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= Add to Maternal Death Wiki Page = Definition

This may explain the CDC’s definition, extending the period of consideration “within 1 year of the end of pregnancy.” Adding to the WHO definition, the CDC also mentions that this death can be irrespective of the outcome of the pregnancy. [1]

Severe Maternal Morbidity (SMM)

Severe Maternal Morbidity (SMM) includes any unexpected outcomes from labor or delivery that cause both short and long-term consequences to the mother’s overall health. [3] The CDC uses certain diagnosis codes for maternal morbidity, and using these definitions that rely on these codes should be used with careful consideration since some may miss cases, have a low predictive value, or may be difficult for different facilities to operationalize. [13] There are certain screening criteria that may be helpful and are recommended through the American College of Obstetricians and Gynecologists as well as the Society for Maternal-Fetal Medicine (SMFM). These screening criteria for SMM are for transfusions of four or more units of blood and admission of a pregnant woman or a postpartum woman to an ICU facility or unit. [13]

The greatest proportion of women with SMM are those who require a blood transfusion during delivery, mostly due to excessive bleeding. Blood transfusions given during delivery due to excessive bleeding has increased the rate of mothers with SMM. [3] The rate of SMM has increased almost 200% between 1993 (49.5 per 100,000 live births) and 2014 (144.0 per 100,000 live births). This can be seen with the increased rate of blood transfusions given during delivery, which increased from 1993 (24.5 per 100,000 live births) to 2014 (122.3 per 100,000 live births). [3]

The increased rate for SMM can also be indicative of potentially increased rates for maternal mortality, since without identification and treatment of SMM, these conditions would lead to increased maternal death rates. Therefore, diagnosis of SMM can be considered a “near miss” for maternal mortality. [13] With this consideration, several different expert groups have urged obstetric hospitals to review SMM cases for opportunities that can lead to improved care, which in turn would lead to improvements with maternal health and a decrease in the number of maternal deaths.

Risk Due to Youth

Women of adolescent age have a greater risk of complication and death due to pregnancy than any other age group. This risk is greatest for adolescent girls under the age of 15. The leading cause of death for girls at the age of 15 in developing countries is complication through pregnancy and childbirth. They have more pregnancies, on average, than women in developed countries and it has been shown that 1 in 180 fifteen year old girls in developing countries who become pregnant will die due to complications during pregnancy or childbirth. This is compared to women in developed countries, where the likelihood is 1 in 4900 live births.[2]

However, in the United States, as many women of older age continue to have children, trends have seen the maternal mortality rate to rise in some states, especially among women over 40 years old. [5]

Major Causes

The major complications that have been associated with nearly 75% of all maternal deaths include severe bleeding, infections, high blood pressure during pregnancy (also called pre-eclampsia and eclampsia), complications from delivery, and unsafe abortion practices. [2] Maternal mortality caused by severe bleeding and infections are mostly after childbirth. The remaining major causes of maternal death worldwide area associated with diseases such as AIDS during pregnancy and malaria. Risk factors associated with increased maternal death include the age of the mother, obesity before becoming pregnant, other pre-existing chronic medical conditions, and cesarean delivery. [3],[5]

Pregnancy-related deaths between 2011 and 2014 in the United States have been shown to have major contributions from non-communicable diseases and conditions, and the following list shows some of the more common causes related to maternal death[1]:


 * Cardiovascular    diseases, 15.2%.
 * Non-cardiovascular    diseases, 14.7%.
 * Infection    or sepsis, 12.8%.
 * Hemorrhage,    11.5%.
 * Cardiomyopathy,    10.3%.
 * Thrombotic    pulmonary embolism, 9.1%.
 * Cerebrovascular    accidents, 7.4%.
 * Hypertensive    disorders of pregnancy, 6.8%.
 * Amniotic    fluid embolism, 5.5%.
 * Anesthesia    complications, 0.3%.

Prevention for Maternal Death

It was estimated that in 2015, a total of 303,000 women died due to causes related to pregnancy or childbirth. [4] The majority of these causes were either severe bleeding, sepsis, eclampsia, labor that had some type of obstruction, and consequences from unsafe abortions. All of these causes are either preventable or have highly effective interventions. [4] Another factor that contributes to the maternal mortality rate that have opportunities for prevention are access to prenatal care for women who are pregnant. Women who do not receive prenatal care are between three and four times more likely to die from complications resulting from pregnancy or delivery than those who receive prenatal care. For women in the United States, 25% do not receive the recommended number of prenatal visits, and this number increases for women among specific demographic populations: 32% for African American women and 41% for American Indian and Alaska Native women. [11]

Women who have unwanted pregnancies who have access to reliable information as well as compassionate counseling and quality services for the management of any issues that arise from abortions (whether safe or unsafe) can be beneficial in reducing the number of maternal deaths. [7] Also, in regions where abortion is not against the law, then abortion practices need to be safe in order to effectively reduce the number of maternal deaths related to abortion.

Global Trends in Maternal Death

Between 1990 and 2015, the maternal mortality ratio has decreased from 385 deaths per 100,000 live births to 216 maternal deaths per 100,000 live births. [4] Some factors that have attributed to the decreased maternal deaths seen between this period are in part to the access that women have gained to family planning services and skilled birth attendance, meaning a midwife, doctor, or trained nurse), with back-up obstetric care for emergency situations that may occur during the process of labor. [4] This can be examined further by looking at statistics in some areas of the world where inequities in women’s access to health care services reflect an increased number of maternal deaths. Over 85% of the hundreds of thousands of women who die each year during childbirth (or throughout their pregnancy) live in sub-Saharan Africa and Southern Asia. [4] The high maternal death rates also reflect access to health services between the poor communities compared to women who are rich. [2]

Global Response to Maternal Death

United Nations Efforts: Sustainable Development Goals

The United Nations has a list of goals termed the Sustainable Development Goals, that aim to reduce the maternal mortality ration to 70 deaths per 100,000 live births by the year 2030. [6] Some of the specific aims of the Sustainable Development Goals are to prevent unintended pregnancies by ensuring more women have access to contraceptives, as well as providing women who become pregnant with a safe environment for delivery with respectful and skilled care during delivery. This also includes providing women with complications during delivery timely access to emergency services through obstetric care.[4]

The United Nations Population Fund (UNFPA; formerly known as the United Nations Fund for Population Activities) have established programs that support efforts in reducing maternal death. These efforts include education and training for midwives, supporting access to emergency services in obstetric and newborn care networks, and providing essential drugs and family planning services to pregnant women or those planning to become pregnant. [4] They also support efforts for review and response systems regarding maternal deaths.

WHO Efforts

The WHO has a global strategy and goal to end preventable death related to maternal mortality. [2] A major goal of this strategy is to identify and address the causes of maternal and reproductive morbidities and mortalities, as well as disabilities related to maternal health outcomes. The collaborations that this strategy introduces are to address the inequalities that are shown with access to reproductive, maternal, and newborn services, as well as the quality of that care. They also ensure that universal health coverage is essential for comprehensive health care services related to maternal and newborn health. The WHO strategy also implements strengthening health care systems to ensure quality data collection to better respond to the needs of women and girls, as well as ensuring responsibility and accountability to improve the equity and quality of care provided to women.

United States Trends in Maternal Death

The maternal mortality rate has actually been increasing within the United States for the past 27 years. The rate has steadily increased from 7.2 deaths in 1987 to 18.0 deaths per 100,000 live births in 2014. [1] Between 2011 and 2014, there were 7,208 deaths that were reported to the CDC that occurred for women within a year of the end of their pregnancy. Out of this there were 2,726 that were found to be pregnancy-related deaths. [1]

The past 60 years have consistently shown considerable racial disparities in pregnancy-related deaths. Between 2011 and 2014, the mortality rations for different racial populations based on pregnancy-related deaths were as follows: 12.4 deaths per 100,000 live births for white women, 40,0 for black women, and 17.8 for women of other races. [11] This shows that black women have between three and four times greater chance of dying from pregnancy-related issues. It has also been shown that one of the major contributors to maternal health disparities within the United States is the growing rate of non-communicable diseases. [11]

It is unclear why pregnancy-related deaths in the United States have increased. It seems that the use of computerized data servers by the states and changes in the way deaths are coded, with a pregnancy checkbox added to death certificates in many states, have been shown to improve the identification of these pregnancy-related deaths. However, this does not contribute to decreasing the actual number of deaths. Also, errors in reporting of pregnancy status have been seen, which most likely leads to overestimation of the number of pregnancy-related deaths. [1] Again, this does not contribute to explaining why the death rate has increased, but does show complications between reporting and actual contributions to the overall rate of maternal mortality. [11]

United States Response to Maternal Death

Even though 99% of births in the United States are attended by some form of skilled health professional, the maternal mortality ratio in 215 was 14 deaths per 100,000 live births[4] and it has been shown that the maternal mortality rate has been increasing. Also, the United States is not as efficient at preventing pregnancy-related deaths when compared to most of the other developed nations. [11]

The United States took part in the Millennium Development Goals (MDGs) set forth from the United Nations. The MDGs ended in 2015 but were followed-up in the form of the Sustainable Development Goals starting in 2016. The MDGs had several tasks, one of which was to improve maternal mortality rates globally. Despite their participation in this program as well as spending more than any other country on hospital-based maternal care, however, the United States has still seen increased rates of maternal mortality. This increased maternal mortality rate was especially pronounced in relation to other countries who participated in the program, where during the same period, the global maternal mortality rate decreased by 44%.[11] Also, the United States is not currently on track to meet the Healthy People 2020 goal of decreasing maternal mortality by 10% by the year 2020, and continues to fail in meeting national goals in maternal death reduction. [11] Only 23 states have some form of policy that establishes review boards specific to maternal mortality as of the year 2010. [11]

In an effort to respond to the maternal mortality rate in the United States, the CDC requests that the 52 reporting regions (all states and New York City and Washington DC) to send death certificates for all those women who have died and may fit their definition of a pregnancy-related death, as well as copies of the matching birth or death records for the infant. [1] However, this request is voluntary and some states may not have the ability to abide by this effort.

The Affordable Care Act (ACA) provided additional access to maternity care by expanding opportunities to obtain health insurance for the uninsured and mandating that certain health benefits have coverage. It also expanded the coverage for women who have private insurance. This expansion allowed them better access to primary and preventative health care services, including for screening and management of chronic diseases. An additional benefit for family planning services was the requirement that most insurance plans cover contraception without cost sharing. However, more employers are able to claim exemptions for religious or moral reasons under the current administration. Also under the current administration, the Department of Health and Human Services (HHS) has decreased funding for pregnancy prevention programs for adolescent girls. [5]

Those women covered under Medicaid are covered when they receive prenatal care, care received during childbirth, and postpartum care. These services are provided to nearly half of the women who give birth in the United States. Currently, Medicaid is required to provide coverage for women whose incomes are at 133% of the federal poverty level in the United States. [5]

Antenatal Care

For developing regions, where it has been shown that maternal mortality is greater than in developed nations, antenatal care has increased from 65% in 1990 to 83% in 2012. [6]

Unsafe Abortion Practices

Abortions are more common in developed regions than developing regions of the world. An estimated 26% of all pregnancies that occur in the world, 41%  of induced abortions occur in developed regions and 23% of them occur in developing regions.[7]

Unsafe abortion practices are defined by the WHO as procedures that are “carried out by persons either lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.” [7][8] Using this definition, the WHO estimates that out of the 45 million abortions that are performed each year globally, 19 million of these are considered unsafe. Also, 97% of these unsafe abortions occur in developing countries. [7][9]

Maternal deaths caused by improperly performed procedures are preventable and contribute 13% to the maternal mortality rate worldwide. This number is increased to 25% in countries where other causes of maternal mortality are low, such as in Eastern European and South American countries. This makes unsafe abortion practices the leading cause of maternal death worldwide. [7]

Risks for Unsafe Abortion

Social factors impact a woman’s decision to seek abortion services, and these can include fear of abandonment from the partner, family rejection and lack of employment. Social factors such as these can lead to the consequence of undergoing an abortion that is considered unsafe. [9]

Measuring Rates of Unsafe Abortion

One proposal for measuring trends and variations in risks to maternal death associated with maternal death is to measure the percentage of induced abortions that are defined unsafe (by the WHO) and by the ratio of deaths per 100,000 procedures, which would be defined as the abortion mortality ratio. [7]

There are four primary types of data sources that are used to collect abortion-related maternal mortality rates. These four sources are confidential enquiries, registration data, verbal autopsy, and facility-based data sources. A verbal autopsy is a systematic tool that is used to collect information on the cause of death from lay-people and not medical professionals.[10]

Confidential enquires for maternal deaths do not occur very often on a national level in most countries. Registration systems are usually considered the “gold-standard” method for mortality measurements. However, they have been shown to miss anywhere between 30-50% of all maternal deaths. [10] Another concern for registration systems is that 75% of all global births occur in countries where vital registration systems do not exist, meaning that many maternal deaths occurring during these pregnancies and deliveries may not be properly record through these methods. There are also issues with using verbal autopsies and other forms of survey in recording maternal death rates. For example, the family’s willingness to participate after the loss of a loved one, misclassification of the cause of death, and underreporting all present obstacles to the proper reporting of maternal mortality causes. Finally, an potential issue with facility-based data collection on maternal mortality is the likelihood that women who experience abortion-related complications to seek care in medical facilities. This is due to fear of social repercussions or legal activity in countries where unsafe abortion is common since it is more likely to be legally restrictive and/or more highly stigmatizing. [10] Another concern for issues related to errors in proper reporting for accurate understanding of maternal mortality is the fact that global estimates of maternal deaths related to a specific cause present those related to abortion as a proportion of the total mortality rate. Therefore, any change, whether positive or negative, in the abortion-related mortality rate is only compared relative to other causes, and this does not allow for proper implications of whether abortions are becoming more safe or less safe with respect to the overall mortality of women. [10]

Prevention for Unsafe Abortion

Providing safe services for pregnant women within family planning facilities is applicable to all regions. This is an important fact to consider since abortion is legal in some way in 189 out of 193 countries worldwide. [7] Promoting effective contraceptive use and information distributed to a wider population, with access to high-quality care, can significantly make strides towards reducing the number of unsafe abortions. However, this alone will not eliminate the demand for safe services. [12]

Policy regarding Maternal Mortality

In countries where abortion practices are not considered legal, it is necessary to look at the access that women have to high-quality family planning services, since some of the restrictive policies around abortion could impede access to these services. These policies may also affect the proper collection of information for monitoring maternal health around the world. [7]

= Maternal Mortality = A pregnancy-related death is defined as the death of a woman while pregnant or within 1 year of the end of a pregnancy –regardless of the outcome, duration or site of the pregnancy–from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Young adolescents face a higher risk of complications and death as a result of pregnancy than other women.

Increases in maternal age, pre-pregnancy obesity, preexisting chronic medical conditions, and cesarean delivery.

The global maternal mortality ratio has fallen from 385 maternal deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015.

maternal deaths have fallen as women have gained access to family planning and skilled birth attendance with backup emergency obstetric care. (midwife, a doctor or a trained nurse)

The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich and poor. Of the hundreds of thousands of women who die during pregnancy or childbirth each year, over 85 per cent live in sub-Saharan Africa and Southern Asia.

The risk of maternal mortality is highest for adolescent girls under 15 years old and complications in pregnancy and childbirth is a leading cause of death among adolescent girls in developing countries.

Women in developing countries have, on average, many more pregnancies than women in developed countries.

the probability that a 15 year old woman will eventually die from a maternal cause – is 1 in 4900 in developed countries, versus 1 in 180 in developing countries.

The major complications that account for nearly 75% of all maternal deaths are:


 * severe bleeding (mostly bleeding after childbirth)
 * infections (usually after childbirth)
 * high blood pressure during pregnancy (pre-eclampsia and eclampsia)
 * complications from delivery
 * unsafe abortion.

The remainder are caused by or associated with diseases such as malaria, and AIDS during pregnancy.

Maternal mortality is usually defined as the death of a woman during pregnancy or within 42 days after delivery when the cause is directly or indirectly related to pregnancy.

maternal mortality has continued to rise in some states, particularly among women over 40 years of age.

women who become pregnant, specifically rising maternal age at first birth and the increasing prevalence of obesity, hypertension, and diabetes in young women.

Sustainable Development Goals
According to the United Nations Sustainable Development Goals, their target is to reduce the maternal mortality rate to 70 deaths per 100,000 live births by the year 2030.

The best way to achieve this ambitious target is to: ensure all women have access to contraception to avoid unintended pregnancies; provide all pregnant women with skilled and respectful care in a safe environment during delivery; and make sure women with complications have timely access to quality emergency obstetric care.

Antenatal Care
In developing regions where the maternal mortality rate is higher than developed nations, antenatal care has increased from 65% to 83% between 1990 and 2012.

Unsafe Abortion Practices
An estimated 26% of all pregnancies worldwide are terminated by induced abortion: 41% in developed regions and 23% in developing regions.

We propose two indicators for monitoring trends and variations in abortion-related risks to maternal health: the percentage of induced abortions that are unsafe as defined by the WHO—that is, procedures “that are carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both,”35 and the ratio of abortion deaths per 100 000 procedures (the abortion mortality ratio).

Because abortion is permitted by law, on at least some grounds, in 189 of the 193 countries of the world, this mandate to provide safe services within health and family planning facilities for those who are eligible applies virtually everywhere.

Preventable deaths from improperly performed procedures constitute 13% of maternal mortality globally, and 25% or more in some countries where maternal mortality from other causes is relatively low (e.g., Eastern Europe and South America), making unsafe abortion the leading single cause of maternal mortality worldwide.

The persistence of restrictive policies in many countries should be a major cause for alarm, however. These policies impede women’s access to high-quality services, often with disastrous results, in addition to impeding the collection of reliable data for the global monitoring of maternal health.

Definition of unsafe abortion conditions according to WHO: “that are carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both."

WHO estimates that 19 million of the approximately 45 million abortions performed annually worldwide are unsafe according to their definition, with 97% of all unsafe procedures being performed in developing countries.

All over the world, the prevalence of unsafe abortion is estimated at 19-20 million, of which 97% are in developing countries.

In addition, the factors those permeate the abortion situation also known because they are present in most of the identified cases, such as fear of abandonment (by the partner), family rejection and lack of employment. Against this background, we will have the consequence of an unsafe abortion.

Estimates of abortion-related mortality are primarily developed from four types of data sources: confidential enquiries, vital registration data, verbal autopsy– a systematic tool used to collect health information from lay-person informants and assess causes of death [4] and facility-based data sources.

National-level confidential enquiries into causes of maternal mortality only occur in a handful of countries. While vital registration systems are considered the gold-standard for mortality measurement, they have been shown to miss up to 3050 % of all maternal deaths. In addition, 75 % of global births take place in countries without existing vital registration systems [5–7]. For both facility-surveys and verbal autopsies, willingness to participate in studies, misclassification, and underreporting present obstacles to the collection of robust data. In countries where unsafe abortion is common, it is often also legally restricted, and/or highly stigmatized. In these settings, fear of legal or social repercussions, lead women who experience abortion-related complications to be less likely than women experiencing other kinds of pregnancy-related complications to seek care in medical facilities.

abortion-related deaths are prone to being misclassified as non-abortion-related maternal deaths, or even as non-maternal deaths—again resulting in absolute and relative underestimates of abortion-related deaths.

First, global estimates of cause-specific maternal death present abortionrelated mortality as a proportion of total mortality. Any increase or decrease in abortion-related mortality is relative to other causes and does not necessarily imply that abortions have become safer or less safe with respect to mortality.

Policy and Response to Maternal Mortality
UNFPA helps to train midwives, supports emergency obstetric and newborn care facilities and networks, and provides essential drugs and family planning services. UNFPA also supports the implementation of maternal death review and response systems, which help officials understand how many women are dying, why, and how to respond.

In the United States, 99% of births are attended by a skilled health professional. However, the maternal mortality ratio in 14 deaths per 100,000 live births in 2015.

As part of the Global Strategy and goal of Ending Preventable Maternal Mortality, WHO is working with partners towards:


 * addressing inequalities in access to and quality of reproductive, maternal, and newborn health care services;
 * ensuring universal health coverage for comprehensive reproductive, maternal, and newborn health care;
 * addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities; and
 * strengthening health systems to collect high quality data in order to respond to the needs and priorities of women and girls; and
 * ensuring accountability in order to improve quality of care and equity.

Each year, CDC requests the 52 reporting areas (50 states, New York City, and Washington DC) to voluntarily send copies of death certificates for all women who died during pregnancy or within 1 year of pregnancy, and copies of the matching birth or fetal death certificates, if they have the ability to perform such record links.

in the United States steadily increased from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths  per 100,000 live births in 2014.

The reasons for the overall increase in pregnancy-related mortality are unclear. The use of computerized data linkages by the states, changes in the way causes of death are coded, and  the addition of a pregnancy checkbox to the death certificate in many states  have likely improved identification of pregnancy-related deaths over time. However, errors in reported pregnancy status have been described, potentially leading to  overestimation of the number of pregnancy-related deaths.

improvements in data accuracy are not enough to account for the alarming rise in MMR.

Of the 7,208 deaths within a year of the end of pregnancy that occurred during 2011–2014 and were reported to CDC, 2,726 were found to be pregnancy-related. The pregnancy-related mortality ratios were 17.8, 15.9, 17.3, and 18.0 deaths  per 100,000 live births in 2011, 2012, 2013, and 2014, respectively.

Considerable racial disparities in pregnancy-related mortality exist. During 2011-2014, the pregnancy-related mortality ratios were:


 * 12.4 deaths per 100,000 live births for white women.
 * 40.0 deaths per 100,000 live births for black women.
 * 17.8 deaths per 100,000 live births for women of other races.

this difference in risk has remained unchanged for the past six decades.

The graph below shows percentages of pregnancy-related deaths in the United States during 2011–2014 caused by:


 * Cardiovascular diseases, 15.2%.
 * Non-cardiovascular diseases, 14.7%.
 * Infection or sepsis, 12.8%.
 * Hemorrhage, 11.5%.
 * Cardiomyopathy, 10.3%.
 * Thrombotic pulmonary embolism, 9.1%.
 * Cerebrovascular accidents, 7.4%.
 * Hypertensive disorders of pregnancy, 6.8%.
 * Amniotic fluid embolism, 5.5%.
 * Anesthesia complications, 0.3%.

The United States (U.S.) fares worse in preventing pregnancy-related deaths than most other developed nations.

Despite participation in the Millennium Development Goals (MDGs) and spending more than any other country on hospital-based maternity care, the MMR in the U.S. increased from 17 deaths per 100,000 live births in 1990 to 26 deaths per 100,000 live births in 2015. During the same time period, the global MMR decreased by 44%.

The U.S. has also failed to meet prior national goals for maternal mortality reduction and is not on track to meet the modest Healthy People 2020 goal of reducing maternal mortality by 10% between 2007 and 2020.

A major driver of maternal health disparities in the U.S. is the growing contribution of non-communicable diseases to maternal mortality.

As of 2010, only 23 states have a full or partial policy establishing maternal mortality review boards.

The ACA improved access to maternity care for many women by expanding opportunities to obtain health insurance and mandating coverage of essential health benefits.

Medicaid covers prenatal care, care during childbirth, and postpartum care for nearly half the women who give birth in the United States.

current federal regulations require Medicaid to cover pregnant women with incomes up to 133% of the federal poverty level.

The ACA expanded privately insured women’s access to primary and preventive health services, including chronic disease screening and management.

The ACA also required most insurance plans to cover contraception without cost sharing. The current administration is now weakening the ACA’s contraceptive coverage requirements by allowing more employers to claim exemptions on religious or moral grounds.

the Department of Health and Human Services has reduced funding for adolescent pregnancy prevention programs, an ominous sign of the deprioritization of evidence-based reproductive health policy.

Prevention
Although promoting more effective contraceptive use with good information and wider access to high-quality care can go a long way toward reducing the numbers of abortions, it will not eliminate the need or demand for safe services.

Women with unwanted pregnancies should have access to reliable information and compassionate counseling; to quality services for the management of complications arising from (unsafe) abortion; and—crucially—where abortion is not against the law, that such abortion should be safe.

In 2015, an estimated 303,000 women died of causes related to pregnancy or childbirth. A majority of them died from severe bleeding, sepsis, eclampsia, obstructed labour and the consequences of unsafe abortions – all causes for which there are highly effective interventions.

Access to prenatal care also appears to play a role: Women receiving no prenatal care are three to four times more likely to have a pregnancy-related death than women who receive prenatal care. Approximately 25% of all U.S. women do not receive the recommended number of prenatal visits; this number rises to 32% among African Americans and to 41% among American Indian or Alaska Native women.

Severe Maternal Morbidity
Severe maternal morbidity (SMM) includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.

Women who received blood transfusions (procedure in which a patient is given donated blood, generally in response to excessive bleeding around delivery) account for the greatest fraction of women with SMM.

The overall rate of SMM increased almost 200% over the years, from 49.5 in 1993 to 144.0 in 2014. This increase has been mostly driven by blood transfusions, which increased from 24.5 in 1993 to 122.3 in 2014.

It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death.

Responding to these concepts, multidisciplinary expert groups have called for all obstetric hospitals to review their cases of severe maternal morbidity to look for opportunities for improvement in care that could lead to improved maternal outcomes and fewer maternal deaths.

Definitions of severe maternal morbidity that rely on diagnosis codes, such as the Centers for Disease Control and Prevention’s definition, may miss cases, have a relatively low positive predictive value (0.40) and, at a practical level, maybe difficult for facilities to operationalize.

The College and SMFM recommend using two criteria to screen for severe maternal morbidity: 1) transfusion of 4 or more units of blood and 2) admission of a pregnant or postpartum woman to an ICU.

Relevance to the Topic
The abstract of the topic at the beginning of the page seems to lack detail about the topic and simply lists associated subjects and career studies. However, they do have links to these pages, so this information is appropriately represented for a further exploration of the connection between Environmental Studies and the associated fields. The definition of Environmental Studies is concise and accurately represents what the discipline entails, which is good for a quick understanding of a complex topic.

Out of Date and Missing Information
The page does not contain any out of date knowledge because there is no statistics or numbers represented that can become out of date over time. However, there is a lot of content that is missing and information that can be beneficial in explaining the topic in more detail. There is a brief history of the Environmental Studies discipline, but only as it pertains to Syracuse University, Middlebury College, the Environmental Studies Association of Canada (ESAC), and the Association for Environmental Studies and Sciences (AESS). There are other areas that have Environmental Studies that clould be included here. Also, it seems that they are only including the history of the discipline as it pertains to the academic studies, and not the discipline itself.

Improvements to the Topic
To improve this topic, they can begin by explaining the content and focus of Environmental Studies a bit more. Also, the authors could include more on the history of the significance of having an Environmental Studies discipline as well as the history of its implementation throughout the world, rather than the North America. Also, they could explain more on the introduction into academic studies in colleges, as well as more information on what specifically these programs entail to provide prospective students additional information. Finally, I also think it would be beneficial to delve a bit more into the career paths and job opportunities related to this field.

Neutrality of the Content
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Source Functionality and Support of Topic
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Sources Properly Cited
The sources are properly cited throughout the discussion of the topic and they clearly credit which source provided the information on their topic.