Virginia Pregnancy-Associated Mortality Surveillance System (PAMSS)

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Introduction

The historical decline of maternal death in the United States during the 20th century is hailed as a remarkable public health achievement.  The maternal mortality rate steadily dropped from approximately 850 maternal deaths per 100,000 live births in 1900 to approximately 7.5 deaths in 1982.  Advances in medical technology have been credited with spurring this decline. Since 1982, however, no further declines in maternal mortality have been recorded.  In 1987, the CDC established the National Pregnancy Mortality Surveillance System to compile and analyze data for epidemiologic studies of maternal deaths in the United States so that prevention strategies could be developed to address the plateau in these rates.  A summary of maternal deaths in Virginia between 1981 and 1991 showed a trend similar to that found across the United States.  In 1981, Virginia had 21 maternal deaths with a range from 4 to 14 in the following ten years.

Healthy People 2000 goals included reduction of maternal mortality rates to 5 per 100,000 live births.  Goals for 2010 included a further reduction to 3.3 maternal deaths/100,000 live births.  Neither goal was reached.  The most recent Healthy People Goal (2020) is 11.4 deaths per 100,000 live births which represents a 10% decrease from the 2007 maternal mortality rate of 12.7.  Maternal mortality surveillance programs received renewed attention in efforts to reduce these rates.  Early endeavors to assess the magnitude and cause of maternal death on local and regional levels became the point of reference for reestablishment of review and surveillance programs.

Definitions

Several definitions are used to describe deaths of women surrounding pregnancy.  Maternal mortality is defined using the International Classification of Diseases (ICD) as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes.” 1 This definition is currently used by the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics in its publications of maternal mortality statistics in the United States.

The American College of Obstetricians and Gynecologists (ACOG) and CDC’s Maternal Mortality Study Group developed new terms in 1986 to broaden the definition of maternal mortality.  The purpose of the new definitions was to expand the group under study to better define the incidence and describe the causes of death that occur during or near a pregnancy.  These new terms are:  pregnancy-associated death and pregnancy-related death.  Apregnancy-associated death is defined as the death of a woman while pregnant or within one year of the termination of a pregnancy irrespective of the cause of death or the outcome of the pregnancy. 2   This term refers to the temporal relationship between the pregnancy and the death.  A pregnancy-related death is any pregnancy-associated death resulting from one or more of the following:  complications of the pregnancy itself; the chain of events initiated by the pregnancy that led to death; or aggravation of an unrelated condition by physiological effects of the pregnancy that subsequently caused death. 3

Virginia PAMSS Case Ascertainment

In 2002, the Virginia Department of Health’s Offices of the Chief Medical Examiner and Family Health Services formed a partnership to identify and study pregnancy-associated death in Virginia so that public health prevention and intervention strategies could be developed.  Virginia’s Pregnancy-Associated Mortality Surveillance System (PAMSS) uses the broad definition, pregnancy-associated death, for its surveillance focus.  Beginning with deaths that occurred in 1999, cases have been identified by the Virginia Department of Health’s Office of Health Statistics using three methods:

 

• Through the International Classification of Diseases, Tenth Revision (ICD), cause of death code in the “pregnancy, childbirth and the puerperium” categories.

 

 

• By matching birth or fetal death certificate with maternal death certificate information.

 

• By selecting cases where a Commonwealth of Virginia death certificate indicates the decedent was pregnant within three months of the death.  This is a check box on Virginia’s death certificate.

 

Each year, maternal death certificates along with matched infant birth or fetal death certificates are provided to PAMSS.  Data from these documents are abstracted into a database.  This serves as the foundation for surveillance of cause and manner of death, demographics of women affected, temporal relationship between the end of pregnancy and death, and outcome of the pregnancy.   This surveillance system allows for the epidemiologic study of patterns and trends related to these deaths and helps inform policy decisions of public health importance.