Reducing maternal mortality in Georgia : 2013 case review update

Reducing
Maternal Mortality
in Georgia
2013 Case Review Update

November 2017

REDUCING MATERNAL MORTALITY IN GEORGIA | 1

Reducing
Maternal Mortality
in Georgia
Update on 2012 Georgia Maternal Mortality Cases
AFTER THE GEORGIA MATERNAL MORTALITY 2012 Case Review Report was published in June 2015, one additional case was identified and reviewed by the Georgia Maternal Mortality Review Committee (MMRC). The death was determined to be pregnancy-related. Based on the revised findings, 86 maternal deaths were identified, of which 26 (30%) deaths were pregnancy-related and 60 (70%) deaths were pregnancy-associated, not related.
THE RELEASE OF THE FIRST REPORT of the Georgia MMRC included numerous recommendations and opportunities for prevention. Although work has begun on a number of the 2012 recommendations, additional focus and development is needed in each category addressed. Many issues identified in the 2012 cases are reoccurring issues identified in 2013 and further validate the work of the committee and the need for action.
2|GEORGIA DEPARTMENT OF PUBLIC HEALTH

Update on 2012 Recommendations

CLINICAL PRACTICE AND EDUCATION
There is a continued need for education of both clinicians and patients regarding the use of prescription medications, nonprescription and illicit drugs both during pregnancy and the postpartum period.

THE FOCUS SHOULD CONTINUE ON:
Appropriate use of medications for chronic medical conditions; especially cardiomyopathies and cardiac conditions, and anxiety and depression
Education and counseling of women on maintenance medications
Follow-up care for pregnancy and postpartum and intra pregnancy care for women with chronic medical conditions

PUBLIC HEALTH/VITAL STATISTICS
The pregnancy checkbox on death certificates is an opportunity to help identify pregnancy-associated deaths. The review of 2012 cases identified checkbox errors which resulted in non-pregnant women being referred to the Georgia MMRC. A 2012 report recommendation included identifying opportunities for the timely identification and correction of errors on death certificates related to the pregnancy checkbox. The Georgia MMRC worked closely with the Georgia Office of Vital Records and the CDC Division of Reproductive Health to develop a process of identifying death certificates with potential checkbox errors, and making timely corrections. Georgia implemented the process in 2016 to improve the accuracy of information included on the death certificate pregnancy checkbox.

GEORGIA MMRC COMMITTEE DEVELOPMENT:
Due to improved case identification and abstraction processes, chart reviews have increased in efficiency. The Georgia MMRC has five part-time abstractors trained and strategically placed around the state to facilitate case reviews. This allows the Georgia MMRC Committee Coordinator to more efficiently

delegate and carry out the work of the committee. The Georgia MMRC utilizes the CDC's latest case abstraction system for data collection.
The Georgia MMRC collaborated with the CDC on development of a policy and interview guide for family/relative interviews which is in practice now. THE GEORGIA MATERNAL MORTALITY REVIEW COMMITTEE (MMRC) consists of The

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Review of 2013 Georgia Maternal Mortality Cases

THE GEORGIA MATERNAL MORTALITY Review Committee (MMRC) consists of approximately 45 members. The members represent various geographic locations, specialties, facilities, and systems that interact with, and impact maternal and child health.
The mission of the Georgia MMRC is to "identify pregnancy-associated deaths, review those caused by pregnancy complications and other selected deaths, and identify problems contributing to these deaths and interventions that may reduce these deaths." The processes used for identification and review of 2013 maternal deaths in Georgia were consistent with the processes used for the 2012 case review.
Please reference the 2012 Case Review report via the following link for a detailed description:
https://dph.georgia.gov/sites/dph.georgia.gov/files/
MCH/MMR_2012_Case_Review_June2015_final.pdf
MATERNAL MORTALITY CASE DEFINITIONS In 2013, the Georgia MMRC identified 79 pregnancyassociated deaths overall (deaths during pregnancy or within one year of pregnancy from any cause),

which will be referred to as total maternal deaths in this report. Upon review by the Georgia MMRC, the maternal deaths were grouped into two mutually exclusive categories: pregnancy-associated, not related deaths and pregnancy-related deaths, which are defined below.
PREGNANCY-ASSOCIATED, NOT RELATED DEATHS The death of a woman while pregnant or within one year of the end of pregnancy, due to a cause unrelated to pregnancy (e.g. motor vehicle crash, homicide or cancer, as determined by the Georgia MMRC).
PREGNANCY-RELATED DEATHS The death of a woman while pregnant or within one year of the end 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.

4|GEORGIA DEPARTMENT OF PUBLIC HEALTH

79 86 GEORGIA HAD

MATERNAL DEATHS IN 2013, COMPARED TO

DEATHS IN 2012.

OVERVIEW OF 2013 GEORGIA MATERNAL MORTALITY CASES
Multiple strategies of case identification yielded 79 total maternal deaths (pregnancyrelated and pregnancy-associated, not related) in Georgia during 2013 compared to 86 deaths in 2012. Forty-seven deaths (59 percent) occurred while pregnant or within one year of the end of pregnancy, due to a cause unrelated to pregnancy (pregnancy-associated, not related). Thirty-two deaths (41 percent) were found to be related to or aggravated by the cause of pregnancy or its management (pregnancy-related) (Figure 1).

FIGURE 1: Maternal Mortality Case Review, 2013

Pregnancy-related deaths
N=32 (41%)

Pregnancy-associated, not related deaths N=47 (59%)

79
TOTAL MATERNAL
DEATHS
(PREGNANCY-RELATED AND
PREGNANCY-ASSOCIATED,
NOT RELATED) IN GEORGIA
DURING 2013

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16 32 IN GEORGIA DURING 2013, (50%) OF THE PREGNANCY-RELATED
DEATHS WERE DETERMINED BY THE MMRC TO BE PREVENTABLE

Preventability and Chance to Alter the Outcome

ONE OF THE UNIQUE AND CRITICAL roles of the Georgia MMRC is to determine actionable items that can eliminate preventable maternal deaths. The Centers for Disease Control and Prevention (CDC) has defined preventability for the case review process as: "A death is considered preventable, if the committee determines that there was at least some chance of the death being averted by one or more reasonable changes to patient, community, provider, facility, and/or systems factors."1

Specifically, the Georgia MMRC answers the following questions to determine preventability:
1|Was this death preventable? 2|Was there any chance to alter the outcome?
In Georgia during 2013, sixteen (50 percent) of the 32 pregnancy-related deaths were determined by the MMRC to be preventable (Table 1).

TABLE 1: Preventability of Pregnancy-Related Maternal Deaths, Georgia, 2013

PREVENTABLE

TOTAL N (%)
N=79

PREGNANCYA S S O C I AT E D
N (%)
N=47

PREGNANCYR E L AT E D N (%)
N=32

YES

21 (26.6%)

5 (10.6%)

16 (50.0%)

NO

58 (73.4%)

42 (89.4%)

16 (50.0%)

6|GEORGIA DEPARTMENT OF PUBLIC HEALTH

60% OF THE PREGNANCY-RELATED DEATHS OCCURED

42 WITHIN THE FIRST

DAYS AFTER THE END OF PREGNANCY

Demographics
AS SHOWN IN TABLE 2 (following page), the majority (79 percent) of the pregnancy-associated, not related deaths occurred more than 42 days postpartum. However, 60 percent of the pregnancy-related deaths occurred within the first 42 days after the end of pregnancy.
Approximately, 50 percent of the 79 total maternal deaths occurred among women 29 years of age and younger, with the youngest death occurring to a 15 year-old and the oldest death occurring to a 45 year- old woman. Of the 79 maternal deaths reviewed, a greater proportion of the women with advanced maternal age (35 years and older) died of pregnancy-related causes (60 percent) versus pregnancyassociated, not related causes (40 percent).
Non-Hispanic Black/African-Americans and Non-Hispanic White/Caucasians accounted for 47

percent and 43 percent, respectively, of the total maternal deaths. However, racial/ethnic disparities existed among the proportion of pregnancy-related and pregnancy-associated, not related deaths, not related cases. For example, of the 32 pregnancy-related deaths, Black/ African-American was the most predominant racial/ ethnic group (66 percent), while for the 47 pregnancyassociated, not related deaths, White/Caucasian was the most predominant racial/ethnic group (60 percent).
Nearly half (48 percent) of the 79 total maternal deaths occurred among women that were never married. The highest level of education attained by more than 80 percent of the 79 total maternal deaths was a high school diploma or less. Seventy-three percent of the total maternal deaths occurred among residents of an urban setting (any Georgia county with 35,000 or more total population per year by the 2000 Census)

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w

50% OF PREGNANCY-RELATED DEATHS OCCURRED AMONG

29 WOMEN

YEARS OF AGE AND YOUNGER

Demographic Factors

TABLE 2: Demographic Factors Associated With Maternal Deaths, Georgia, 2013

TOTAL N (%)

PREGNANCY-ASSOCIATED PREGNANCY-RELATED

N (%)

N (%)

TIMING OF DEATH

N=79

TOT

N=32

While pregnant

16 (20.3%)

8 (17.0%)

8 (25.0%)

Less than one day

4 (5.1%)

0 (0.0%)

4 (12.5%)

1-42 days postpartum

12 (15.2%)

2 (4.3%)

10 (31.3%)

43+ days postpartum

47 (59.5%)

37 (78.7%)

10 (31.3%)

AGE

N=79

N=47

N=32

<20

5 (6.3%)

3 (6.4%)

2 (6.3%)

20-24

20 (25.3%)

10 (21.3%)

10 (31.3%)

25-29

17 (21.5%)

13 (27.7%)

4 (12.5%)

30-34

23 (29.1%)

16 (34.0%)

7 (21.9%)

35-39

7 (8.9%)

4 (8.5%)

3 (9.4%)

40+

7 (8.9%)

1 (2.1%)

6 (18.8%)

RACE/ETHNICITY

N=79

N=47

N=32

Black or African American

37 (46.8%)

16 (34.0%)

21 (65.6%)

White or Caucasian

34 (43.0%)

28 (59.6%)

6 (18.8%)

Hispanic

6 (7.6%)

2 (4.3%)

4 (12.5%)

Asian

2 (2.5%)

1 (2.1%)

1 (3.1%)

Marital Status

N=79

N=47

N=32

Married

34 (43.0%)

19 (40.4%)

15 (46.9%)

"Married, but separated"

4 (5.1%)

3 (6.4%)

1 (3.1%)

Never married

38 (48.1%)

23 (48.9%)

15 (46.9%)

Divorced

2 (2.5%)

2 (4.3%)

0 (0.0%)

Widowed

1 (1.3%)

0 (0.0%)

1 (3.1%)

HIGHEST LEVEL OF EDUCATION ATTAINED

N=79

N=47

N=32

No High School Diploma

24 (30.4%)

14 (29.8%)

10 (31.3%)

High School Diploma

41 (51.9%)

24 (51.1%)

17 (53.1%)

Associate's Degree

5 (6.3%)

3 (6.4%)

2 (6.3%)

Bachelor's Degree

5 (6.3%)

3 (6.4%)

2 (6.3%)

Master's Degree

3 (3.8%)

2 (4.3%)

1 (3.1%)

Doctorate or Professional Degree

1 (1.3%)

1 (2.1%)

0 (0.0%)

GEOGRAPHY (PLACE OF RESIDENCE)

N=79

N=47

N=32

Urban

58 (73.4%)

34 (72.3%)

24 (75.0%)

Rural

21 (26.6%)

13 (27.7%)

8 (25.0%)

8|GEORGIA DEPARTMENT OF PUBLIC HEALTH

(53%) 47 SLIGHTLY OVER HALF

OF THE

PREGNANCY-ASSOCIATED, NOT RELATED

DEATHS WERE AMONG WOMEN WITH A GRAVIDA OF 1 TO 2

Pregnancy Factors
GRAVIDITY REFERS TO the number of pregnancies, current and past, a woman has had regardless of the outcome.2 Slightly over half (53 percent) of the 47 pregnancy-associated, not related deaths were among women with a gravida of 1 to 2, compared to the 10 pregnancy-related deaths (31 percent) with a gravida of 1 to 2, and 10 pregnancyrelated deaths (31 percent) with a gravida of 5 or more. Parity refers to the number of pregnancies a woman has had that reached viability (20 weeks gestation), regardless of the number of fetuses or outcomes.2 Among the 47 pregnancy-associated, not related deaths, there was an almost even distribution of parity categories: nulliparous (34 percent), primiparous (26 percent) and multiparous (23 percent). Forty-one percent of the 32 pregnancy-related deaths occurred among multiparous women (Table 3).
Information on the inter-pregnancy interval was missing for a high proportion of the 44 maternal deaths with a previous live birth (34 percent). However, among these 44 women that had a

previous live birth, 22 (50 percent) of the pregnancies were conceived based on the recommended birth spacing guideline (18 months or more).3

TABLE 3: Pregnancy Factors Associated With Maternal Mortality, Georgia, 2013

TOTAL N (%)

PREGNANCY-ASSOCIATED PREGNANCY-RELATED

N (%)

N (%)

GRAVIDA

N=79

N=47

N=32

1 to 2

35 (44.3%)

25 (53.2%)

10 (31.3%)

3 to 4

20 (25.3%)

12 (25.5%)

8 (25.0%)

5+

12 (15.2%)

2 (4.3%)

10 (31.3%)

Unknown

12 (15.2%)

8 (17.0%)

4 (12.5%)

PARITY

N=79

N=47

N=32

Nulliparous

23 (29.1%)

16 (34.0%)

7 (21.9%)

Primiparous

20 (25.3%)

12 (25.5%)

8 (25.0%)

Multiparous

24 (30.4%)

11 (23.4%)

13 (40.6%)

Unknown

12 (15.2%)

8 (17.0%)

4 (12.5%)

INTERPREGNANCY INTERVAL

N=44

N=23

N=21

<18 months

7 (15.9%)

3 (13.0%)

4 (19.0%)

18+ months

22 (50.0%)

15 (65.2%)

7 (33.3%)

Unknown

15 (34.1%)

5 (21.7%)

10 (47.6%)

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(69%) 32 MORE THAN TWO-THIRDS

OF

PREGNANCY-RELATED DEATHS

HAD A PRE-EXISTING MEDICAL CONDITION

INFORMATION ON PRE-PREGNANCY weight and pre-existing medical conditions was missing for 28 percent of the 79 total maternal deaths. Fourteen pregnancy-related deaths (44 percent) had at-risk prepregnancy weights (overweight, obese, or morbidly obese) compared to 21 pregnancy-associated, not related deaths (45 percent) classified as having at-risk prepregnancy weights (Table 4). More than two-thirds (69 percent) of 32 pregnancy-related deaths had a preexisting medical condition. A pre-existing medical condition includes, but is not limited to, hypertension, diabetes, or asthma. Information on the trimester in which prenatal care was initiated was missing for 25 percent of the 79 total maternal deaths. However, more than half of the women that died of pregnancy-

associated, not related causes (55 percent) and pregnancyrelated causes (50 percent) began prenatal care in the first trimester.
Of the 79 total maternal deaths, 63 resulted in a delivery (live birth or fetal death). Twenty-four of the 63 maternal deaths that resulted in a delivery were found to be pregnancy-related deaths. Among the 24 pregnancy-related deaths, ninety-six percent had a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) attend the labor and delivery, 50 percent delivered at a facility with a Level I and II perinatal care level (Table 4), and 71 percent delivered by Cesarean (Figure 2).

Pregnancy-related (N=24)

7 deaths

17 deaths

Pregnancy-associated, not related (N=39)

15 deaths

24 deaths

0

5

10

15

20

25

30

Cesarian Vaginal

FIGURE 2: Maternal Deaths That Resulted in a Live Birth or Fetal Death (N=63) by Mode of Delivery, Georgia, 2013

10|GEORGIA DEPARTMENT OF PUBLIC HEALTH

INFORMATION ON THE TRIMESTER IN WHICH PRENATAL CARE WAS INITIATED

25% 79 WAS MISSING FOR

OF THE

TOTAL MATERNAL DEATHS

TABLE 4: Prenatal/Intrapartum Factors Associated With Maternal Mortality, Georgia, 2013

PRE-PREGNANCY WEIGHT Underweight (BMI: less than 18.5) Normal Weight (Bmi: 18.5-24.9)

TOTAL N (%)
N=79 3 (3.8%) 19 (24.1%)

PREGNANCYA S S O C I AT E D
N (%)
N=47
3 (6.4%) 13 (27.7%)

PREGNANCYR E L AT E D N (%)
N=32
0 (0.0%) 6 (18.8%)

Overweight (BMI: 25.0-29.9) Obese (BMI: 30.0-39.9) Morbidly obese (BMI: 40.0 or greater) Unknown

16 (20.3%) 11 (13.9%) 8 (10.1%) 22 (27.8%)

12 (25.5%) 6 (12.8%) 3 (6.4%) 10 (21.3%)

4 (12.5%) 5 (15.6%) 5 (15.6%) 12 (37.5%)

PRE-EXISTING MEDICAL PROBLEMS

N=79

N=47

N=32

Yes No Unknown

45 (57.0%) 12 (15.2%) 22 (27.8%)

23 (48.9%) 9 (19.1%) 15 (31.9%)

22 (68.8%) 3 (9.4%) 7 (21.9%)

TRIMESTER PRENATAL CARE BEGAN

N=79

N=47

N=32

First trimester Second trimester Third trimester None

42 (53.2%) 12 (15.2%)
3 (3.8%) 2 (2.5%)

26 (55.3%) 8 (17.0%) 0 (0.0%) 0 (0.0%)

16 (50.0%) 4 (12.5%) 3 (9.4%) 2 (6.3%)

Unknown LABOR AND DELIVERY PRACTITIONER

20 (25.3%) N=63

13 (27.7%) N=39

7 (21.9%) N=24

MD/DO CNM/CM

60 (95.2%) 2 (3.2%)

37 (94.9%) 1 (2.6%)

23 (95.8%) 1 (4.2%)

Unknown MODE OF DELIVERY

1 (1.6%) N=63

1 (2.6%) N=39

0 (0.0%) N=24

Vaginal

31 (49.2%)

24 (61.5%)

7 (29.2%)

Cesarean

32 (50.8%)

15 (38.5%)

17 (70.8%)

PERINATAL LEVEL OF CARE OF DELIVERY FACILITY Basic (Level I) Specialty (Level II) Subpecialty (Level III)

N=63 7 (11.1%) 17 (27.0%) 24 (38.1%)

N=39 4 (10.3%) 8 (20.5%) 17 (43.6%)

N=24 3 (12.5%) 9 (37.5%) 7 (29.2%)

Regional center (Level IV)

15 (23.8%)

10 (25.6%)

5 (20.8%)

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79 52% AMONG THE

TOTAL MATERNAL DEATHS,

WERE MEDICAID RECIPIENTS

18% AND

RECEIVED PRIVATE INSURANCE

Additional Factors

INFORMATION REGARDING the participation of women in the Georgia Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was missing for twenty-nine percent of the 79 total maternal deaths. However, thirty-eight women (48 percent) participated in WIC. Among the 79 total maternal deaths, 52 percent were Medicaid recipients, 18 percent received private insurance, and payor informations was not available for 23 percents of total deaths (Table 5). Information about the presence of social or psychological issues was missing for a high proportion of the total maternal deaths (43 percent). Particularly as it relates to substance abuse, incarceration, social or emotional stress, or homelessness, where noted in the data gathered through abstraction, 14 (18 percent) of the 79 total maternal deaths did not have a social or emotional issue.

TABLE 5: Other Public Health Factors Associated With Maternal Mortality, Georgia, 2013

TOTAL N (%)

PREGNANCY-ASSOCIATED N (%)

PREGNANCYR E L AT E D N (%)

WIC PARTICIPANT

N=79

N=47

N=32

Yes

38 (48.1%)

26 (55.3%)

12 (37.5%)

No

18 (22.8%)

11 (23.4%)

7 (21.9%)

Unknown

23 (29.1%)

10 (21.3%)

13 (40.6%)

SOCIAL OR PSYCHOLOGICAL ISSUE PRESENT*

N=79

N=47

N=32

Yes

14 (17.7%)

7 (14.9%)

7 (21.9%)

No

31 (39.2%)

17 (36.2%)

14 (43.8%)

Unknown

34 (43.0%)

23 (48.9%)

11 (34.4%)

PAYOR

N=79

N=47

N=32

Medicaid

41 (51.9%)

25 (53.2%)

16 (50.0%)

Private

14 (17.7%)

9 (19.1%)

5 (15.6%)

Other

3 (3.8%)

2 (4.3%)

1 (3.1%)

Self-pay

3 (3.8%)

1 (2.1%)

2 (6.3%)

Unknown

18 (22.8%)

10 (21.3%)

8 (25.0%)

*Substance abuse, incarceration, social or emotional stress or homelessness

12|GEORGIA DEPARTMENT OF PUBLIC HEALTH

REDUCING MATERNAL MORTALITY IN GEORGIA | 13

32 THE GEORGIA MMRC IDENTIFIED

DEATHS, THAT WERE PREGNANCY-RELATED,

(25%) WITH CARDIOMYOPATHY BEING THE LEADING CAUSE

.

Cause of Death

FIGURE 3: Pregnancy-Related Deaths by Cause of Death, Georgia, 2013
Number of Deaths
0123456789 Cardiomyopathy
Hemorrage Embolism
Cardiovascular and Coronary Conditions Infections
Pregnancy-Specific Conditions Anesthesia Complications
Mental Health Conditions Other

PREGNANCY-RELATED DEATHS BY CAUSE OF DEATH

THE GEORGIA MMRC identified 32 deaths that (e.g. gestational diabetes, hyperemesis, liver disease

were pregnancy-related. Cardiomyopathy was the lead- of pregnancy) (6 percent), anesthesia complications

ing cause of pregnancy-related deaths, which accounted (6 percent), and mental health conditions (6 percent).

for one-quarter of the 32 pregnancy-related deaths. Four The two maternal deaths due to mental health

of these eight cases had post-partum/peripartum

conditions were related to depression/suicide,

cardiomyopathy. The second-leading cause of pregnancy- and was determined to be pregnancy-related by

related deaths were hemorrhage (16 percent) and

the Georgia MMRC. Four (13 percent) of the

embolism (16 percent). Two of the five (40%) maternal 32 pregnancy-related deaths were classified as having

deaths due to hemorrhage involved obstetric

"Other" causes of death, which included pre-

hemorrhages and two of the five (40%) deaths due

eclampsia, pulmonary disorders, autoimmune

to embolism involved amniotic fluid embolisms.

disease, and unintentional injuries (Figure 3).

Other causes of pregnancy-related deaths, included The unintentional injury was a motor vehicle crash

cardiovascular and coronary conditions (6 percent), that was determined to be pregnancy-related by

infections (6 percent), conditions unique to pregnancy the Georgia MMRC.

14|GEORGIA DEPARTMENT OF PUBLIC HEALTH

47 THE GEORGIA MMRC IDENTIFIED

DEATHS THAT WERE PREGNANCY-ASSOCIATED,

NOT RELATED, WITH MOTOR VEHICLE CRASHES AS THE MOST FREQUENT CAUSE

PREGNANCY-RELATED DEATHS BY CAUSE OF DEATH AND TIMING OF DEATH

EMBOLISM (13 percent) and conditions unique to pregnancy (e.g. gestational diabetes, hyperemesis, liver disease of pregnancy) (6 percent) were the leading causes of pregnancy-related deaths that occurred while the decedent was pregnant or within one day postpartum. Between 1 to 42 days postpar-

tum, the leading causes of pregnancy-related deaths were cardiomyopathy/cardiovascular (6 percent) and coronary conditions (6 percent). The leading causes of pregnancy-related deaths that occurred between 43 to 364 days postpartum were cardiomyopathy (16 percent) followed by hemorrhage (6 percent).

PREGNANCY-ASSOCIATED, NOT RELATED DEATHS BY CAUSE OF DEATH

THE GEORGIA MMRC identified 47 deaths that were pregnancy-associated, not related. The seven most- frequent causes were motor vehicle crashes (19 percent), drug toxicity (15 percent), homicide (13 percent), respiratory conditions (11 percent), cardiomyopathy (6 percent), cardiovascular and coronary

conditions (6 percent), and suicide (6 percent). The pregnancy-associated, not related deaths classified with "Other" causes of death included, but were not limited to, deaths caused by cancer, diabetes, sepsis, and seizures (Figure 4).

FIGURE 4: Pregnancy-Associated, Not Related Deaths by Cause of Death, Georgia, 2013
Number of Deaths
0 1 2 3 4 5 6 7 8 9 10 Motor Vehicle Crashes
Drug Toxicity Homicide
Respiratory Cardiomyopathy Cardiovascular and Coronary Conditions
Suicide Cancer Diabetes
Sepsis Other
REDUCING MATERNAL MORTALITY IN GEORGIA | 15

KEY OPPORTUNITIES: EDUCATION OF CLINICIANS, PATIENTS AND THE COMMUNITY ...
Key Opportunities for Prevention:
AFTER A SECOND FULL YEAR of reviewing maternal deaths in the state of Georgia, the Georgia MMRC has found many opportunities for prevention. These opportunities fall in to two main categories: Education of clinicians, patients and the community regarding potential
or actual problems that most commonly lead to poor maternal outcomes and potential deaths Early identification of risk factors associated with maternal mortality, and then appropriate follow-up of these problems.
16|GEORGIA DEPARTMENT OF PUBLIC HEALTH

REGARDING PROBLEMS THAT LEAD TO POOR MATERNAL OUTCOMES & DEATHS

2013 Case Findings:

THE AREAS OF HIGHEST CONCERN that most frequently result in poor outcomes in Georgia are:

Cardiomyopathies and cardiovascular conditions such as hypertension
Risk factors and symptoms of cardiomyopathy not recognized or assessed by patient or provider
Inadequate follow-up of cardiovascular symptoms or chronic cardiac disease
Hemorrhage
Delayed recognition and treatment of hemorrhage in post-partum women by both patients and clinicians
Anxiety/Depression
Inadequate screening of pregnant and postpartum women for depression and other mental health issues
Possible lack of access to mental health services
Potential lack of awareness by patients or providers of benefits and safety of antidepressant therapy during pregnancy and post-partum
ADDITIONAL KEY FINDINGS:
Obesity Fifty eight percent of the reviewed maternal mortality cases were documented as morbidly obese with a BMI of greater than 30. Obesity coexisted with medical problems such as cardiovascular disease, hypertension, diabetes and postpartum complications.
Inadequate assessment or monitoring of obese pregnant and postpartum women
Lack of referral to a maternal fetal medicine specialist or cardiologist for morbid obesity

Lack of calculated BMI or height and pre-pregnant weight
Inadequate embolism prophylaxis for obese patients on bedrest or with decreased mobility
Chronic Medical Conditions
Women with chronic medical conditions not receiving referrals or interconceptual care to treat those chronic conditions during pregnancy
Women with high risk or chronic conditions possibly not receiving preconceptual or early pregnancy counseling on the increased risk for them during pregnancy
Drugs in Pregnancy
Inappropriate usage of prescription, nonprescription and illicit drugs during pregnancy and post-partum
Lack of prescription history being available to the provider
Inappropriate mixing or adding of medications to those prescribed
Lack of screening for prescription and/or illegal substance abuse
Availability of high risk care
Lack of transfer or referral to a higher level of care
Inability of incarcerated pregnant women to get the appropriate level of care
Lack of standardization for treatment and referral of high risk pregnancies

REDUCING MATERNAL MORTALITY IN GEORGIA | 17

Recommendations based on 2013 Case Review

THE GEORGIA MMRC believes that through a multidisciplinary effort, Georgia can bring to fruition the opportunities for prevention of maternal deaths. State-wide action is recommended to bring about the education that is needed. Three main areas are included in our recommendations: Medical Education, Community Education and Policy-

Medical Education Opportunities:

Community Education Opportunities:

Partner with the Georgia Perinatal Quality Collaborative (GaPQC) to implement Alliance for Innovation for Maternal Health (AIM) patient safety bundles related to cardiovascular disease and hemorrhage in pregnancy
Encourage a complete medical history including height, weight, pre-pregnant weight and BMI

Partner with Department of Community Health and other community agencies to promote prenatal care throughout pregnancy including evidencebased programs such as centering pregnancy
Publicize the importance of following health care provider recommendations to ensure a healthy pregnancy

Consider cardiovascular, Maternal Fetal Medicine (MFM) and/or telemedicine consults for morbidly obese pregnant women whenever possible
Encourage depression screening during pregnancy and during post-partum period
Utilize mental health treatment protocols, and refer appropriately depending on results. Consider telemedicine referral
Encourage patients to take prescribed medications. If patient has not been taking her medications, inquire as to why, and try to resolve the problem

Publicize healthy eating habits and weights
Continue contraception education, especially LARCs for at risk women, to facilitate best pregnancy outcomes
Publicize dangers of smoking during pregnancy and promote smoking cessation resources, including the Georgia Tobacco Quit Line
Promote the regional perinatal system for referral and treatment of high risk pregnancies
Policy Recommendations:

When appropriate try to prescribe generic medications, especially those supported by Medicaid formulary and those offered through free or discounted medication programs

Support legislation that will preserve the women's health care system including rural Labor and Delivery units, so that all expectant mothers have access to care within a reasonable distance.

Publicize the importance of following provider recommendations to ensure a healthy pregnancy
Encourage interconceptual and post-partum follow-up and care

Funding for Public Health departments should be maintained and increased when possible to meet the demand for women's health care services
Work to extend insurance coverage into the months after delivery to treat and manage high-risk co-morbidities such as hypertension, cardiac disease and obesity

18|GEORGIA DEPARTMENT OF PUBLIC HEALTH

Georgia Maternal Mortality Review Committee Development:
Currently there are 4 part-time abstractors working with the MMRC, and one full time Coordinator. Additional abstraction support is needed to facilitate the volume of case reviews, and a state-wide education coordinator is needed to develop education and improvement initiatives
Continue to evaluate maternal death and work to make recommendations regarding clinical care, patient education and legislative action to help significantly decrease the rate of maternal death in Georgia
Integrate Regional Perinatal Centers and clinicians in the state of Georgia to improve care for women with chronic disease and high-risk conditions
Incorporate the new CDC abstraction tool, MMRIA, into daily use when it is available
Allow fax or electronic transfer of medical records to expedite MMRC abstraction

Reference
1The Centers for Disease Control and Prevention Foundation. Report from Maternal Mortality Review Committees: A View Into Their Critical Role; retrieved on March 13, 2017 from: http://www. cdcfoundation.org/sites/default/files/upload/pdf/ MMRIAReport.pdf
2 The American Congress of Obstetricians and Gynecologists, Obstetric Data Definitions (version 1); retrieved on March 16, 2017 from: https://www. acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf
3Healthy People 2020, Family Planning; retrieved on March 16, 2016 from: https://www.healthypeople. gov/2020/topics-objectives/objective/fp-5

REDUCING MATERNAL MORTALITY IN GEORGIA | 19

2013 ANNUAL REPORT CASE REVIEW UPDATE
Reducing
Maternal Mortality in Georgia
GEORGIA DEPARTMENT OF PUBLIC HEALTH