Three Peer-Reviewed Articles on Maternal Mortality

Am J Obstet Gynecol 2000 Nov;183(5):1207-12

Maternal deaths in an urban perinatal network, 1992-1998.

Panting-Kemp A, Geller SE, Nguyen T, Simonson L, Nuwayhid B, Castro L.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, 
University of Illinois at Chicago, 60612, USA.

OBJECTIVE: The object of this study was to use an in-depth peer-review process to determine the maternal mortality ratio at a single urban perinatal center and to identify factors associated with fatal outcomes to elucidate opportunities for preventive measures to reduce the maternal mortality ratio. 

STUDY DESIGN: Between 1992 and 1998 all maternal deaths occurring within our perinatal network were identified. A peer-review committee was established to review all available data for each death to determine the underlying cause of death, whether it was related to pregnancy, and whether the death was potentially preventable. 

RESULTS: There were 131,500 births and 42 maternal deaths, for a maternal mortality ratio of 31.9 maternal deaths per 100,000 live births. The adjusted pregnancy-related maternal mortality ratio was 22.8 maternal deaths per 100,000 live births, with 37% of those deaths (11/30) deemed potentially preventable and a provider factor cited in >80% of these. Pulmonary embolus and cardiac disease together accounted for 40% of the pregnancy-related deaths. 

CONCLUSION: Local maternal mortality ratios identified through a peer-review process indicate that the magnitude of the problem is much greater than is recognized through national death certificate data. The high proportion of potentially preventable maternal deaths indicates the need for improvement in both patient and provider education if we are to reduce the maternal mortality ratio to 3.3 maternal deaths per 100,000 live births, the stated national health goal of Healthy People 2000.

PMID: 11084567 [PubMed - indexed for MEDLINE] 


1: Am J Obstet Gynecol 2000 Nov;183(5):1187-97
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Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999.
Mozurkewich EL, Hutton EK.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA.

OBJECTIVE: The aim of this study was to compare a trial of labor with elective repeat cesarean delivery among women with previous cesarean delivery. 

STUDY DESIGN: We searched MEDLINE and EMBASE databases from 1989 through 1999 with the following
terms: vaginal birth after cesarean delivery, trial of labor, trial of scar, and uterine rupture. We included all controlled trials from
developed countries in which the control group had been eligible for a trial of labor. Outcomes of interest were uterine rupture,
hysterectomy, maternal febrile morbidity, maternal mortality, 5-minute Apgar score <7, and fetal or neonatal mortality. We computed pooled odds ratios for each outcome. 

RESULTS: The search strategy identified 52 controlled studies, 37 of which were excluded
because many of the control subjects were not eligible for a trial of labor. Fifteen studies with a total of 47,682 women were included. Uterine rupture occurred more frequently among women undergoing a trial of labor than among those undergoing elective repeat cesarean delivery (odds ratio, 2.10; 95% confidence interval, 1.45-3.05). There was no difference in maternal mortality risk between the 2 groups (odds ratio, 1.52; 95% confidence interval, 0.36-6.38). Fetal or neonatal death (odds ratio, 1.71; 95% confidence interval, 1.28-2.28) and 5-minute Apgar scores <7 (odds ratio, 2.24; 95% confidence interval, 1.29-3.88) were more frequent in the trial of labor group than in the control group. Mothers undergoing a trial of labor were less likely to have febrile morbidity (odds ratio, 0.70; 95% confidence interval, 0.64-0.77) or to require transfusion (odds ratio, 0.57; 95% confidence interval, 0.42-0.76) or hysterectomy (odds ratio, 0.39; 95% confidence interval, 0.27-0.57). 

CONCLUSION: A trial of labor may result in small increases in the uterine rupture rate and in fetal and neonatal mortality rates with respect to elective repeat cesarean delivery. Maternal morbidity, including febrile morbidity, and the need for transfusion or hysterectomy may be reduced with a trial of labor.

PMID: 11084565 [PubMed - indexed for MEDLINE]


CDC: Maternal Deaths Remain Steady .    c The Associated Press      By RUSS BYNUM

ATLANTA (AP) -- The rate at which American women die from pregnancy and childbirth complications hasn't budged in 15 years.

Every year from 1982 to 1996, maternal deaths occurred at a rate of seven or eight per 100,000 live births, the Centers for Disease Control and Prevention reported Thursday. It said half of all such deaths are preventable.

Like infant mortality, maternal deaths are used as a measure of a country's overall health. In some developing nations, maternal death rates are as high as 1,700 per 100,000 births. In other countries, such as Norway and Switzerland, maternal deaths occur at about half the U.S. rate. The CDC said the United States will probably fall short of its goal of 3.3 maternal deaths per 100,000 births by 2000. Researchers said such deaths are rare enough that many doctors may not notice the problem. Also, many women now see pregnancy as risk-free and fail to seek prenatal care, said Dr. Isabella Danel, a CDC epidemiologist.

The CDC identified maternal deaths by looking at death certificates. However, researchers said such deaths are underreported and the real rates could be three times higher. More than half of maternal deaths are caused by bleeding, infection, pregnancy-induced high blood pressure and tubal pregnancies -- complications that can be prevented or treated with early diagnosis, the CDC said. Many doctors have little experience handling life-threatening births, said Dr. James Gell, an obstetrician and gynecologist who teaches at Wayne State University Medical School in Detroit.

``The average obstetrician may never encounter a maternal death during a lifetime of practice,'' Gell said. ``So, as a result, he may not be as well prepared for the sudden, calamitous situation when it does arrive.'' Still, Gell said he is not alarmed that the U.S. maternal death rate hasn't declined since 1982. ``We're getting down to an almost irreducible minimum,'' he said. ``I'm not sure we can get much lower.''

The CDC said differences in maternal deaths between black and white women indicate room for improvement. It found that maternal deaths of black women ranged from 18 to 22 per 100,000 births, compared with five to six deaths per 100,000 births for white women. ``That makes us think the problem is access to health care and treatment,'' Danel said.

Women with unintended pregnancies are also considered a high-risk group. ``Women who want a pregnancy are usually very careful -- they eat right, they read all the books,'' Danel said. ``Women who don't want the pregnancy don't do that.''