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ICD-10 codes for indirect causes of maternal deaths 8

ICD-10 codes for indirect causes of maternal deaths 8

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Objective To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. Methods We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe...

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Context 1
... investigated the underlying cause of death for those who had been assigned to a subset of 46 ICD-10 codes that we suspected of being maternal deaths but did not have maternal codes from the ICD-10 O chapter. 25 (The list of the 46 ICD codes are available from the corresponding author). In addition to these 46 codes, we also investigated: deaths that were assigned maternal codes found in the ICD-10 O chapter (Table 1); deaths with suspicious or incomplete codes; deaths with complications but without a valid underlying cause of death; and all death certificates where the pregnancy checkbox had been ticked. ...
Context 2
... This study was approved by the ethics committee of the National Insti- tute of Public Health, Mexico. Table 1 presents the ICD-10 categories and associated sub-categories and titles for codes used for deaths identified as indirect obstetric deaths, as listed in the manual. The list includes all codes that constitute the internationally agreed definition of indirect maternal death. ...
Context 3
... enfoque podría ayudar al sistema sanitario a reconsiderar su estrategia para reducir las muertes maternas por causas obstétricas indirectas, incluyendo la prevención de embarazos no deseados y la mejora del cuidado prenatal y postobstétrico. Table 3. Cause of death reclassified as indirect maternal deaths, Mexico, 2006-2013 ICD-10 block 8 Title No. ...

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... The MMR has been widely acknowledged as a general indicator of overall health in populations, the status of women in society, and the functioning of health-care systems [34]. The MMR denotes the number of maternal deaths per 100,000 live births [35]. Maternal death is defined as the death of a woman while pregnant or within 42 days of pregnancy terminationirrespective of the duration and the site of the pregnancyfrom any cause related to or aggravated by the pregnancy or its management, but not from an accidental or incidental cause [35,36]. ...
... The MMR denotes the number of maternal deaths per 100,000 live births [35]. Maternal death is defined as the death of a woman while pregnant or within 42 days of pregnancy terminationirrespective of the duration and the site of the pregnancyfrom any cause related to or aggravated by the pregnancy or its management, but not from an accidental or incidental cause [35,36]. Our study analyzed maternal deaths and live births that occurred among women without social security coverage and were registered in their place of residence. ...
... Consistent with previous studies and in order to achieve an inclusive analysis, our estimate focused on women between the ages of 10-54y and included post-discharge maternal deaths as well as deaths from sequelae of obstetric or other indirect causes previously documented as relevant [35,36]. Maternal death information was drawn from the mortality databases of the National Health Information System (SINAIS by its Spanish initials) [10]; birth information was drawn from the population projections 2005-2030 of the National Population Council (CONAPO by its Spanish initials) [10]. ...
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Ensuring regular and timely access to efficient and quality health services reduces the risk of maternal mortality. Specifically, improving technical efficiency (TE) can result in improved health outcomes. To date, no studies in Mexico have explored the connection of TE with either the production of maternal health services at the primary-care level or the maternal-mortality ratio (MMR) in populations without social security coverage. The present study combined data envelopment analysis (DEA), longitudinal data and selection bias correction methods with the purpose of obtaining original evidence on the impact of TE on the MMR during the period 2008–2015. The results revealed that MMR fell 0.36% (P < 0.01) for every percentage point increase in TE at the jurisdictional level or elasticity TE-MMR. This effect proved lower in highly marginalized jurisdictions and disappeared entirely in those with low- or medium-marginalization levels. Our findings also highlighted the relevance of certain social and economic aspects in the attainment of TE by jurisdictions. This clearly demonstrates the need for comprehensive, cross-cutting policies capable of modifying the structural conditions that generate vulnerability in specific population groups. In other words, achieving an effective and sustainable reduction in the MMR requires, inter alia, that the Mexican government review and update two essential elements: the criteria behind resource allocation and distribution, and the control mechanisms currently in place for executing and ensuring accountability in these two functions.
... 22 Furthermore, MM is a phenomenon concentrated in specific parts of the country and is closely associated with poverty. 23,24 The relationship between government expenditure and MM has scarcely been studied owing mainly to the difficulty of identifying government expenditure on maternal health (GE) in a timely manner. While relevant literature indicates that such a relationship exists, 25 its magnitude is as yet uncertain. ...
... Following previous studies, 23,33 we calculated the annual municipal MM ratio and according to place of residence. ...
... This focus on mortality is being addressed, as data collection is increasingly utilising indices such as 'severe maternal morbidity' or 'near-miss events' 26 to gain a more comprehensive picture of various medical contributions, rather than just the simplistic final event of mortality. 27,28 The classification system of 'direct' and 'indirect' deaths is likely to remain for now. Perhaps, we should consider generating terms that describe obstetric conditions that are predictable by the recognition of co-morbidities earlier in pregnancy, or those which require knowledge of multi-organ physiology; whether or not the condition is specific to pregnancy seems satisfying but inconsequential. ...
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Introduction: Medical complications in pregnancy contribute significantly to maternal morbidity in sub-Saharan Africa. Anecdotally, obstetricians in Uganda do not feel equipped to treat complex medical cases, and receive little support from physicians. Methods: The aim of the study was to quantify the burden of complex medical conditions on the obstetric high dependency unit at Mulago National Referral Hospital, and potential deficiencies in the referral of cases and training in obstetric medicine. A prospective audit was taken on the obstetric high dependency unit from April to May 2014. In addition, 50 trainees in obstetrics and gynaecology filled a nine-point questionnaire regarding their experiences. Results: Complex medical disorders of pregnancy accounted for 22/106 (21%) admissions to the high dependency unit, and these cases were responsible for 51% of total bed occupancy, and had a case fatality rate of 6/22 (27.2%). Only 6/14 (43%) of referrals to medical specialties were fulfilled within 48 h. Of the six women who died due to medical conditions, three specialty referrals were made, none of which were fulfilled. Trainees reported deficiencies in obstetric medicine training and in referral of complex conditions. They were least confident addressing non-communicable conditions in pregnancy. Discussion: Deficiencies exist in the care of women with complex medical conditions in pregnancy in Uganda. Frameworks of obstetric medicine training and referral of complex cases should be explored and adapted to the sub-Saharan African setting.
... After the implementation of the Intentional Search and Reclassification of Maternal Deaths System (BIRMM, acronym in Spanish) in 2002, approximately 20% maternal deaths originally classified as non-maternal deaths were recovered [4][5][6]. Due to improving registries, indirect maternal deaths have been analyzed with a greater degree of certainty [7], as well as the contribution of late maternal deaths and obstetric sequelae deaths to maternal mortality in Mexico [8]. Nevertheless, despite the gains in the measurement of maternal mortality, the MMR has not declined as expected, which points to insufficient knowledge of its determinants. ...
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Background Quality of obstetric care may not be constant within clinics and hospitals. Night shifts and weekends experience understaffing and other organizational hurdles in comparison with the weekday morning shifts, and this may influence the risk of maternal deaths. Objective To analyze the hourly variation of maternal mortality within Mexican health institutions. Methods We performed a cross-sectional multivariate analysis of 3,908 maternal deaths and 10,589,444 births that occurred within health facilities in Mexico during the 2010–2014 period, using data from the Health Information Systems of the Mexican Ministry of Health. We fitted negative binomial regression models with covariate adjustment to all data, as well as similar models by basic cause of death and by weekdays/weekends. The outcome was the Maternal Mortality Ratio (MMR), defined as the number of deaths occurred per 100,000 live births. Hour of day was the main predictor; covariates were day of the week, c-section, marginalization, age, education, and number of pregnancies. Results Risk rises during early morning, reaching 52.5 deaths per 100,000 live births at 6:00 (95% UI: 46.3, 62.2). This is almost twice the lowest risk, which occurred at noon (27.1 deaths per 100,000 live births [95% U.I.: 23.0, 32.0]). Risk shows peaks coinciding with shift changes, at 07:00, and 14:00 and was significantly higher on weekends and holidays. Conclusions Evidence suggests strong hourly fluctuations in the risk of maternal death with during early morning hours and around the afternoon shift change. These results may reflect institutional management problems that cause an uneven quality of obstetric care.
... Mungra et al. reported a MMR of 226 between 1991 and 1993, which indicates a 42% reduction in maternal deaths and an improvement in underreporting from 64% to 26% [4,5]. A comparison of the MMR and underreporting is difficult, as to our best knowledge there are few countries that have performed a RAMoS of confidential enquiry [16][17][18][19]. ...
... Though our study suggests that, over the years, there is a growing reliability on identification of maternal deaths, the underreporting rate in Suriname (26%) is still higher than reported in Jamaica (20%), Argentina (9.5%) and Mexico (13%) [16][17][18][19]. ...
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Background The fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors. Methods A reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors. Results In the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases. Conclusion Despite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.
... The new system reclassified a further 10% of direct deaths as indirect, leading to an overall 6.8% increase in maternal deaths categorised as indirect. 18 Despite these problems in measurement, a comparison of the WHO analysis of the causes of maternal deaths between two time periods, 1990-2002 and 2003-2009 showed that the proportion of deaths due to indirect causes has increased substantially in LMICs, the most notable increase being in Latin America and the Caribbean (Table 1). A recent systematic review suggested that 28% of maternal deaths in LMICs in 2003-2009 were due to indirect causes compared with 27% due to haemorrhage and 14% due to hypertensive disorders. ...
... Effects of this epidemiological transition are already evident in Mexico where the rate of indirect maternal death has remained unchanged during a period of eight years (13.3 per 100,000 live births in 2013 compared with 12.2 per 100,000 live births in 2006) in contrast to a significant decline in direct maternal deaths. 18 While China has made rapid progress in reducing maternal deaths, a study reported a doubling of indirect maternal deaths in the large metropolitan Wuhan city within a decade from 15 per 100,000 live births in 2001 to 37 per 100,000 live births in 2012; cardiac disease was the leading cause. 31 Similarly, maternal mortality has decreased in Sri Lanka, but the proportion of deaths due to indirect causes has increased steadily from 1930 to 2000. ...
... Yet, these strategies have been shown to have no significant effect on reducing the substantial burden of indirect maternal deaths. 17 Lessons from the confidential enquiries into maternal deaths from the UK, 4,10 Kerala in India, 37 South Africa 21 and studies from other countries 7,18,31,32 suggest the need for policy actions to ensure that health services for pregnant women with medical and mental health conditions are designed to provide appropriate evidence-based multidisciplinary care across the entire pathway; pre-pregnancy, during pregnancy and delivery, and postpartum. In recognition of the potential risks of pregnancy associated with pre-existing conditions, women should be informed about the risks and receive pre-pregnancy counselling from those with expertise in their medical condition and pregnancy. ...
Article
Indirect maternal deaths outnumber direct deaths due to obstetric causes in many high-income countries, and there has been a significant increase in the proportion of maternal deaths due to indirect medical causes in low- to middle-income countries. This review presents a detailed analysis of indirect maternal deaths in the UK and a perspective on the causes and trends in indirect maternal deaths and issues related to care in low- to middle-income countries. There has been no significant decrease in the rate of indirect maternal deaths in the UK since 2003. In 2011–2013, 68% of all maternal deaths were due to indirect causes, and cardiac disease was the single largest cause. The major issues identified in care of women who died from an indirect cause was a lack of clarity about which medical professional should take responsibility for care and overall management. Under-reporting and misclassification result in underestimation of the rate of indirect maternal deaths in low- to middle-income countries. Causes of indirect death include a range of communicable diseases, non-communicable diseases and nutritional disorders. There has been evidence of a shift in incidence from direct to indirect maternal deaths in many low- to middle-income countries due to an increase in non-communicable diseases among women in the reproductive age. The gaps in care identified include poor access to health services, lack of healthcare providers, delay in diagnosis or misdiagnosis and inadequate follow-up during the postnatal period. Irrespective of the significant gains made in reducing maternal mortality in many countries worldwide, there is evidence of a steady increase in the rate of indirect deaths due to pre-existing medical conditions. This heightens the need for research to generate evidence about the risk factors, management and outcomes of specific medical comorbidities during pregnancy in order to provide appropriate evidence-based multidisciplinary care across the entire pathway: pre-pregnancy, during pregnancy and delivery, and postpartum.
... Not everyone has regular access to services. Ministries of health need to increase access to and use of effective contraception among the poor, which continues to be a central strategy to reduce maternal mortality [13]. ...
... Additionally, in Nicaragua, the healthcare delivery model stresses community participation and reinforces the community distribution of contraceptives in hard-to-reach areas [4,23]. Although development aid for family planning programs has fallen significantly in the region [7,13], strategic international investments could incentivize governments to address unmet needs in the poorest areas. ...
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Objective: To identify factors associated with contraceptive use among women in need living in the poorest areas in five Mesoamerican countries: Guatemala, Honduras, Nicaragua, Panama and State of Chiapas (Mexico). Study design: We analyzed baseline data of 7049 women of childbearing age (15-49years old) collected for the Salud Mesoamérica Initiative. Data collection took place in the 20% poorest municipalities of each country (July, 2012-August, 2013). Results: Women in the poorest areas were very poorly informed about family planning methods. Concern about side effects was the main reason for nonuse. Contraceptive use was lower among the extremely poor (<$1.25 USD PPP per day) [odds ratio (OR): 0.75; confidence interval (CI): 0.59-0.96], those living more than 30min away from a health facility (OR 0.71, CI: 0.58-0.86), and those of indigenous ethnicity (OR 0.50, CI: 0.39-0.64). Women who were insured and visited a health facility also had higher odds of using contraceptives than insured women who did not visit a health facility (OR 1.64, CI: 1.13-2.36). Conclusions: Our study showed low use of contraceptives in poor areas in Mesoamerica. We found the urgent need to improve services for people of indigenous ethnicity, low education, extreme poverty, the uninsured, and adolescents. It is necessary to address missed opportunities and offer contraceptives to all women who visit health facilities. Governments should aim to increase the public's knowledge of long-acting reversible contraception and offer a wider range of methods to increase contraceptive use. Implications: We show that unmet need for contraception is higher among the poorest and describe factors associated with low use. Our results call for increased investments in programs and policies targeting the poor to decrease their unmet need.
... The association of poverty and maternal mortality is well-documented [28]. Our group has found that women residing in poorer regions of Mexico experience more direct maternal death, which includes abortion-related death, than women in wealthier areas, for example [29]. ...
... Mexico decreased its maternal mortality ratio by more than 50% between 1990 and 2013, 21 and several states, including Oaxaca, Tlaxcala, and Queretaro, recorded even larger reductions in their maternal mortality ratio since 1990, 32 which probably contributed to state-level improvements in female life expectancy. Leading causes of maternal deaths-haemorrhage during childbirth, maternal hypertension, and indirect causes-have decreased since 1990, though indirect causes increasingly account for a greater proportion of YLLs. ...
... Leading causes of maternal deaths-haemorrhage during childbirth, maternal hypertension, and indirect causes-have decreased since 1990, though indirect causes increasingly account for a greater proportion of YLLs. 32 Additional gains against such maternal causes are crucial for further improvement of women's health in Mexico, particularly in states with high marginalisation. Nonetheless, other conditions, especially cancers, led to comparable, or even higher, DALY rates in women of reproductive age. 2 These results emphasise the continued need to further scale-up universal coverage of maternal health services and to strengthen the overall health system capacity to support women's health needs in Mexico. ...
Article
Background: Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time. Methods: We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors. Findings: From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1-3·8), from 72·1 years (71·8-72·3) to 75·5 years (75·3-75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9-14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6-23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013. Interpretation: Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state. Funding: Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.
... The association of poverty and maternal mortality is well-documented [28]. Our group has found that women residing in poorer regions of Mexico experience more direct maternal death, which includes abortion-related death, than women in wealthier areas, for example [29]. ...
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Objective: A recent publication (Koch et al 2015) claimed that Mexican states with more restrictive abortion laws had lower levels of maternal mortality. Our objectives are to replicate the analysis, re-analyze the data, and offer a critique of the key flaws of the Koch study. Study design: We used corrected maternal mortality data (2006-2013), live births, and state-level indicators of poverty. We replicate the published analysis. We then re- classified state-level exposure to abortion on demand based on actual availability of abortion (Mexico City versus the other 31 states) and test the association of abortion access and the Maternal Mortality Ratio (MMR) using descriptives over time, pooled chi-square tests and regression models. We included 256 state-year observations. Results: We did not find significant differences in MMR between México City (MMR=49.1) and the 31 states (MMR=44.6; p=0.44). Using Koch's classification of states, we replicated published differences of higher MMR where abortion is more available. We found a significant, negative association between MMR and availability of abortion in the same multivariable models as Koch, but using our state classification (beta = -22.49, 95% CI = -38.9 - 15.99). State-level poverty remains highly correlated with MMR. Conclusion: Koch makes errors in methodology and interpretation, making false causal claims about abortion law and MMR. MMR is falling most rapidly in Mexico City, but our main study limitation is an inability to draw causal inference about abortion law or access and maternal mortality. We need rigorous evidence about the health impacts of increasing access to safe abortion worldwide. Implications: Transparency and integrity in research is crucial, and perhaps even more in politically contested topics such as abortion. Rigorous evidence about the health impacts of increasing access to safe abortion worldwide is needed.