I10 I11 I12 I26 I42 I49-I50 I60 I61 I62 I74 I80 I82 I95 I99 J90 K65 N17-N19 O08 M32 R57

Disease/Disorder
Septicemia Diabetes mellitus Hereditary hemolytic anemia inc. sickle cell
Anemia Coagulation defects Essential hypertension Hypertensive heart disease Hypertensive renal disease Acute pulmonary heart disease/Embolism
Cardiomyopathy Cardiac Dysrhythmias/heart failure
Subarachnoid hemorrhage Intracerebral hemorrhage Other unspecified intracranial hemorrhage Arterial embolism/thromboses
Phlebitis Venous embolism
Hypotension Hemorrhage Pleurisy effusion Peritonitis Acute Renal Failure Pulmonary embolism Systemic lupus erythematosus Shock without mention of trauma

Number of deaths1
194 129 18 19 37 39 35
9 50 52 142 48 52 12 3 6 2 16 0 7 6 84 2 22 56

Number of Potential Pregnancy-related deaths
1 1

1 The total number of deaths for these ICD codes does not equal the number of certificates reviewed because of multiple ICD codes on each certificate.

The data were gathered from death certificates reported to 1999 Vital Statistics. Pregnancy-related deaths identified by ICD-10 pregnancy chapter codes (O00-O99) or by linkage of WRA death certificates to birth or fetal death certificates for the year prior to death were excluded. Death certificates that met the above criteria were manually reviewed for selected keywords that could indicate pregnancy (Table 2). The keywords were chosen to capture pregnancy-related conditions and were identified with the assistance of the local obstetrician and CDC

occurred outside of Georgia and these were excluded from the analysis due to lack of access to the certificate. The remaining 822 certificates were reviewed manually for selected keywords.
Among the 822 certificates reviewed, two were identified with a selected keyword. The keywords on the certificates that led us to consider these deaths as possible pregnancy-related deaths were: Case number 1 - septic shock, pulmonary embolism; Case number 2- dilated cardiomyopathy with corresponding ICD-10 codes of I126 acute pulmonary heart disease/embolism, and I142

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cardiomyopathy. To determine the pregnancy-related status of these two deaths, we obtained hospital or autopsy records. After review of medical
records, we found that these deaths were not pregnancy-related.
Discussion In this study we did not identify any pregnancy-related deaths beyond those reported through the ICD-10 pregnancy codes or by linkage of vital records. However, several limitations of this study should be considered. First, we did not manually review all the death certificates of all women of reproductive age regardless of cause of death. While it is possible that a pregnancyrelated death may have occurred among the other 1,802 women, the chances are rare given that we found no additional pregnancy-related deaths among the subset of one-third of all certificates reviewed which met selective criteria with an increased chance of a pregnancy-related condition. Second, medical record review of all 822-death certificates might have identified more cases; however, again we believe this is unlikely due to the selection criteria. Third, we did not examine deaths from 1998 when the ICD-9 codes were used. Use of ICD-10 codes, beginning in 1999, has increased the number of pregnancy-related deaths in Georgia and the number of maternal deaths reported for the U.S.A. In 1998 in Georgia,

using ICD-9, 10 pregnancy-related deaths were found, compared with 24 using ICD-10 in 1999. Similarly, NCHS identified 281 maternal deaths in 1998, compared with 401 in 1999, when ICD-10 was used. Had we conducted the same study for 1998 deaths, we might have identified more 1998 pregnancyrelated deaths with the manual review reflecting the impact of death coding criteria.
It has been well documented that multiple data sources are needed for comprehensive pregnancy-related mortality surveillance. Thus far in Georgia, use of the ICD-10 pregnancy chapter codes and the linkage of deaths of WRA to fetal death and live birth records seems to have identified the vast majority of pregnancy-related deaths. The addition of any case identification method needs to consider the yield of cases identified and the resources required. Manual review of deaths among women of reproductive age with selected non-pregnancy ICD-10 codes identified no additional cases and the primary resource was staff time. Approximately 13 working days were required to identify and review death certificates in this study. This study indicates that selective review of death certificates among WRA based on ICD-10 codes from outside the pregnancy chapter did not help identify pregnancy-related deaths and the additional resources required for such a review, although not
extensive, are probably not justified.

Table 2.

Keywords selected to identify potential pregnancy-related deaths from manual death certificate review.

Abortion Amnionitis Amniotic fluid Antepartum Cardiomyopathy-induced by pregnancy Cesarian Chorioamnionitis Choriocarcinoma

Dilated cardiomyopathy Eclampsia Ectopic/tubal pregnancy Embolism Endometritis Fetal death Full term delivery Gestational trophoblastic disease

HELLP Syndrome Induced termination Intrapartum Parametritis Peripartum Placenta Placental abruption Postpartum

Preeclampsia Pregnant
Pregnancies
Previa Septic pelvic vein thrombophlebitis Still birth
Third trimester bleeding

Authors: Julia Samuelson, M.P.H., B.S.N. Center for Disease Control Division of Reproductive Health Georgia Division of Public Health
Heena Joshi, M.Sc. Maternal & Child Health Georgia Division of Public Health

Linda Bartlett, M.D., M.H.Sc. Maternal and Infant Health Branch Division of Reproductive Health National Center for Chronic Disease Prevention Centers for Disease Control and Prevention

Cynthia Berg, M.D., M.P.H. Maternal and Infant Health Branch Division of Reproductive Health National Center for Chronic Disease Prevention Centers for Disease Control and Prevention
Corresponding author: Ms Heena Joshi, M.Sc.

References 1. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Healthy People Objectives 2010, Washing-
ton, DC 2. Hoyert DL, Danel I, Tully P. Maternal Mortality, United States and Canada, 1982-1997. Birth 27:1, March 2000. 3. Pregnancy Related Death Among Hispanic, Asian/Pacific Islander and American Indian/Alaskan Native Women-US, 1991-1997, MMWR, May 11,
200:50(18); 361-4. 4. Vital Records Report, Georgia 1999 5. Maternal mortality United States1982-1996, MMWR Sept.4 1998/Vol.47/No.34 6. Pregnancy-related mortality--Georgia, 1990-1992, MMWR, Febr 10, 1995:44(5);93-96 7 Horon, I L, Cheng, D. Enhanced surveillance for pregnancy-associated mortalityMaryland, 1993-1998. JAMA 2001; 285:11. 8. MacKay AP, Rochat R, Smith JC, Berg CJ. The Check Box. Determining pregnancy status to improve maternal mortality surveillance. Am J Prev
Med 2000; 19. 9. CJ Berg, I Danel, Mora G. Guidelines for maternal mortality epidemiological surveillance. Pan American Health Organization Pan American Sanitary
Bureau Regional Office of the World Health Organization Division of Health Promotion and Protection Health of the Family and Population Program 2nd printing March 1998 10. Berg C, Danel I, Zane S, Bartlett L (editors). Strategies to Reduce Maternal Deaths: From Identification to Action. Atlanta: Centers for Disease Control; 2001.
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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

October 2002

Volume 18 Number 10

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 2002

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for July 2002
2002 22 582 11 7 58 470 5 34 32 0 0 3 0 1 0 131 50 5 10 21 7 0 47

Previous 3 Months Total

Ending in July

2000 234

2001 224

2002 132

7736

8360

5600

52

36

22

26

14

19

317

249

198

5089

4645

3243

15

16

18

81

264

118

83

86

92

2

5

2

0

0

0

12

6

8

0

0

0

17

10

5

0

0

0

550

513

422

83

72

276

32

22

21

69

88

51

140

155

92

174

201

57

4

8

0

178

120

133

Previous 12 Months Total

Ending in July

2000 718

2001 703

2002 616

30753

33875

33635

183

193

155

65

49

60

1510

1202

950

20993

20548

18907

80

97

105

372

759

792

309

431

468

11

13

11

0

0

1

68

51

45

5

7

4

73

39

18

0

1

0

2141

1875

1884

328

347

1259

156

111

104

311

326

278

626

608

622

774

884

682

21

28

9

702

667

587

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period
Latest 12 Months: 09/01-08/02 Five Years Ago: 09/97-08/98 Cumulative: 07/81-08/02

Total Cases Reported* <13yrs >=13yrs Total

2

1,739

1,741

6

1,354

1,360

212

25,142 25,354

Percent Female
25.5
18.7
17.6

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

40.1

7.4

2.4

14.1

2.1

34.0

43.0

17.7

5.9

17.1

1.1

15.1

47.7

17.4

5.4

13.4

1.9

14.1

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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Race Distribution (%) White Black Other

18.8 76.5

4.7

23.2 74.1

2.6

34.2 63.5

2.4