BOSTON – A screening tool designed to identify medical and psychosocial risk factors associated with poor pregnancy outcomes also seems to predict maternal traumatic pregnancy–associated death, according to Dr. Nancy S. Hardt.
The Florida Healthy Start Prenatal Risk Screen has been validated for the identification of women who are at risk for preterm delivery or for delivering a low-birth-weight infant. Even low levels of risk on the screening test, which has been offered to all pregnant women in Florida at their first prenatal visit as per state legislative statute since 1991, appear to be associated with an increased likelihood of traumatic maternal death, Dr. Hardt said at the annual meeting of the Pediatric Academic Societies.
"It’s possible that services targeting the reduction of adverse infant outcomes may simultaneously lower pregnant women’s risk of traumatic death," she said. "It doesn’t take a whole lot of practice change to address some of the factors that might be putting the moms at risk, such as dispelling the myth that pregnant women shouldn’t wear seatbelts, asking patients if they feel safe in their homes, and stressing the dangers of substance use and abuse, including prescription drug use."
Dr. Hardt and her colleagues reviewed 600,000 Healthy Start screens from 1999 to 2005, as well as linked data for the concurrent period from Florida’s Enhanced Maternal Mortality Reporting Database. Of the women who died during the period of study, 144 experienced traumatic deaths. These included accidents, homicides, suicides, and drug overdoses, she said, noting that the top four causes of maternal deaths were trauma related.
"It’s possible that services targeting the reduction of adverse infant outcomes may simultaneously lower pregnant women’s risk of traumatic death."
Specifically, the causes of death that had the greatest maternal mortality ratios were transport accidents (13.3), homicide (5.5), accidental poisoning (3.3), and suicide (2.9).
"We have to go through quite a few categories of traumatic deaths before we get to the obstetric-related deaths," such as hypertension disorders (2.7), hemorrhage (2.2), thrombotic embolism (2.2), and infection (2.0), observed Dr. Hardt, professor of pathology and ob.gyn. at the University of Florida in Gainesville.
To evaluate the predictive value of the Healthy Start screen for identifying risk of traumatic death, the investigators used the same screening threshold as that used for identifying women at risk for poor pregnancy outcomes, Dr. Hardt said. "A score of 4 or higher on the [15-item] weighted measure, which includes demographic as well as environmental and social factors, indicates a positive screen for risk of preterm or low-birth-weight delivery and triggers referral to Healthy Start services," Dr. Hardt explained. "We hypothesized that the risk factors for these infant problems would be the same as for maternal death, and as such the screening instruments would work for identifying at-risk moms."
An analysis of the data showed that as a woman’s risk score increased, the probability of traumatic death also increased. In fact, "a woman with a risk score of 4 had nearly 12 times the risk of traumatic death compared to a women with a risk score of zero, and a woman with a risk score of 9 had 52 times the risk of traumatic death compared to one who scored zero," Dr. Hardt said. "What we observed is that with each increase in score of 1, the relative risk of death increased 1.5 to 2 times."
What this means, in terms of a prediction tool, "is that for every 100,000 women with a score of 4, expect nearly 48 traumatic maternal deaths, and for every one with a score of 9, expect 215 traumatic deaths," according to Dr. Hardt.
Many of the specific risk determinants associated with poor pregnancy outcomes are likely the same as those that are predictive of maternal traumatic death, including mental health, substance use, domestic violence, education, and employment/family income status, Dr. Hardt said.
Dr. Hardt said she had no relevant financial disclosures.