Abigail R. Koch

Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011.

OBJECTIVE: To examine whether being pregnant or postpartum was associated with excess risk for homicide among females in Illinois and to describe the association between pregnancy status and homicide by race, ethnicity, and age group. METHODS: This is a retrospective, multicohort, ecologic study of females of reproductive age in Illinois between 2002 and 2011 using Illinois Department of Public Health maternal mortality data and vital records data. We compared pregnancy-associated homicides with live births using &khgr;2 tests. Among maternal deaths in the state, we calculated mortality rates per 100,000 live births for homicide and other violent causes and the leading direct obstetric causes. We calculated aggregate, pregnancy-associated, and nonpregnancy associated homicide rates stratified by race or ethnicity and age group. RESULTS: There were 636 pregnancy-associated deaths in Illinois from 2002 to 2011. Of these, 82 (13%) were the result of homicide (5.0 [95% confidence interval (CI) 4.0–6.2]/100,000 live births). There were 931 homicides among females of reproductive age not associated with pregnancy (2.88 [95% CI 2.70–3.07]/100,000 population). More than half of the homicides were women aged 20–29 years (n=53 [64.6%]), non-Hispanic black women (n=43 [52.4%]), women residing in Cook County (n=47 [57.3%]), and unmarried women (n=57 [69.5%]). Pregnant and postpartum females aged 10–29 years were at twice the risk of homicide compared with their nonpregnant or postpartum counterparts (relative risk 2.20 [95% CI 1.70–2.85]). Non-Hispanic black and Hispanic females experienced higher rates of homicide than non-Hispanic white females irrespective of pregnancy or age. CONCLUSION: Although all violence against women must be addressed, we recommend that state maternal mortality review committees, in addition to reviewing deaths resulting from obstetric and clinical causes, should conduct in-depth reviews of pregnancy-associated homicides and other violent deaths.

Maternal Cardiovascular Mortality in Illinois, 2002–2011

OBJECTIVE To describe the demographic characteristics of women in Illinois who died from cardiovascular disease during pregnancy or up until 1 year postpartum, addressing specific etiologies, timing of death, proportion of potentially preventable mortality, and factors associated with preventability. METHODS This is a retrospective analysis from the Illinois Department of Public Health Maternal Mortality Review process using International Classification of Diseases, 9th Revision codes that attributed cardiovascular disease as the immediate or underlying cause of maternal death in Illinois from 2002 to 2011. We categorized the etiology of cardiovascular mortality, analyzed demographic factors associated with cardiovascular mortality in comparison with noncardiovascular causes, defined the relationship to pregnancy, and identified factors associated with preventability. RESULTS There were 636 deaths in Illinois from 2002 to 2011 of pregnant women or within 1 year postpartum. One hundred forty women (22.2%) died of cardiovascular causes, for a cardiovascular mortality rate of 8.2 (95% confidence interval 6.9-9.6) per 100,000 live births. Women with cardiovascular mortality were likely to be older and die postpartum. The most common etiologies were related to acquired cardiovascular disease (97.1%) as compared with congenital heart disease (2.9%). Cardiomyopathy was the most common etiology (n=39 [27.9%]), followed by stroke (n=32 [22.9%]), hypertensive disorders (n=18 [12.9%]), arrhythmias (n=15 [10.7%]), and coronary disease (n=13 [9.3%]). Nearly 75% of cardiac deaths were related to pregnancy as compared with 35.3% of noncardiac deaths. More than one fourth of cardiac deaths (28.1%) were potentially preventable, attributable primarily to health care provider and patient factors. CONCLUSION From 2002 to 2011, more than one fifth of maternal deaths in Illinois were attributed to cardiovascular disease such as cardiomyopathy. More than one fourth of these deaths were potentially preventable. Health care provider and patient factors were identified, which may be modifiable through education and intensive postpartum monitoring, which may diminish mortality. State maternal mortality reviews can identify opportunities for reducing maternal deaths.

Addressing maternal deaths due to violence: the Illinois experience

Homicide, suicide, and substance abuse accounted for nearly one fourth of all pregnancy-associated deaths in Illinois from 2002 through 2013. Maternal mortality review in Illinois has been primarily focused on obstetric and medical causes and little is known about the circumstances surrounding deaths due to homicide, suicide, and substance abuse, if they are pregnancy related, and if the deaths are potentially preventable. To address this issue, we implemented a process to form a second statewide maternal mortality review committee for deaths due to violence in late 2014. We convened a stakeholder group to accomplish 3 tasks: (1) identify appropriate committee members; (2) identify potential types and sources of information that would be required for a meaningful review of violent maternal deaths; and (3) revise the Maternal Mortality Review Form. Because homicide, suicide, and substance abuse are closely linked to the social determinants of health, the review committee needed to have a broad membership with expertise in areas not required for obstetric maternal mortality review, including social service and community organizations. Identifying additional sources of information is critical; the state Violent Death Reporting System, case management data, and police and autopsy reports provide contextual information that cannot be found in medical records. The stakeholder group revised the Maternal Mortality Review Form to collect information relevant to violent maternal deaths, including screening history and psychosocial history. The form guides the maternal mortality review committee for deaths due to violence to identify potentially preventable factors relating to the woman, her family, systems of care, the community, the legal system, and the institutional environment. The committee has identified potential opportunities to decrease preventable death requiring cooperation with social service agencies and the criminal justice system in addition to the physical and mental health care systems. Illinois has demonstrated that by engaging appropriate members and expanding the information used, it is possible to conduct meaningful reviews of these deaths and make recommendations to prevent future deaths.

Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative

Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage. Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 (n = 64 before training initiative) and 2010 (n = 71 after training initiative) were identified by a two‐factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related. Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p < 0.01) and delay or inappropriate treatment (76.5 vs. 39.5%, p < 0.01). System factors also differed (32.4 vs. 7.9%, p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p < 0.01) between 2006 and 2010. Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.

A global view of severe maternal morbidity: moving beyond maternal mortality

BackgroundMaternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).Severe maternal morbidity in high-income countriesSince the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.Severe maternal morbidity in low and middle income countriesThe highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.Effects of SMM on delivery outcomes and infantsSevere maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.ConclusionIncreasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

A novel obstetric medical device designed for autotransfusion of blood in life threatening postpartum haemorrhage

Abstract Postpartum haemorrhage (PPH) is an obstetric emergency caused by excessive blood loss after delivery, which is the leading cause of maternal mortality worldwide. PPH can lead to volume depletion, hypovolemic shock, anaemia and ultimately death. The prevalence of PPH is disproportionately higher in low resource settings where there is limited access to skilled medical care and safe blood supplies. Current management strategies target both prevention and treatment of PPH however no alternatives currently exist to address the lack of safe blood supplies which are considered essential in emergency obstetrical care. Autotransfusion is used to salvage blood loss in a variety of clinical settings but has never been used in the context of vaginal delivery. We describe the development and testing of a novel device for the collection, filtration and autotransfusion of blood lost due to PPH. The prototype device is inexpensive and easily operated so that it may be practically deployed in low resource settings. The device is comprised of a blood collection drape, a pump apparatus, three leukocyte reduction filters and a reservoir for filtered blood. Preliminary testing demonstrates efficacy of microbial load reduction of up to 97.3%. To reduce cost and improve safety, the device is modular in design such that the drape, tubing, filters and transfusion bag may be stored sterile, used once and discarded; while the pump apparatus may be used indefinitely without the need for sterilisation. Preliminary results indicate the device confers a low cost and potentially effective means of collecting, pumping, filtering and returning blood to a patient following PPH in settings that lack safe blood supplies. This device shows promise as a method of stabilising patients suffering of PPH in low resource settings until definitive treatment is rendered with the ultimate goal of reducing maternal mortality globally.

In Pursuit of Solving a Global Health Problem: Prototype Medical Device for Autotransfusing Life-Threatening Postpartum Hemorrhage in Resource-Limited Settings

Purpose of ReviewThe purpose of the review is to provide an overview of innovative technologies being developed to prevent and treat postpartum hemorrhage in resource-limited settings and to discuss a promising new device designed specifically to address the lack of safe blood supplies in many areas of the world.Recent FindingsThere are several new technologies being used or tested to address the significant global health problem of postpartum hemorrhage, the leading cause of maternal morbidity and mortality worldwide. None of these new technologies have addressed the persistent lack of safe blood supplies in low resource settings which is an essential pillar of comprehensive emergency obstetric care. With this aim in mind, a prototype obstetrical medical device was designed with the capability to autotransfuse women suffering life-threatening postpartum hemorrhage in low resource settings.SummaryPostpartum hemorrhage remains the leading cause of maternal morbidity worldwide and efforts are needed, more than ever, to achieve the Sustainable Development Goals of improving maternal mortality especially in resource-limited settings. Despite many effective new technologies such as the non-pneumatic anti-shock garment, improvised uterine balloon tamponade devices, and new drugs such as tranexamic acid, none has addressed the lack of safe blood supplies that are critical to treating PPH. A prototype medical device has been developed, and preliminary testing for functionality and filter function has been successful and shows great promise. Further testing is still needed and is ongoing in preparation for human clinical trials.