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Aflaki K, Vigod SN, Sprague AE, Cook J, Berger H, Aoyama K, Jhirad R, Ray JG. Maternal Deaths Using Coroner's Data: A Latent Class Analysis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102349. [PMID: 38190888 DOI: 10.1016/j.jogc.2024.102349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Knowledge regarding the antecedent clinical and social factors associated with maternal death around the time of pregnancy is limited. This study identified distinct subgroups of maternal deaths using population-based coroner's data, and that may inform ongoing preventative initiatives. METHODS A detailed review of coroner's death files was performed for all of Ontario, Canada, where there is a single reporting mechanism for maternal deaths. Deaths in pregnancy, or within 365 days thereafter, were identified within the Office of the Chief Coroner for Ontario database, 2004-2020. Variables related to the social and clinical circumstances surrounding the deaths were abstracted in a standardized manner from each death file, including demographics, forensic information, nature and cause of death, and antecedent health and health care factors. These variables were then entered into a latent class analysis (LCA) to identify distinct types of deaths. RESULTS Among 273 deaths identified in the study period, LCA optimally identified three distinct subgroups, namely, (1) in-hospital deaths arising during birth or soon thereafter (52.7% of the sample); (2) accidents and unforeseen obstetric complications also resulting in infant demise (26.3%); and (3) out-of-hospital suicides occurring postpartum (21.0%). Physical injury (22.0%) was the leading cause of death, followed by hemorrhage (16.8%) and overdose (13.3%). CONCLUSION Peri-pregnancy maternal deaths can be classified into three distinct sub-types, with somewhat differing causes. These findings may enhance clinical and policy development aimed at reducing pregnancy mortality.
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Affiliation(s)
- Kayvan Aflaki
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Simone N Vigod
- Department of Psychiatry, Women's College Hospital, Toronto, Canada
| | - Ann E Sprague
- Better Outcomes Registry and Network - Ontario, Ottawa, Canada
| | - Jocelynn Cook
- Society of Obstetricians and Gynecologists of Canada, Ottawa, Canada
| | - Howard Berger
- Departments of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Canada
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Reuven Jhirad
- Office of the Chief Coroner for Ontario/Ontario Forensic Pathology Service, Toronto, Canada
| | - Joel G Ray
- Departments of Medicine and Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Canada.
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Cheung KW, Seto MTY, Wang W, So PL, Hui ASY, Yu FNY, Chung WH, Shu W, Yim M, Au TST, Lo TK, Ng EHY. Characteristics of Maternal Mortality Missed by Vital Statistics in Hong Kong, 2000-2019. JAMA Netw Open 2023; 6:e230429. [PMID: 36811857 PMCID: PMC9947727 DOI: 10.1001/jamanetworkopen.2023.0429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Reducing maternal mortality is a global objective. The maternal mortality ratio (MMR) is low in Hong Kong, China, but there has been no local confidential enquiry into maternal death, and underreporting is likely. OBJECTIVE To determine the causes and timing of maternal death in Hong Kong and identify deaths and their causes that were missed by the Hong Kong vital statistics database. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted among all 8 public maternity hospitals in Hong Kong. Maternal deaths were identified using prespecified search criteria, including a registered delivery episode between 2000 to 2019 and a registered death episode within 365 days after delivery. Cases as reported by the vital statistics were then compared with the deaths found in the hospital-based cohort. Data were analyzed from June to July 2022. MAIN OUTCOMES AND MEASURES The outcomes of interest were maternal mortality, defined as death during pregnancy or within 42 days after ending the pregnancy, and late maternal death, defined as death more than 42 days but less than 1 year after end of the pregnancy. RESULTS A total of 173 maternal deaths (median [IQR] age at childbirth, 33 [29-36] years) were found, including 74 maternal mortality events (45 direct deaths and 29 indirect deaths) and 99 late maternal deaths. Of 173 maternal deaths, 66 women (38.2%) of individuals had preexisting medical conditions. For maternal mortality, the MMR ranged from 1.63 to 16.78 deaths per 100 000 live births. Suicide was the leading cause of direct death (15 of 45 deaths [33.3%]). Stroke and cancer deaths were the most common causes of indirect death (8 of 29 deaths [27.6%] each). A total of 63 individuals (85.1%) died during the postpartum period. In the theme-based approach analysis, the leading causes of death were suicide (15 of 74 deaths [20.3%]) and hypertensive disorders (10 of 74 deaths [13.5%]). The vital statistics in Hong Kong missed 67 maternal mortality events (90.5%). All suicides and amniotic fluid embolisms, 90.0% of hypertensive disorders, 50.0% of obstetric hemorrhages, and 96.6% of indirect deaths were missed by the vital statistics. The late maternal death ratio ranged from 0 to 16.36 deaths per 100 000 live births. The leading causes of late maternal death were cancer (40 of 99 deaths [40.4%]) and suicide (22 of 99 deaths [22.2%]). CONCLUSIONS AND RELEVANCE In this cross-sectional study of maternal mortality in Hong Kong, suicide and hypertensive disorder were the dominant causes of death. The current vital statistics methods were unable to capture most of the maternal mortality events found in this hospital-based cohort. Adding a pregnancy checkbox to death certificates and setting up a confidential enquiry into maternal death could be possible solutions to reveal the hidden deaths.
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Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Mimi Tin-Yan Seto
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Weilan Wang
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Hong Kong, China
| | - Annie S. Y. Hui
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong, China
| | - Florrie Nga-Yui Yu
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong, China
| | - Wai Hang Chung
- Department of Obstetrics and Gynaecology, United Christian Hospital, Hong Kong, China
| | - Wendy Shu
- Department of Obstetrics and Gynaecology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Minnie Yim
- Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong, China
| | - Tiffany Sin-Tung Au
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Tsz Kin Lo
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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Thorne SA, Cook JL, D'Souza R. The Role of National Pregnancy Surveillance Systems in Improving Maternal Mortality and Morbidity: The Next Steps for Canada. Can J Cardiol 2021; 37:1904-1907. [PMID: 34474122 DOI: 10.1016/j.cjca.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Sara A Thorne
- Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Jocelynn L Cook
- Department of Obstetrics and Gynecology, University of Ottawa, and the Society of Obstetricians and Gynaecologists of Canada, Ottawa, Ontario, Canada
| | - Rohan D'Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Aflaki K, Park AL, Nelson C, Luo W, Ray JG. Identifying maternal deaths with the use of hospital data versus death certificates: a retrospective population-based study. CMAJ Open 2021; 9:E539-E547. [PMID: 34021011 PMCID: PMC8177910 DOI: 10.9778/cmajo.20200201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Accurate identification of maternal deaths is paramount for audit and policy purposes. Our aim was to determine the accuracy and completeness of data on maternal deaths in hospital and those recorded on a death certificate, and the level of agreement between the 2 data sources. METHODS We conducted a retrospective population-based study using data for Ontario, Canada, from Apr. 1, 2002, to Dec. 31, 2015. We used Canadian Institute for Health Information (CIHI) databases to identify deaths during inpatient, emergency department and same-day surgery encounters. We captured Vital Statistics deaths in the Office of the Registrar General, Deaths (ORGD) data set. Deaths were considered within 42 days and within 365 days after a pregnancy outcome (live birth, miscarriage, ectopic pregnancy or induced abortion) for all multiple and singleton pregnancies. We calculated agreement statistics and 95% confidence intervals (CIs). RESULTS Among 1 679 455 live births and stillbirths, 398 pregnancy-related deaths in the ORGD data set were mapped to a birth in CIHI databases, and 77 (16.2%) were not. Among 2 039 849 recognized pregnancies, 534 pregnancy-related deaths in the ORGD data set were linked to CIHI records, and 68 (11.3%) were not. Among live births and stillbirths, after pregnancy-related deaths in the ORGD data set not matched to a maternal death in the CIHI databases were removed, concordance measures between CIHI and ORGD records for maternal death within 42 days after delivery included a κ value of 0.87 (95% CI 0.82-0.91) and positive percent agreement of 0.88 (95% CI 0.83-0.94). The corresponding measures were similar for maternal death within 42 days after the end of a recognized pregnancy. When unlinked pregnancy-related deaths in the ORGD data set were retained, agreement measures declined for death within 42 days after a live birth or stillbirth (κ = 0.68, 95% CI 0.62-0.74). For maternal death within 365 days after a live birth or stillbirth, or after the end of a recognized pregnancy, the concordance statistics were generally favourable when unlinked pregnancy-related deaths in the ORGD data set were removed but were substantially declined when they were retained. INTERPRETATION Maternal mortality cannot be ascertained solely with the use of hospital data, including beyond 42 days after the end of pregnancy. To improve linkage, we propose including health insurance numbers on provincial and territorial medical death certificates.
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Affiliation(s)
- Kayvan Aflaki
- Institute of Medical Science (Aflaki), University of Toronto; ICES Central (Park), Toronto, Ont.; Maternal, Child and Youth Health Division (Nelson, Luo), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Departments of Medicine (Ray) and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont
| | - Alison L Park
- Institute of Medical Science (Aflaki), University of Toronto; ICES Central (Park), Toronto, Ont.; Maternal, Child and Youth Health Division (Nelson, Luo), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Departments of Medicine (Ray) and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont
| | - Chantal Nelson
- Institute of Medical Science (Aflaki), University of Toronto; ICES Central (Park), Toronto, Ont.; Maternal, Child and Youth Health Division (Nelson, Luo), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Departments of Medicine (Ray) and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont
| | - Wei Luo
- Institute of Medical Science (Aflaki), University of Toronto; ICES Central (Park), Toronto, Ont.; Maternal, Child and Youth Health Division (Nelson, Luo), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Departments of Medicine (Ray) and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont
| | - Joel G Ray
- Institute of Medical Science (Aflaki), University of Toronto; ICES Central (Park), Toronto, Ont.; Maternal, Child and Youth Health Division (Nelson, Luo), Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, Ont.; Departments of Medicine (Ray) and Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.
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Boutin A, Cherian A, Liauw J, Dzakpasu S, Scott H, Van den Hof M, Cook J, Blake J, Joseph KS. Database Autopsy: An Efficient and Effective Confidential Enquiry into Maternal Deaths in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:58-66.e4. [PMID: 32980284 DOI: 10.1016/j.jogc.2020.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause. METHODS We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately. RESULTS We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and <5 (<6%), to complications of management. There were 21 (25%) maternal deaths with indirect obstetric causes, and <5 (<6%) with undetermined causes. Of 120 late maternal deaths, 16 (13%) had direct obstetric causes, among them, 9 deaths by suicide (56%). One hundred late maternal deaths (83%) had indirect obstetric causes; and <5 (<4%) had undetermined causes. CONCLUSIONS The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.
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Affiliation(s)
- Amélie Boutin
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital of British Columbia, Vancouver, BC.
| | - Arlin Cherian
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital of British Columbia, Vancouver, BC
| | - Jessica Liauw
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital of British Columbia, Vancouver, BC
| | - Susie Dzakpasu
- Maternal and Infant Health Section, Public Health Agency of Canada, Ottawa, ON
| | - Heather Scott
- Department of Obstetrics and Gynaecology, Dalhousie University and the IWK Health Centre, Halifax, NS
| | - Michiel Van den Hof
- Department of Obstetrics and Gynaecology, Dalhousie University and the IWK Health Centre, Halifax, NS
| | - Jocelynn Cook
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON; Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON
| | - Jennifer Blake
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON; Department Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - K S Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia and the Children's and Women's Hospital of British Columbia, Vancouver, BC; School of Population and Public Health, University of British Columbia, Vancouver, BC
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Mental Health and Maternal Mortality-When New Life Doesn't Bring Joy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:67-73.e1. [PMID: 32978085 DOI: 10.1016/j.jogc.2020.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize the incidence and risk factors associated with maternal suicide during the peripartum period in an Alberta population. Our secondary objective was to characterize the incidence and risk factors associated with traumatic death in this same population. METHODS This is a retrospective cohort study compared all-cause mortality with death by trauma (suicide, homicide, MVA, drug toxicity) using data collected by the Alberta Perinatal Health Program from 1998 to 2015. Data were summarized using descriptive statistics. The maternal mortality rate was calculated, and χ2 tests were used to determine between group differences with the statistical significance set at P < 0.05. RESULTS There were 206 perinatal maternal deaths in Alberta from 1998 to 2015; 68 (33%) were due to trauma, 17 (8%) were the result of suicide, 4 (2%) were the result of homicide, and 24 (12%) were related to drug toxicity. The pregnancy-related maternal mortality rate for suicide up to 365 days after birth was 2.05 deaths per 100 000 deliveries. Of these, 29.4% occurred during pregnancy and 70.6%, in the first year postpartum. For homicides, 62.5% of occurred in pregnancy and 37.5% occurred in the first year postpartum. CONCLUSION Close to 1 in 5 maternal deaths in Alberta is related to suicide or drug toxicity. We must escalate strategies to prevent deaths from suicide and drug toxicity, as well as increase funding for mental health and addictions screening and treatment.
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