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Safe Motherhood in the United States

Source: MCHJFB 6(4) 215–272 (2002).
http://www.kluweronline.com/issn/1092-7875/contents*

Introductory Commentary: Pregnancy and Women's Lives in the Twenty-First Century: The United States Safe Motherhood Movement
Lynne S. Wilcox, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

Safe Motherhood in the United States: Challenges for Surveillance
Trude A. Bennett, Department of Maternal and Child Health, School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Melissa M. Adams, Department of Maternal and Child Health, School of Public Health, The University of Alabama at Birmingham

Objectives: Maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities. However, existing surveillance efforts are poorly developed, and pregnancy-related deaths and illnesses tend to be underreported. To formulate recommendations for improved surveillance, the authors reviewed existing data on maternal health. Methods: This review examines the scope and quality of existing information and the strengths and limitations of definitions of maternal mortality and morbidity used in data collection and reporting. Results: This review suggests numerous gaps in surveillance of U.S. maternal health. Psychological as well as physical morbidity, and the presence and adequacy of appropriate treatment, should be ascertained. Quality of pregnancy-related care at the clinical and community levels, and the impact on mortality and morbidity, must be assessed. Collection of morbidity data outside of health care delivery sites is also essential. Trade-offs between nationally representative and other less comprehensive data sources, such as sentinel clinics, large healthcare organizations, and public healthcare financing systems, should be considered. Conclusion: Maternal health remains an important frontier for U.S. public health surveillance efforts. Improved surveillance offers opportunities for reducing pregnancy-related mortality and gaining a better understanding of the relationship between maternal morbidity and mortality.

Surveillance in a Time of Changing Health Care Practices: Estimating Ectopic Pregnancy Incidence in the United States
Suzanne B. Zane, Maternal Health Team, Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Burney A. Kieke Jr, Statistics and Computer Resources Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Juliette S. Kendrick,  Office of the Director, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Carol Bruce, Maternal Health Team, Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

Objectives: Ectopic pregnancy is a common condition with significant health consequences; complications are a major cause of maternal mortality in the United States. Accurate ascertainment of the number of ectopic pregnancies occurring in the United States has been dramatically affected by changing medical practices, causing estimates based on hospital data to be falsely low. This study was performed to identify nationally representative data on ectopic pregnancies and determine overlap of these data, to calculate the annual weighted number of ectopic pregnancies and confidence intervals for these estimates, and to determine barriers to estimation of ectopic pregnancy incidence. Methods: To assess whether a national estimate of the incidence of ectopic pregnancy could be calculated, we analyzed 1992–1999 data from the six nationally representative data sets that include information on ectopic pregnancy. We examined relevant data in each data set and assessed whether any combination of data sets could be used to estimate ectopic pregnancy incidence. We calculated weighted estimates and 95% confidence intervals for hospitalizations, outpatient surgeries, outpatient medical procedures, and physician visits for and self-reports of ectopic pregnancy. Results: Small sample sizes severely limited calculation of estimates of ectopic pregnancy. Data needed for assessing multiple counting was not available consistently. The likelihood of multiple counting of cases was substantial when data set counts were combined. Conclusions: A reliable incidence rate for ectopic pregnancy in the United States could not be estimated from existing nationally representative data sources. Major advances in diagnosis and treatment of ectopic pregnancy have affected surveillance in two ways: inpatient hospital treatment of ectopic pregnancy has decreased, and multiple health care visits for a single ectopic pregnancy have increased. Alternate means of surveillance are needed to improve understanding of risk factors and trends for ectopic pregnancy, and we recommend examination of the databases of public and private insurance systems and managed care systems. Similar alternate means of surveillance may be needed for other health conditions with comparable changes in management of care.

Socioeconomic and Racial/Ethnic Disparities in Unintended Pregnancy Among Postpartum Women in California
Catherine Cubbin, Department of Family and Community Medicine, University of California, San Francisco
Paula A. Braveman, Department of Family and Community Medicine, University of California
Kristen S. Marchi, Department of Family and Community Medicine, University of California
Gilberto F. Chavez, Maternal and Child Health Branch, California Department of Health Services
John S. Santelli, Division of Reproductive Health, U.S. Centers for Disease Control and Prevention
Brenda J. Colley Gilbert, Division of Reproductive Health, U.S. Centers for Disease Control and Prevention

Objective: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. Methods: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. Results: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. Conclusions: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.
 

Correlates of Self-Reports of Being Very Depressed in the Months After Delivery: Results from the Pregnancy Risk Assessment Monitoring System
Kevin H. Gross, Human and Environmental Sciences, Department of Child Development and Family Relations, East Carolina University
Chris S. Wells, Health Statistics Section, Colorado Department of Public Health and Environment
Anne Radigan-Garcia, Public Health Information Group, New York State Department of Health
Patricia M. Dietz, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

Objective: This study identified correlates of self-reports of being very depressed in the months after delivery in a population-based sample of women. Methods: We analyzed data on 14,609 recent mothers from the Centers for Disease Control and Prevention's (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS). The sample included mothers who delivered a live birth in Colorado, New York State, and North Carolina from 1996 (New York only) to 1999. We assessed risk factors for self-reports of being very depressed in the months after delivery using logistic regression. Results: Overall, 5.9% (95% CI = 5.3, 6.4) of new mothers reported being very depressed in the months after delivery. Women who reported that their pregnancy was a “very hard time” or “one of the worst times of my life” had the highest prevalence of reporting being very depressed in the months after delivery (24.9%, 95% CI = 21.3, 28.5) and, when all risk factors were adjusted for simultaneously, were 4.6 times (95% CI = 3.1, 6.3) more likely to report being very depressed in the months after delivery than other women. Other significant risk factors for self-reports of being very depressed in the months after delivery included experiencing partner-associated stress (OR = 1.9, 95% CI = 1.5, 2.5), physical abuse during pregnancy (OR = 1.6, 95% CI = 1.1, 2.4), and not breast-feeding (OR = 1.4, 95% CI = 1.1, 1.8). Conclusions: The highest prevalence for self-reports of being very depressed in the months after delivery was in women who reported that their pregnancy was a “very hard time” or “one of the worst times of my life.” Clinicians need to be aware of the needs of some women for mental health services both during and after pregnancy.

Insulin and the “Thrifty” Woman: The Influence of Insulin During Pregnancy on Gestational Weight Gain and Postpartum Weight Retention
Theresa O. Scholl, Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, Stratford
Xinhua Chen, Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine

Objectives: To test Neel's hypothesis among pregnant women: a high maternal insulin concentration in early pregnancy increases the risk of weight gain, overweight, and obesity among nondiabetic, low-income gravidas of racial and ethnic minority groups from Camden, New Jersey. Methods: Fasting insulin was obtained from 461 gravidas at entry to prenatal care. Insulin quartile was related to rate of gestational weight gain and excess weight gain during pregnancy (≥90th percentile) and to retained weight and excess weight retention at 4–6 weeks postpartum (≥90th percentile). The relationship between excess retained weight and excessive insulin increase (≥90th percentile) was also examined. Results: Compared with gravidas with an insulin concentration in the lowest three quartiles, gravidas with the highest insulin quartile had a significantly higher rate of gestational weight gain (nonobese women only) and average weight retained postpartum (all women). Compared with an insulin concentration in the lowest three quartiles, the highest insulin quartile was associated with a 2.05-fold (95% confidence interval [CI] = 1.07–3.93) risk of an excessive rate of gestational weight gain and a 3.58-fold (95% CI = 1.87–6.84) risk of excess weight retained postpartum. Excess weight retained postpartum was linked to a 2.63-fold (95% CI = 1.00–6.89) risk of an excessive increase in insulin concentration postpartum. Conclusions: Our results support Neel's hypothesis and suggest that a high maternal insulin concentration is associated with increased gestational weight gain and increased weight retention postpartum. High insulin concentration may contribute to pregnancy-related changes in weight and thus may be linked to maternal overweight and obesity postpartum as well as to future risk of gestational and Type 2 diabetes mellitus.

Note from the Field: Evaluation of Maternal Death Surveillance: A Community Process
Marianne E. Zotti, Centers for Disease Control and Prevention, Division of Reproductive Health, and Bureau of Women's Health, Mississippi State Department of Health
Hazel D. Gaines, Bureau of Women's Health, Mississippi State Department of Health
Corrie A. Moncrief, Bureau of Women's Health, Mississippi State Department of Health

The Mississippi State Department of Health found that the Centers for Disease Control and Prevention guidelines for evaluating surveillance systems could be used as a community approach in changing a maternal mortality surveillance system. This experience caused us to think more broadly about maternal mortality, challenge the guideline process, and ultimately embark on a new surveillance system. System changes included ensuring dissemination of findings, increasing number and type of stakeholders, including nonmedical factors, heightening awareness of maternal mortality, promoting timely reviews, reviewing our regulatory authority, adding field staff notification about maternal deaths, expanding the definition of maternal death, and combining surveillance systems—all of which leads to improved maternal mortality surveillance in Mississippi.

Concluding Commentary: Safe Motherhood: Values, Purpose, and Possibility
James S. Marks, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention

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Date last reviewed: 03/21/2006
Content source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion