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BACKGROUND: Although rare, pregnancy-associated mortality (PAM) (sub-divided into pregnancy-related (PRM) and non-pregnancy related (NPM)) is a primary indicator of the overall health status of women, the effectiveness of obstetrical care and the health care system. PAM is increasing across the United States and in Michigan; rates are disproportionately higher among Non-Hispanic (NH) African American (AA) and Native American (NA) women. Although improvements in case ascertainment and surveillance may account for part of this increase, other factors such as increasing prevalence of comorbidities and loss of providers may be influencing this rate. As these are sentinel events, it is essential to identify policy, system, provider, community and patient level factors that may influence the outcome. The purpose of this analysis was to examine the association between use of services (such as WIC or entry into prenatal care within the first trimester) and PAM, PRM and NPM.
METHODS: Data for this case-control study were from the Michigan Maternal Death File linked to Michigan Live Birth Files, 2008 to 2010. Cases (N=112) were defined as women who died within one year of delivering a live birth. Four controls (N=448) per case were selected by a simple random sample of the Michigan Live Birth File. Predictor variables and covariates were limited to those in the birth file. Logistic regression was used to examine the association of services with PAM, PRM and NPM, adjusted for covariates (i.e. race/ethnicity, age, low prenatal BMI, etc.)
RESULTS: First trimester entry into prenatal care (PNC1) was inversely associated with PAM (AOR 0.392, 0.243-0.63), PRM (AOR 0.390, 0.19-0.81) and NPM (0.230, 0.116-0.455). Interaction between PNC1 and race/ethnicity was significant for NPM. Although a non-significant inverse association was found among NH AA/NA women with PNC1, those who lacked PNC1 had higher odds of NPM (AOR 8.915, 2.60-30.6). A protective effect was seen among Non-NH AA/NA with PNC1 (AOR 0.112, 0.033-0.38). Low prenatal BMI was associated with PAM (AOR 2.618, 1.03-6.657) and NPM (AOR 3.47, 1.23-9.7487). WIC enrollment was inversely associated with PRM, but this association was not significant.
CONCLUSIONS: Entry into prenatal care during the first trimester was found to be inversely associated with mortality among Michigan women within one year of delivering a live birth during the study period. Although these results suggest that improving early access to prenatal care would decrease PAM, further study is needed to better understand this relationship and the influence of upstream factors that may influence enrollment and mortality.