Pregnancy-related Mortality Research Articles

Abstract 11733: Racial Disparities in Cardiometabolic Risk Factors Among Pregnant Women in the United States

Background: Pregnancy-related mortality has notably increased in the United States over the past 3 decades, with cardiovascular disease as the leading cause of mortality post-partum. Significant racial disparities have been noted in pregnancy-related mortality in the US. We sought to study contemporary trends and disparities in cardiometabolic risk factors (CMRFs) among pregnant women in the US. Methods: We used the 2016-2020 natality database maintained by the CDC. We identified pregnant women with first live birth and known self-reported race (Black vs White). We explored overall prevalence (aggregated 2016-2020) and relative changes (between 2016 and 2020) in CMRFs: pre-pregnancy diabetes (Pre-DM), gestational diabetes (G-DM), pre-pregnancy hypertension (Pre-HTN), gestational hypertension (G-HTN), smoking, and obesity. Results: A total of 3,141,830 pregnancies in White women and 436,895 pregnancies in Black women were noted. Overall, Black mothers had higher rates of Pre-DM, Pre-HTN, G-HTN, and obesity, but lower rates of smoking and G-DM. From 2016-2020, there were significant increases in all CMRFs, except smoking, which decreased. There was a more significant increase in Pre-DM and G-HTN in Black mothers, while there were more significant increases in Pre-HTN and obesity in White mothers. A 15% relative increase in the prevalence of any CMRF was seen in both races. Conclusions: In this large analysis of pregnant mothers in the US, cardiometabolic risk factors were present in 35% of White mothers and 43% of Black mothers, with significant increases from 2016 to 2020 in both races. Future studies should focus on identifying mechanisms of the observed associations.

Abstract 12219: Social Vulnerability and Cardiometabolic Risk Factors in Pregnant Women in the United States

Background: In recent years, pregnancy-related mortality rates in the US have increased, with cardiovascular disease accounting for a third of all pregnancy-related mortality. The association between cardiometabolic (CM) health and social determinants of health have not been well understood. Objectives: We sought to investigate the relationship between social vulnerability and prevalence of CM risk factors in pregnant women in the US. Methods: In this cross-sectional analysis, we linked natality files including all pregnancies resulting in live births in the US (aggregated 2016-2020) with county-level social vulnerability index (SVI), a composite metric of social risk factors with four major domains: socioeconomic, household composition/disability, minority status/language, and housing type/transportation. We investigated the association between SVI and its subdomains with county-level prevalence of maternal pre-pregnancy diabetes, pre-pregnancy hypertension, tobacco use, and obesity. Results: A total of 18,953,511 pregnancies were analyzed across 577 counties. All CM risk factors were associated with SVI and/or its 4 subcomponents to varying degrees. Obesity was strongly associated with overall SVI (R=0.52, P<0.001) with an even stronger relationship with socioeconomic vulnerability (R=0.6, P<0.001) and household composition/disability (R=0.66, P<0.001). The rate of pre-pregnancy diabetes was associated with overall SVI (R=0.27, p<0.001), with similar association with socioeconomic vulnerability (R=0.26, P<0.001) and household composition/disability (R=0.28, P<0.001). Chronic hypertension was weakly associated with overall SVI (R=0.15, P<0.001) with similar association with socioeconomic vulnerability (R=0.19, P<0.001) and household composition/disability (R=0.22, P<0.001). Tobacco use was not associated with overall SVI (R=0.034, p=0.41), but was strongly associated with minority status/language (R=-0.71, P<0.001). Conclusion: Social vulnerability and its domains are associated with prevalence of CM risk factors in pregnant women in the US. Further studies are needed to investigate the impact of targeting social determinants of health to improve CM risk and mortality in pregnant women.

Implementation of a pharmacological prophylaxis bundle to prevent obstetric-associated venous thromboembolism.

Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population. This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home. An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Women's risk of death beyond 42 days post partum: a pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa

WHO's standard definitions of pregnancy-related and maternal deaths only include deaths that occur within 42 days of delivery, termination, or abortion, with major implications for post-partum care and maternal mortality surveillance. We therefore estimated post-partum survival from childbirth up to 1 year post partum to evaluate the empirical justification for the 42-day post-partum threshold. We used prospective, longitudinal Health and Demographic Surveillance System (HDSS) data from 30 sites across 12 sub-Saharan African countries to estimate women's risk of death from childbirth until 1 year post partum from all causes. Observations were included if the childbirth occurred from 1991 onwards in the HDSS site and maternal age was 10-54 years. We calculated person-years as the time between childbirth and next birth, outmigration, death, or the end of the first year post partum, whichever occurred first. For six post-partum risk intervals (0-1 days, 2-6 days, 7-13 days, 14-41 days, 42-122 days, and 4-11 months), we calculated the adjusted rate ratios of death relative to a baseline risk of 12-17 months post partum. Between Jan 1, 1991, and Feb 24, 2020, 647 104 births occurred in the HDSS sites, contributing to 602 170 person-years of exposure time and 1967 deaths within 1 year of delivery. After adjustment for confounding, mortality was 38·82 (95% CI 33·21-45·29) times higher than baseline on days 0-1 after childbirth, 4·97 (3·94-6·21) times higher for days 2-6, 3·35 (2·64-4·20) times higher for days 7-13, and 2·06 (1·74-2·44) times higher for days 14-41. From 42 days to 4 months post partum, mortality was still 1·20 (1·03-1·39) times higher (ie, a 20% higher risk), but deaths in this interval would be excluded from measurement of pregnancy-related mortality. Extending the WHO 42-day post-partum threshold up to 4 months would increase the post-partum pregnancy-related mortality ratio by 40%. This multicountry study has implications for measurement and clinical practice. It makes the case for WHO to extend the 42-day post-partum threshold to capture the full duration of risk of pregnancy-related deaths. There is a need for a new indicator to track late pregnancy-related deaths that occur beyond 42 days, which are otherwise excluded from global maternal health surveillance efforts. Our results also emphasise the need for international agencies to disaggregate estimates by antepartum, intrapartum, postpartum, and extended post-partum periods. Additionally, the schedule and content of postnatal care packages should reflect the extended duration of post-partum risk. The UK Economic and Social Research Council.

Outcome of Gestational Diabetes during Pregnancy and at Delivery

Gestational diabetes (GDM) is a state of intolerance to glucose that initiates or is first diagnosed during gestation. About 1-14% of all pregnancies are complicated by GDM. The pregnancy-related morbidity and mortality in gestational diabetes is lower than in overt diabetes; however, if left untreated, it is significantly higher than in nondiabetic women. Treating GDM is important because appropriate treatment reduces side effects on the mother and newborn. GDM during pregnancy has a number of adverse short- and long-term consequences for both the mother and the fetus. Aim: To establish the relationship between gestational diabetes and complications related to pregnancy and childbirth. Study Design: A prospective cohort study. Place and Duration: The study was conducted at the Karachi Aga Khan University Hospital in the Department of Obstetrics and Gynecology from 22 November, 2018 to 22 May 2019, six months after the approval of the study. Methods: 130 patients, 65 patients in the GDM group and 65 patients in the non-GDM group were enrolled in the study. Demographic data were presented as standard deviation and mean as well as simple descriptive statistics, while qualitative variables as percentage and frequency. Chi-square test was applied for comparison of the incidence of complications related to pregnancy and childbirth. P<0.05 was considered statistically significant. Relative risk was calculated. Results: 130 total patients, including 65 patients in GDM group and 65 patients in non GDM group were included. Mean age in GDM and non GDM group was 29.27±2.79 years and 28.49±3.40 years. Outcome of pregnancy in GDM and non GDM group showed that 27 (41.5%) and 18 (27.7%) had pregnancy induced hypertension, 07 (10.8%) and 03 (4.6%) had pre-eclampsia, 29 (44.6%) and 07 (10.8%) had polyhydramnios, 04 (6.2%) and 02 (3.1%) had antepartum hemorrhage, 01 (1.5%) and 06 (9.2%) had premature rupture of membrane, 11 (16.9%) and 09 (13.8%) had preterm labour, 13 (20%) and 04 (6.2%) had urinary tract infection. Outcome of pregnancy in GDM and non GDM group showed 51 (78.5%) and 33 (50.8%) had induction of labour, 17 (26.2%) and 14 (21.5%) had low birth weight, 14 (51%) and 03 (4.6%) had macrosomia, 02 (3.1%) and 01 (1.5%) had birth injury and 10 (15.4%) and 11 (16.9%) had NICU admission. Conclusion: Gestational diabetes (GDM) is the utmost communal medicinal complication of pregnancy. It has negative consequences for the mother and the newborn baby. Maintaining glycemia in GDM decreases the morbidity of both baby and mother. Keywords: Gestational diabetes mellitus, delivery outcome, pregnancy outcome, maternal and fetal outcomes.

Preventive Care Utilization among Rural versus Urban Women 12 Months Prior to Pregnancy.

IntroductionPregnancy-related mortality in the United States occurs in 32.3 per 100,000 live births. Rural maternal mortality rates were even higher, and these patients were less likely to receive routine care. The purpose of this cross-sectional study was to compare primary and prenatal care and health behaviors among perinatal mothers living in rural and urban Kansas.MethodsData were collected from 1,971 pregnant women who participated in Phase 8 Pregnancy Risk Assessment Monitoring System (PRAMS) for Kansas between 2016 and 2018. Respondent location (urban or rural based on NIH classification) was abstracted from birth certificates and frequencies of healthcare visits and secondary healthcare variables were compared.ResultsMost respondents (75.1%, n = 1,481) resided in an urban area. Most (84.4%, n = 1,664) women were Caucasian, and the largest category (31.1%, n = 613) was 25 to 29 years old. More urban women reported visiting an obstetrician/gynecologist within 12 months before pregnancy than rural women (p < 0.0001). Urban women reported attending pre-pregnancy dental visits (p = 0.019) and teeth cleanings (p = 0.004) more than rural women. Of the 35.7% of respondents (n = 516) who reported receiving pre-pregnancy counseling on folic acid, prenatal vitamins, or multivitamins, 78.9% (n = 407) resided in an urban area.ConclusionsRural women reported fewer routine primary and prenatal care behaviors compared to their urban counterparts. Efforts are needed to improve access to obstetrician/gynecologist services, especially for women in rural areas.

The trend of the distribution of ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy

BackgroundEctopic pregnancy is a life-threatening occurrence and is an important cause of pregnancy-related mortality. We launched the study to investigate the distribution and its variation trend of the ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy, to provide information for further clinical practice.MethodsA total of 3915 patients were included in our study to calculate the distribution of the implantation sites of ectopic pregnancies. Then, we performed a χ2 test for trend and calculated the quantity of each type of ectopic pregnancy during 2012–2015 and 2016–2019 to analyse the variation trend.Results(1) The proportion of each site of ectopic pregnancy was as follows: tubal pregnancy (84.70%), ovarian pregnancy (1.56%), caesarean scar pregnancy (8.63%), abdominal pregnancy (0.61%), cornual pregnancy (2.68%), cervical pregnancy (0.49%), heterotopic pregnancy (0.43%). (2) Through the χ2 test for trend, the ratio of caesarean scar pregnancy to ectopic pregnancy showed an upward trend (P = 0.005). From 2012 to 2015 and 2016–2019, the ratio of caesarean scar pregnancy to ectopic pregnancy increased from 5.74 to 11.81% (P < 0.001). (3) A total of 72.78% (246/338) caesarean scar pregnancy patients had one caesarean delivery, 25.15% (85/338) had two caesarean deliveries, and 2.07% (7/338) had three caesarean deliveries. A total of 80.18% (271/338) had aborted before. The most common clinical manifestations were amenorrhea (98.52%), abdominal pain (25.74%) and vaginal bleeding (67.76%), the most common sign was uterine enlargement (46.75%).ConclusionAs the ratio of caesarean scar pregnancy increases, the caesarean delivery rate should be decreased to decrease the morbidity of caesarean scar pregnancy.

Standardizing Obstetric Hemorrhage Management Using a Checklist Bundle

A standardized checklist to guide postpartum hemorrhage (PPH) management was implemented as a quality improvement project because of the lack of standardized processes and clear policy guidelines. PPH is a leading cause of pregnancy-related morbidity and mortality in the United States. Implementation of a standardized checklist assists in empowering and supporting nurses in advocating for obstetric patients as well as increases knowledge of necessary interventions to decrease maternal morbidity and mortality.

A Case of 31 WKS Primi with Acute Hypertensive Left Heart Failure with Severe Pre- Eclampsia Secondary to Graves’ Disease

Graves’ disease, a well-known cause of hyperthyroidism, is an autoimmune disease with multi-system involvement. More prevalent among young women, it appears as an uncommon cardiovascular complication during pregnancy, posing a diagnostic challenge, largely owing to difficulty in detecting the complication, because of a low index of suspicion of Graves’ disease presenting during pregnancy. Globally, cardiovascular disease is an important factor for pregnancy-related morbidity and mortality. Here, we report a case of 24 years old primi with Graves’ disease detected for the first time in pregnancy presenting with acute hypertensive left heart failure and severe pre-eclampsia. She was found to have abnormal thyroid function tests compatible with the diagnosis of Graves’ disease. Emphasis is placed on the spectrum of clinical presentations of Graves’ disease, and the importance of considering this thyroid disorder as a possible aetiological factor for such a presentation in pregnancy.

Developmental Origins of Pregnancy-Related Morbidity and Mortality in Black U.S. Women.

In the US, Black women are at disproportionate risk for pregnancy-related morbidity and mortality (PRMM). Disparities in PRMM have been tied to elevated rates of obstetric cardiometabolic complications for Black women. Research seeking to elucidate the determinants of Black PRMM to date have focused predominantly on risk factors occurring during pregnancy (e.g., health risk behaviors, quantity and quality of prenatal care, provider behaviors, and attitudes). Meanwhile, other research investigating the developmental origins of health and disease (DOHaD) model indicates that the origins of adult cardiometabolic health can be traced back to stress exposures occurring during the intrauterine and early life periods. Despite the relevancy of this work to Black PRMM, the DOHaD model has never been applied to investigate the determinants of Black PRMM. We argue that the DOHaD model represents a compelling theoretical framework from which to conceptualize factors that drive racial disparities PRMM. Research and intervention working from a developmental origins orientation may help address this urgent public health crisis of Black PRMM.

Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor

Pregnancy-related morbidity and mortality continue to disproportionately affect birthing people who identify as Black. The use of race-based risk factors in medicine exacerbates racial health inequities by insinuating a false conflation that fails to consider the underlying impact of racism. As we work toward health equity, we must remove race as a risk factor in our guidelines to address disparities due to racism. This includes the most recent US Preventive Services Taskforce, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine guidelines for aspirin prophylaxis in preeclampsia, where the risk factor for "Black race" should be replaced with "anti-Black racism." In this commentary, we reviewed the evidence that supports race as a sociopolitical construct and the health impacts of racism. We presented a call to action to remove racial determination in the guidelines for aspirin prophylaxis in preeclampsia and more broadly in our practice of medicine.

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

BackgroundReducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.MethodsWe performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.ResultsWe identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.ConclusionZimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Implementing a Statewide Speakers Bureau to Address Maternal Morbidity and Mortality

ObjectiveTo implement a speakers bureau to educate providers, health caregivers, and staff practicing within Tennessee hospitals on evidence-based practice recommendations related to opioid use disorder in pregnancy, postpartum hemorrhage, maternal hypertension, and implicit bias. DesignQuality improvement project. Setting/Local ProblemMultiple health care facilities throughout Tennessee, where rates of pregnancy-related mortality are greater than the national average and where Black women are three times as likely as White women to die of pregnancy complications. ParticipantsSpeakers (n = 47) included obstetricians, advanced practice providers, and nurses. Program attendees (n = 369) included providers and caregivers representing five health care facilities. Intervention/MeasurementsSpeakers were provided standardized training to disseminate best practice methods. Current evidence-based presentations regarding the top maternal mortality concerns were formatted for educational events at five Tennessee health care facilities. Independent outcome measures using electronic survey instruments were collected for speakers and audience participants. Speakers evaluated training methods, and participants evaluated the quality and efficacy of the information provided. ResultsBased on speaker evaluations, 70.59% rated the quality of training as 5 of 5, and 76.47% rated the relevance of training as 5 of 5. Overall, 16 of 17 (94.1%) speakers stated that adequate training was provided. Analysis of participant evaluations reported that 57.5% were very confident (5/5) that the information learned through the speakers bureau will improve their care of pregnant and postpartum people. Additionally, 71% were very likely (5/5) to apply the information to their practice. ConclusionThis project showed the dissemination of best practices by promoting knowledge, supporting practice change, and improving retained information in maternity providers and caregiver participants. Implementation of speakers bureaus to educate providers and caregivers within health care facilities has the potential to influence practice change and decrease maternal morbidity and mortality rates in the state of Tennessee.

Loving Mothers’ Hearts: Screening for Undiagnosed Cardiomyopathy in Peripartum Women [A229

INTRODUCTION: Peripartum cardiomyopathy (PPCM) is a leading cause of pregnancy-related maternal mortality, but it is easily treated if diagnosed early. Better screening allows earlier treatment, which can decrease maternal mortality. Prognosis is closely linked to left ventricular ejection fraction (LVEF) at time of diagnosis and treatment. There are no consensus screening guidelines for PPCM. METHODS: To address this need, we have created a PPCM screening questionnaire (PSQ), which is used to calculate a PPCM Severity Index (PSI). The PSQ was distributed on social media to women with PPCM (N ∼4,900), preeclampsia (N ∼3,000), uncomplicated pregnancies, and participants enrolled from a cross-sectional sample of peripartum patients presenting to a single maternity center. Peripartum participants in this ongoing, Institutional review board‒approved study (n=1,500) are screened for PPCM using bedside echocardiography. The LVEF measurements are paired with PSI scores and N-terminal pro b-type natriuretic peptide (NT-proBNP) levels for analysis. Study participants are offered free serial echocardiographic assessments at 0–2 weeks, 4–6 weeks and 5–12 months postpartum. RESULTS: Preliminary data show that PSI scores are correlated with degree of LV dysfunction and can differentiate between women with PPCM (n=178), healthy pregnant controls (n=32), and women with preeclampsia (n=43). Postpartum PSI scores were more specific for PPCM than pregnant PSI scores. The most frequent symptoms reported by PPCM patients are dyspnea (94%), orthopnea (84%), and fatigue (79%). CONCLUSION: The PSQ is an effective screening tool for PPCM and, if used in conjunction with BNP testing and echocardiography, may significantly reduce pregnancy-related maternal mortality.

Pregnancy-associated and pregnancy-related deaths in the United States military, 2003–2014

The Centers for Disease Control and Prevention has reported a steady increase in the US pregnancy-related mortality ratio since national surveillance began in 1987, although trends are partially induced by concurrent improvements in the identification of pregnancy-related deaths. No previous work has evaluated pregnancy-associated and pregnancy-related deaths among active-duty service members, a population with comprehensive health coverage and stable employment. This study aimed to assess trends and variations in pregnancy-associated and pregnancy-related deaths in the US military. Live births to active-duty service members were captured in Department of Defense Birth and Infant Health Research program data from 2003 to 2014. Pregnancy-associated deaths (deaths temporally related to pregnancy from any cause) were identified through 1 year after pregnancy end date using National Death Index Plus data from the Joint Department of Defense and Department of Veterans Affairs Suicide Data Repository. Pregnancy-associated deaths were classified as pregnancy-related (causally related to pregnancy) based on cause-of-death codes in the National Death Index Plus data, administrative medical encounter data, and medical record review. Pregnancy-related deaths were reported including and excluding deaths from suicide and unintentional overdose. Mortality ratios (deaths per 100,000 live births) were reported overall, triennially, and by selected characteristics; the relative contribution of each cause of death to all pregnancy-associated deaths was reported overall and by age, race and ethnicity, and marital status. Timing of death relative to pregnancy end date was assessed by cause of death. A total of 179,252 live births occurred to active-duty service members from 2003 to 2014. Pregnancy-associated and pregnancy-related mortality ratios were 41.3 (95% confidence interval, 32.4-51.8) and 18.4 (95% confidence interval, 12.7-25.9), respectively. Excluding deaths from suicide and unintentional overdose, the pregnancy-related mortality ratio was 11.2 (95% confidence interval, 6.8-17.2). Deaths from suicide and unintentional overdose composed a larger proportion of pregnancy-related deaths over time and accounted for 17.6% of all pregnancy-associated deaths. Deaths from other pregnancy-related causes accounted for a greater share of deaths among older vs younger service members (≥30 years: 41.2%; 18-29 years: 22.8%) and non-Hispanic Black vs White service members (33.3% vs 24.1%). Pregnancy-related deaths, excluding suicide and unintentional overdose, were more likely to occur within 42 days of pregnancy end date; in contrast, deaths from suicide, overdose, assault, and undetermined intent were more likely to occur between 42 days and 1 year after pregnancy. Pregnancy-associated and pregnancy-related deaths varied over time and by age and race and ethnicity. Suicide and overdose are major recent causes of pregnancy-related death among active-duty service members.

County-Level Associations Between Pregnancy-Related Mortality Ratios and Contextual Sociospatial Indicators.

To characterize county-level differences in pregnancy-related mortality as a function of sociospatial indicators. We conducted a cross-sectional multilevel analysis of all pregnancy-related deaths and all live births with available ZIP code or county data in the Pregnancy Mortality Surveillance System during 2011-2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic White women aged 15-44 years. The exposures included 31 conceptually-grounded, county-specific sociospatial indicators that were collected from publicly available data sources and categorized into domains of demographic; general, reproductive, and behavioral health; social capital and support; and socioeconomic contexts. We calculated the absolute difference of county-level pregnancy-related mortality ratios (deaths per 100,000 live births) per 1-unit increase in the median absolute difference between women living in counties with higher compared with lower levels of each sociospatial indicator overall and stratified by race and ethnicity. Pregnancy-related mortality varied across counties and by race and ethnicity. Many sociospatial indicators were associated with county-specific pregnancy-related mortality ratios independent of maternal age, population size, and Census region. Across domains, the most harmful indicators were percentage of low-birth-weight births (absolute ratio difference [RD] 6.44; 95% CI 5.36-7.51), percentage of unemployed adults (RD 4.98; 95% CI 3.91-6.05), and food insecurity (RD 4.92; 95% CI 4.14-5.70). The most protective indicators were higher median household income (RD -2.76; 95% CI -3.28 to -2.24), percentage of college-educated adults (RD -2.28; 95% CI -2.81 to -1.75), and percentage of owner-occupied households (RD -1.66; 95% CI -2.29 to -1.03). The magnitude of these associations varied by race and ethnicity. This analysis identified sociospatial indicators of pregnancy-related mortality and showed an association between pregnancy-related deaths and place of residence overall and stratified by race and ethnicity. Understanding county-level context associated with pregnancy-related mortality may be an important step towards building public health evidence to inform action to reduce pregnancy-related mortality at local levels.

Analytical validation of a novel panel of biomarkers for a test for preeclampsia

Preeclampsia is a serious condition responsible for much pregnancy-related morbidity and mortality. Diagnosis of preeclampsia is difficult due to the non-specific and subjective nature of symptoms of the disease. To reduce the subjective decision making and management of preeclampsia, we identified a panel of biomarkers representing multiple and different pathogenic pathways implicated in the etiology of preeclampsia, and developed a test referred to as Preecludia™. An algorithm based on eight biomarkers (cluster of differentiation 274 (CD274), decorin, endoglin, fibroblast growth factor-21 (FGF21), soluble fms-related tyrosine kinase 1 (sFlt-1), kidney injury molecule-1 (KIM-1), free placental growth factor (PlGF), and total PlGF) and gestational age at the time of sample collection was constructed to rule out preeclampsia in women presenting with signs and symptoms of preeclampsia. The analytical performance of each of the individual biomarker assays that comprise the Preecludia™ test was evaluated. Herein we report the test’s precision, analytical range, analytical sensitivity, parallelism, linearity, interference, analytical specificity, analytical accuracy, and stability. The data indicate that these biomarker assays exhibit a high level of inter-run precision of less than 15%, with minimal interference.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana.

Background Approximately 1–2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities. Methods We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant. Results Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33–9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07–0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56–4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy. Conclusion Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

Individual-level and community-level factors associated with eight or more antenatal care contacts in sub-Saharan Africa: evidence from 36 sub-Saharan African countries

ObjectiveTo reduce maternal mortality, the WHO has been introducing several antenatal care (ANC) measures. Pregnancy-related preventable morbidity and mortality, on the other hand, remain alarmingly high. This study was conducted...

Mortality Rates Among U.S. Women of Reproductive Age, 1999–2019

High and increasing levels of pregnancy-related mortality and morbidity in the U.S. indicate that the underlying health status of reproductive-aged women may be far from optimal, yet few studies have examined mortality trends and disparities exclusively among this population. All-cause and cause-specific mortality data for 1999-2019 were obtained from the Centers for Disease Control and Prevention WONDER Underlying Cause of Death database. Levels and trends in mortality between 1999 and 2019 for women aged 15-44 years stratified by age, race/ethnicity, and state were examined. Given the urgent need to address pregnancy-related health disparities, the correlation between all-cause and pregnancy-related mortality rates across states for the years 2015-2019 was also examined. Age-adjusted, all-cause mortality rates among women aged 15-44 years improved between 2003 and 2011 but worsened between 2011 and 2019. The recent increase in mortality among this age group was not driven solely by increases in external causes of death. Patterns differed by age, race/ethnicity, and geography, with non-Hispanic American Indian and Alaskan Native women having 2.3 and non-Hispanic Black women having 1.4 times the risk of all-cause mortality in 2019 compared with that of non-Hispanic White women. Age-adjusted all-cause mortality rates and pregnancy-related mortality rates were strongly correlated at the state level (r=0.75). Increasing mortality among reproductive-aged women has substantial implications for maternal, women's, and children's health. Given the high correlation between pregnancy-related mortality and all-cause mortality at the state level, addressing the structural factors that shape mortality risks may have the greatest likelihood of improving women's health outcomes across the life course.