Use of Vital Statistics in Obstetrics

Updated: Dec 30, 2014

• Author: Nevert Badreldin, MD, MS; Chief Editor: Christine Isaacs, MD more...

Overview
Many of the greatest advances in medicine have come as a result of public health
research interventions. [1, 2] The ability to intervene in the health of populations is
dependent upon development of appropriate tools for measuring health, illness,
interventions, and outcomes. Only by standardizing communication can clinicians hope
to target high-risk populations with effective interventions. Therefore, understanding the
common language of public health is vital.

Maternal Vital Statistics

Maternal vital statistics
Important measures of maternal health across a population include not only mortality
and birth rates but also subtler measures, such as fertility rates and reproductive
mortality rates, among others. [1] If used in a standardized fashion, this information
allows comparison between groups with regard to the most vital function of any
population—reproducing itself. Use of these measures also allows targeted
interventions in order to improve outcomes. [3, 4, 5, 6] Except when specified below, the
listed definitions are generated by the National Center for Health Statistics
(NCHS) [7] with collaboration among international organizations such as the World
Health Organization (WHO). [8]
Birth rate
Birth rate is defined as the number of births per 1,000 population. Of note, men are
included in the population calculation. This is a gross measure of a population's growth.
Less-developed areas tend to have higher birth rates. It is important, however, to
interpret birth rates in the setting of infant and childhood mortality rates, which are
disproportionally high in urban and poor populations worldwide. [8]
Fertility rate
The fertility rate is the number of live births per 1,000 women aged 15-44 years. This
calculation is an attempt to measure the rate at which women of reproductive age are
successfully reproducing. Births certainly occur in women outside this age range and
can artificially curtail the numerator. However, including 10- or 51-year-old females
would disproportionally expand the denominator. Of note, live births are specified.
Although a woman with second-trimester miscarriages might be considered “fertile” by
a reproductive endocrinologist, her deliveries would not be included in the fertility rate.
Maternal mortality ratio
The maternal mortality ratio is defined as the direct and indirect maternal deaths per
100,000 live births. The denominator for this statistic is 100,000 and not 1,000, as is the
case with other vital statistics — this is a triumph of modern medicine. A condition in
which both mother and fetus are lost would both increase the numerator (maternal
death) and decrease the denominator (live birth). Because the rate is very low in
developed nations (approximately 28 deaths per 100,000 population in the United
States in 2013 [8] ), a different methodology would have little effect on the data.
However, 99% of all maternal deaths occur in developing countries, and thus some
authors have argued for a denominator that includes liveborn and stillborn infants. [7, 8]
Direct maternal death rate
Direct maternal death rates are calculated as the number of direct maternal deaths per
100,000 live births. This statistic is defined as death from complications of pregnancy,
delivery, or the puerperium period. Implicit is the notion that had the woman not been
pregnant, the death would not have occurred. In developed countries, direct maternal
deaths are most commonly caused by hemorrhage, hypertensive disorders, and
embolic events. In contrast, in developing countries, sepsis replaces embolic events as
a leading cause of maternal deaths. [9]
Indirect maternal death rate
The indirect maternal death rate is defined as the number of indirect maternal deaths
per 100,000 live births. Indirect deaths often represent underlying medical conditions
aggravated, but not caused by, the pregnancy, including complications from
connective-tissue disease or cardiac conditions, in which the underlying pathology is
independent of the pregnancy, but it was likely to have been exacerbated by
pathophysiologic changes of pregnancy.
It has been estimated that half of direct maternal deaths in the United States may be
preventable through early diagnosis and appropriate medical care of pregnancy
complications. [10] In contrast, indirect maternal deaths may simply reflect the magnitude
of the underlying disorder and may paradoxically reflect advances in medical care that
have allowed women with comorbidities to achieve reproductive age and to undertake
pregnancy.
Nonmaternal death rate
Nonmaternal death rates are calculated as the number of nonmaternal deaths per
100,000 live births. This rate measures only deaths of pregnant or postpartum women
that were neither caused, nor aggravated by, the pregnancy. Examples of this would be
deaths secondary to motor vehicle accidents or homicides.
By distinguishing nonmaternal, direct, and indirect maternal death rates, a much more
sensitive picture of a population's health needs emerges than would be possible with a
lumped rate.
Infant Statistics
Infant statistics
The definitions listed below are not intended to carry any moral, religious, or
philosophical significance but rather to help clinicians to speak a common language.
Abortion
This category is not defined by the National Center for Health Statistics; rather it is
defined by each state as part of its requirements for completion of birth and death
certificates. The most common definition of an abortion is any loss of a fetus that is
younger than 20 weeks' completed gestational age. Because many states allow
elective termination of pregnancy beyond 20 weeks' estimated gestational age, an "or"
provision may exist which would allow inclusion of elective termination beyond 20
weeks' gestation as an abortion. In states without this language in their certification
process, this delivery would be coded as a stillbirth or live birth even though it was
deliberately initiated.
Conversely, some states include any sign of life, regardless of gestational age, to
represent a live birth. This would include the 18-week fetus that takes one reflex gasp
after delivery. Because these deliveries carry a 0% survival rate under any
circumstances, this definition can artificially inflate a region's infant and neonatal
mortality rates.
Induced termination of pregnancy
Induced termination of pregnancy is defined as the purposeful interruption of an
intrauterine pregnancy with the intention other than to produce a live-born infant and
which does not result in a live birth. [11] Unsafe abortion is a major cause of maternal
death and accounts for one in eight maternal deaths yearly. Almost all of these deaths
occur in developing areas. Maternal death is rare where abortion is legal and access is
nonrestrictive, as well as when pregnancy terminations are carried out by skilled health
professionals. [12]
Preterm infant
A preterm infant is defined as an infant delivered between 20 weeks' and 36 weeks 6
days' gestational age. This group can be further subdivided into early preterm and late
preterm infants.
Early preterm is defined as a gestational age between 20 weeks and 33 weeks 6 days
at the time of delivery, whereas late preterm is defined as a gestational age between 34
weeks and 36 weeks 6 days. The risk of poor birth outcomes decreases with advancing
gestational age, and it is substantially greater for early preterm infants. [13]
Postterm infant
The definition of a postterm pregnancy is one that progresses beyond 42 weeks'
completed gestational age. Postterm infants have a higher rate of perinatal morbidity
and mortality. [14]
Stillbirth
A stillbirth is defined as a delivery at or greater than 20 weeks' gestation if the
gestational age is known, or a weight greater than or equal to 350 grams if the
gestational age is not known, in which the infant displays no sign of life as indicated by
the absence of breathing, heart beats, pulsation of the umbilical cord, or definite
movements of voluntary muscles. The cutoff of 350 grams is the 50th percentile for
weight at 20 weeks of gestation. However, note that there is no complete uniformity
among states with regard to birth weight and gestational age criteria for reporting fetal
deaths. [7, 15]
Live birth
Delivery after 20 weeks' gestational age in which any fetal activity is noted is classified
as a live birth. The lower limit of reasonable viability currently remains around 23
weeks' gestational age. Thus, a spontaneous delivery before that time with reflex
motion but no ability to survive with or without intervention would nonetheless be
considered a live birth.
Fetal death rate (stillbirth rate)
The fetal death rate (stillbirth rate) statistic measures the number of stillbirths per 1,000
infants born.
Neonatal mortality rate
The neonatal mortality rate measures infant deaths between 0-28 days of life per 1,000
live births. The neonatal mortality rate reflects losses between the moment of live birth
and 28 days of life. This rate is often divided into early (first 7 d) and late (8-28 d) rates,
as etiologies within these two categories vary. This is slightly different number than the
fetal death rate, which is measured per 1,000 total births.
Perinatal mortality rate
The perinatal mortality rate is calculated as the number of fetal deaths plus neonatal
deaths per 1,000 total births. This statistic attempts to correct the intrinsic problem of
heroic attempts at rescue. The neonatal mortality rate might be quite high, for example,
if pediatricians at an institution attempt to resuscitate all 22-week infants regardless of
signs of life at delivery.
Infant mortality rate
Infant mortality rates are calculated as the number of infants who die prior to their first
birthday per 1,000 live births. In developing countries, the losses due to infectious
diseases far outweigh the inability of technology to deal with preterm births or
congenital anomalies. Thus, infant mortality is often one of the sentinel indicators used
to evaluate a population's overall health and access to health care. [16, 17]
Conclusion
Understanding how a population is coping with the burdens of reproduction is vital.
High-quality population based data are essential in the interpretation of obstetric and
maternal care. This valuable insight can provide populations with the opportunity to
intervene for improved outcomes for women and infants and, therefore, communities as
a whole. [3]