Maternal Mortality In Utah
SCOTT JACOB, MD, LOIS BLOEBAUM RN, GULZAR SHAH, PhD
AND MICHAEL W. VARNER, MD
Objective: To determine trends in maternal deaths in Utah, identify opportunities for
preventive intervention, and analyze the mechanism of reporting maternal deaths.
Methods: A retrospective review was performed of maternal death certificates and
medical records in Utah from January 1, 1982, through December 31, 1994.
Results: Sixty-two maternal deaths were identified. The risk of maternal death
increased with maternal age and parity. The classic triad of hemorrhage (n=8), infection
(n=5), and preeclampsia-eclampsia (n=3) remains an important contributor (16 of 62 or
25.8%). However, trauma (n=10), pulmonary embolism (n=10), and maternal cardiac disease
(n=9) now account for 46.8% (29 of 62) of maternal deaths. A greater number of direct
obstetric causes of maternal death (n=20) were deemed preventable than indirect obstetric
causes (n=1) or nonobstetric causes (n=4).
Conclusion: Trauma, pulmonary embolism, and maternal cardiac disease have emerged as
the most common identifiable causes of maternal death. Improvements in prevention, earlier
diagnosis, and aggressive treatment of these conditions are necessary to achieve the
Public Health Service year 2000 objective of a 50% reduction in maternal mortality ratios
(using the 1987 ratio as a baseline). (Obstet Gynecol 1998;91:187-91).
The United States Public Health Service Year 2000 objective is a fifty percent
reduction in the maternal mortality ratio (using 1987 ratio as a baseline).1 Despite
marked decreases in the United States during the past five decades, maternal deaths remain
devastating obstetric complications. Maternal mortality reviews have traditionally been
used to identify and analyze trends in maternal deaths and to assess the quality of
obstetric health care delivery. National maternal mortality surveillance studies compiled
by the Centers for Disease Control were published in 1991 2 and 1996 3 to
complement previously published state-wide reviews for the past five decades. 4-9
The goals of this study were to analyze trends in maternal deaths in Utah, to identify
at-risk groups along with potential opportunities for preventative intervention and to
analyze the mechanism of maternal death reporting to determine possible improvements for
MATERIALS AND METHODS
During the years 1982 through 1994, 41 maternal deaths were identified by the Utah
Department of Health (UDOH), Bureau of Vital Records. The interval of study was selected
because computerized birth and death certificate data were available and because medical
practices were similar to current practice. The Bureau of Vital Records definition for
maternal death is the death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and the site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management but not from accidental or
The Bureau of Vital Records currently identifies maternal deaths by the following
methods: a) delivery mentioned on death certificate, b) pregnancy mentioned on death
certificate, c) delivery related operation (cesarean section, etc.) mentioned on death
certificate, d) post-partum listed on death certificate, or e) anything associated with
pregnancy mentioned on death certificate. If any of the above are indicated by the
physician who completes the death certificate, a vital records staff person checks the
live birth and fetal death file to ascertain if the delivery has occurred within 42 days
of the death. This method is known to miss a significant proportion of actual cases
because some women are not identified as pregnant, or deceased as a result of pregnancy on
the death certificate 10 . The Utah death certificate does not currently
include a provision to specifically indicate whether the deceased was pregnant at the time
of death. Because underreporting was suspected, we performed a further review of birth and
death certificates by the Bureau of Vital Records using the CDC criteria and a search of
computerized discharge summaries of the state's four tertiary referral centers; we
identified an additional 21 cases. Data were then extracted from patient medical records.
The Utah State Medical Examiner's Office also was used as a resource to supplement missing
or incomplete medical records. Causes of death were then classified according to the 1991
Centers for Disease Control maternal mortality review guidelines 2 . All
maternal deaths identified were deemed either preventable or non preventable by the
authors on the basis of standards of care and medical technology currently available.
A maternal death was defined as any death occurring during pregnancy, or within one
year following termination of pregnancy, resulting from complications of the pregnancy
itself, by a chain of events initiated by the pregnancy or by the aggravation of an
unrelated condition by the physiologic or pharmacologic effects of the pregnancy. Direct
obstetric deaths were defined as maternal deaths resulting from obstetrical complications
of the pregnancy state, labor or puerperium and from interventions, omissions, incorrect
treatment or a chain of events due to any of these complications. Indirect obstetric
deaths were defined as maternal deaths resulting from previously existing disease or
diseases that developed during pregnancy, labor or the puerperium that were not directly
due to obstetric causes but possibly aggravated by the physiologic effects of pregnancy.
Non-obstetric deaths were defined as maternal deaths resulting from accidental or
incidental causes not related to pregnancy or its management 11. Thus an
additional 14 cases were identified using the expanded CDC guidelines, resulting in a
total of 62 evaluable cases.
After the data were reviewed and coded, maternal death ratios (number of maternal
deaths per 100,000 live births) were calculated. Correlations with maternal age, parity,
level of education, urban versus rural residence, and marital status were determined using
chi square statistics. The expected number of deaths for the chi square table were
determined based on actual number of deaths in each category with the assumption that the
deaths will be proportional to the number of live births in each category if the variable
in question had no effect on maternal mortality. Multivariate analysis should have
permitted the elimination of any spurious relationships by controlling for
interrelationship between exogenous variables, but the number of cases under study were
not large enough to permit sensible multivariate analysis.
During the thirteen years included in this review, 62 maternal deaths were identified.
During this same interval, 484,789 live births were registered in the state of Utah,
resulting in an overall maternal mortality ratio of 12.8 per 100,000 live births.
Table 1 shows the
distribution and respective classifications of maternal deaths. Of all the maternal
deaths, 56.5 % were related directly to obstetric causes, 21% were related indirectly to
obstetric causes, 21% were related to non-obstetric causes, and 1.6 % were of unknown
Maternal ages in the study group ranged from 15 to 39 (mean 27.7) years. Chi square
goodness-of-fit testing demonstrated a positive correlation between the number of deaths
and the maternal mortality ratio for progressive maternal age (chi square=8.35, p<
.05), with ratios increasing from 8.5 for maternal ages 15-19 years to 27.1 for maternal
ages 35-39 years.
The risk of maternal mortality increased with progressive parity, though the chi square
test revealed that correlation was statistically non-significant. (chi square=1.40) The
mean gravidity during the study period was 3.1.
Thirty-three (53.2%) of pregnancies resulted in live births. Eleven pregnancies (17.7%)
ended in stillborn fetuses, and an additional ten (16.1%) died undelivered. The remaining
eight cases included tubal ectopic pregnancies(n=3), miscarriage (n=2), unknown neonatal
outcomes (n=2), and gestational trophoblastic disease (n=1).
Of the 62 cases reviewed, 85.5% (N = 53) were married; the maternal mortality ratio was
higher for unmarried women than for married women (14.3 versus 12.4,), the difference
being statistically non-significant. Fifty-seven women (91.9%) were white, four (6.5%)
were Asian-Pacific Islander, and one (1.6%) was Native American. Maternal death ratios
were highest among Asian-Pacific Islander patients (22.3), followed by white patients
(12.6), Hispanic patients (12.1), and Native American patients (12.1). The average
education was 12.4 years for patients in this review, with higher maternal mortality
ratios among women with less than high school education (17.3) than those with high school
diplomas (10.5) or 1 or more years or college (11.1). The average number of prenatal
visits was 7.6, with the second month of pregnancy being the mode for the initiation of
prenatal care. All deaths included in the review were to Utah residents; maternal death
ratios were higher among rural residents (19.1) than among urban residents (12.4).
Thirty-three deaths were investigated by autopsy (53.2%).
Thirty five of the deaths (56.5%) were due to direct obstetric causes (Table 2). The leading
cause of direct obstetric death was pulmonary embolism. Of the ten patients who died as a
result of a pulmonary embolism, two were primigravidas who died following uncomplicated
spontaneous vaginal deliveries. Two other women died following operative vaginal
deliveries and two after scheduled cesarean section. The remaining four deaths were
Hemorrhage was the second most common cause of direct obstetric death. Ruptured tubal
ectopic pregnancies accounted for five of these eight deaths. Two additional women died of
hemorrhagic complications during home births and one died from uncontrollable
intraoperative hemorrhage from complete placenta previa.
Five women died from puerperal infection. Two were caused by group B streptococcus, one
by Bacteroides fragilis and one Klebsiella pneumoniae in association with adult
respiratory distress syndrome. The fifth woman died at 5 weeks postpartum of clinical
sepsis in association with immunosuppression for concurrent systemic lupus
Amniotic fluid embolism was determined to be the cause of four deaths. One of these
women suffered the acute onset of shock and hemorrhage following a suction curettage for
an 11-week missed abortion. Two others died following the acute onset of shock and
respiratory decompensation immediately following operative vaginal deliveries. The fourth
woman, who had a one-month history of chronic abruption, died undelivered at 16 weeks
gestation after the sudden onset of seizures and shock.
Anesthetic complications accounted for three deaths. Two resulted from the
intravascular injection of anesthetic agents during placement of regional anesthesia for
cesarean section. The third woman died from aspiration pneumonitis following general
anesthesia for cesarean delivery.
Complications of pre-eclampsia/eclampsia were the cause of three deaths, two as a
result of intracranial hemorrhage and one from a cardiac arrhythmia from an
atrioventricular nodal hemorrhage.
Fourteen maternal deaths (21%) were from indirect obstetric causes, primarily the
result of cardiac disease (Table 3). Of the eleven deaths from cardiac causes, four were the result
of maternal congenital heart disease. Three of these women had ventricular septal defects
and Eisenmenger physiology, two unrecognized prior to autopsy. Cardiac arrhythmias
accounted for three deaths. In addition, acute myocardial infarction and myocardiopathy
identified preconceptionally each accounted for two additional deaths. Cerebrovascular
accidents accounted for three deaths. All were embolic in nature and occurred during the
Thirteen women (21%) died from non-obstetric causes (Table 4). The most
common cause was trauma (N = 10). Non-obstetric infections accounted for two additional
deaths and the final non-obstetric death was the result of a pancreatic malignancy.
An assessment of preventability was performed in this study (depicted in Tables 2, 3,
& 4). The percentage of deaths determined to be preventable was greatest for direct
obstetric causes and lowest for indirect obstetric causes. The only deaths deemed
preventable in the non-obstetric category were those caused by motor vehicle accidents in
which a single car was involved and where the patient's failure to wear a seatbelt was
This review of maternal mortality in Utah found a ratio of 12.8 deaths per 100,000 live
births over the entire 13-year study period. Although slightly higher than that reported
in the recent CDC reviews 2,3 , this rate is comparable to other recently
published state-wide reviews 4-9,11 . Despite the fact that Utah's population
is largely Caucasian and relatively well-educated, 12 , maternal mortality
remains a significant issue facing pregnant women, their families and health care
professionals in Utah. Maternal mortality in Utah increases with progressive age and
parity, confirming previous other states reviews 2,3,6,13 . This finding is
of concern as data from the Utah Department of Health, Bureau of Vital Records indicates
that the percent of births to women 35 years or older increased from 5.7% of total births
in 1975 to 8.9% of total births in 1995. These observations support Grimes' 14 recent
observation that, in spite of recent and impressive improvements, pregnancy remains a
Pulmonary embolism is now the most common cause of direct obstetric death in Utah.
Although low-dose heparin has yet to be proven effective for prophylaxis during pregnancy 15
, a recent review suggests that low-dose aspirin plus prophylactic heparin may be
efficacious in at-risk women 16 . However, the majority of women in our
series had no obvious clinical risk factors. Certainly, further studies aimed at improving
medical management and prophylaxis for pregnant and puerperal women are critical in order
to reduce this prominent cause of maternal death.
Hemorrhage was the second leading cause of direct obstetric death in this series. Of
these eight maternal deaths, seven were considered preventable, five from ruptured tubal
ectopic pregnancies and two from complications associated with home deliveries (uterine
rupture and uterine atony). Although improved diagnostic techniques (transvaginal
ultrasound, discriminatory serum HCG assays) 17 have decreased overall
maternal morbidity and mortality associated with ectopic pregnancy, these deaths attest
that continued clinical vigilance and suspicion are necessary.
Despite the availability of antibiotics and improvements in the management of labor,
infection remains a significant cause of maternal mortality in this review. Physicians
must appreciate the significance of fever in obstetric patients and should be aggressive
in the evaluation of such patients, including appropriate cultures. Improved patient
education regarding the warning signs and symptoms of postpartum infection seem
increasingly important given the recent emphasis on shortened hospital stays following
Cardiovascular disorders were the leading cause of indirect maternal death in this
series. Particularly striking was the proportion of patients in this review who died of
complications of pulmonary hypertension. A recent report 18 from Utah
demonstrated the potential risks to women with structural heart defects, often repaired
early in life, who then survive to reproductive age. Despite apparently normal cardiac
function, thorough cardiac examinations, including echocardiography, should be considered
in all patients with a known history of repaired congenital heart disease. Careful
monitoring during labor, including multidisciplinary management, may also improve outcome.
Peripartum cardiomyopathy also accounted for two deaths in this series. This condition
is nearly always unforeseen and thus not preventable. Cardiac transplantation is a more
recent therapeutic option for such patients, with recent estimates showing that 11 - 17%
of patients with peripartum cardiomyopathy eventually received cardiac transplants 19
. Although open heart surgery during pregnancy has been performed, exposure to
cardiopulmonary bypass may have serious consequences for the fetus 20 .
Although some international, 21 national, 22 and statewide 5
reviews have chosen not to include non-obstetric deaths in their results, some have
exclusively focused on them 23 . We have included these deaths because the
impact of a maternal death on a family is devastating irrespective of cause. In addition,
there exists the potential for improvement of maternal and fetal outcomes through
education in these areas. Three of the eight deaths resulting from motor vehicle accidents
were deemed preventable because of documented failure of the patient to wear her seatbelt.
Seatbelt use during pregnancy reduces low birth weight and premature delivery rates
related to automobile accidents. 24 Patients should be educated regarding the
relative risks and benefits of seatbelt use during pregnancy 25.
Despite the dramatic decrease in maternal death ratios over the past half-century,
recent studies 26-27 continue to estimate the degree of underreporting to be
as high as 20 to 75%. In our study, 33.9% (21 of 62) of our eligible cases were missed by
traditional death certificate searches, partially as a result of the continuing problem of
inaccurate death certificate reporting. 10,28,29. Modification of death
certificates to include pregnancy status enhances the reporting of pregnancy-related
deaths . Furthermore, a recent study from New York City showed that a review of state
medical examiner reports proved to be the most useful in the ascertainment of maternal
deaths 31 . Perhaps the most cost efficient and systematic monitoring system
is a computerized linkage of birth and fetal death certificates to death certificates of
reproductive age female decedents. Because this system cannot identify pregnancy related
deaths that do not generate a record of pregnancy outcome (eg, ectopic pregnancies,
gestational trophoblastic disease and induced or spontaneous abortions) traditional
methods need to be retained to capture these deaths 10 . The Utah Department
of Health, Bureau of Vital Records has agreed to run a pilot program of this system in an
attempt to more thoroughly identify maternal deaths in future.
Number and Ratios of Maternal Deaths (per 100,000 live births)
in Utah by Classification and Year
RETURN TO TEXT OF REPORT
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