Standard Death Certificates Versus Enhanced Surveillance to Identify Heroin Overdose-Related Deaths.

OBJECTIVES: To compare 2 approaches to identifying heroin-related deaths in cases of overdose: standard death certificates and enhanced surveillance. METHODS: We reviewed Maryland death certificates from 2012 to 2015 in cases of overdose to determine specific mentions of heroin. Counts were compared with estimates obtained through an enhanced surveillance approach that included a protocol considering cause of death, toxicology, and scene investigation findings. RESULTS: Death certificates identified 1130 heroin-related deaths. Enhanced surveillance identified 2182 cases, nearly double the number found through the standard approach. The major factors supporting enhanced surveillance in identifying cases were the presence of morphine, either alone or in combination with quinine, and scene investigation information suggesting heroin use. CONCLUSIONS: Death certificates, the primary source of state and national data on overdose deaths, may underestimate the contribution of heroin to drug-related mortality. Enhanced surveillance efforts should be considered to allow a better understanding of the contribution of heroin to the overdose crisis. Public Health Implications. If enhanced surveillance can be incorporated into the death certificate process, national data on overdoses may better reflect the contribution of heroin to the opioid crisis.

Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality.

OBJECTIVES: Information that would allow the identification of women who were pregnant at the time of death or within the year preceding death has historically been underreported on death certificates. As a result, the magnitude of the problem of pregnancy-associated mortality is underestimated. To improve the identification of these deaths, check boxes for reporting pregnancy status have been added to death certificates in a number of states. We used multiple external data sources to determine whether check boxes have been effective in identifying pregnancy-associated deaths. METHODS: We collected data on deaths occurring among pregnant or recently pregnant women residing in Maryland during the years 2001-2008 using multiple data sources. We determined the percentage of these deaths that could be identified through check boxes placed on death certificates. RESULTS: Overall, 64.5% of pregnancy-associated deaths were identified through pregnancy check boxes on death certificates, including 98.1% of maternal deaths-defined as deaths occurring during pregnancy or within 42 days of delivery from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes-and 46.7% of deaths from nonmaternal causes, such as homicide, suicide, accidents, and substance abuse. CONCLUSIONS: Check boxes on death certificates are effective in identifying pregnancy-associated deaths resulting from maternal causes. However, they are far less effective in identifying deaths resulting from nonmaternal causes, such as homicide, accidental death, and substance abuse, which represent three of the four leading causes of pregnancy-associated death in Maryland.

Intimate-partner homicide among pregnant and postpartum women.

OBJECTIVE: To identify pregnancy-associated homicide cases and to estimate the proportion that were perpetrated by a current or former intimate partner. METHODS: This was an analysis of pregnancy-associated homicides occurring from 1993 to 2008 among Maryland residents using linked birth and death certificates, medical examiner charts, police records, and news publications. RESULTS: Homicides (n=110) were the leading cause of death during pregnancy and the first postpartum year. Women who were African American, younger than 25 years, and unmarried were at the highest risk for homicide. Firearms were the most common (61.8%) method of death. A current or former intimate partner was the perpetrator in 54.5% (n=60) of homicide deaths and a nonpartner in 31.8% (n=35). If the cases (n=15) in which the victim-offender relationship could not be identified are excluded, 63.2% of homicides were committed by an intimate partner. Compared with homicides in which the perpetrator was not an intimate partner, a significantly higher percentage (P<.05) of intimate-partner homicides occurred at home (66.7% compared with 28.6%), among women who had completed more than 12 years of education (23.3% compared with 5.7%), and who were married (28.3% compared with 8.6%). Intimate-partner homicides were most prevalent (25.0%) during the first 3 months of pregnancy and least prevalent during the first 3 months postpartum (5.0%). CONCLUSION: The majority of pregnancy-associated homicides were committed by current or former intimate partners, most commonly during the first 3 months of pregnancy. Efforts to protect women from partners optimally should begin before conception or very early in pregnancy. LEVEL OF EVIDENCE: III.

Neonatal circumcision in Maryland: a comparison of hospital discharge and maternal postpartum survey data.

OBJECTIVE: To study circumcision rates in Maryland using hospital discharge and maternal survey data in order to provide healthcare providers, parents and policy makers with more accurate and comprehensive information about this common yet controversial procedure. METHODS: Secondary data analyses were performed using Maryland hospital discharge data files containing records of 96,457 male newborns, and postpartum survey data collected from 4273 mothers through the Maryland Pregnancy Risk Assessment Monitoring System. RESULTS: Hospital discharge data showed that 75.3% of male infants were circumcised, and survey data showed that 82.3% of male infants were circumcised. The circumcision rate among infants weighing <1500 g at birth was 38.9% using hospital discharge data and 74.5% using maternal survey data. Both sources revealed lower circumcision rates among Asian and Hispanic infants than among non-Hispanic white and non-Hispanic black infants. CONCLUSIONS: Despite reports of decreasing circumcision rates nationally, rates remain high in Maryland. In addition to providing for the inclusion of circumcision procedures that may not have been coded properly in hospital discharge records and procedures that were performed after hospital discharge, maternal survey data provide more comprehensive information than hospital discharge data about parental characteristics and factors relevant to the circumcision decision-making process.

Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality.

OBJECTIVES: I studied the extent to which maternal deaths are underreported on death certificates. METHODS: We collected data on maternal deaths from death certificates, linkage of death certificates with birth and fetal death records, and review of medical examiner records. RESULTS: Thirty-eight percent of maternal deaths were unreported on death certificates. Half or more deaths were unreported for women who were undelivered at the time of death, experienced a fetal death or therapeutic abortion, died more than a week after delivery, or died as a result of a cardiovascular disorder. CONCLUSIONS: The number of maternal deaths is substantially underestimated when death certificates alone are used to identify deaths, and it is unlikely that the Healthy People 2010 objective of reducing the maternal mortality rate to no more than 3.3 deaths per 100000 live births by 2010 can be achieved. Increasing numbers of births to older women and multiple-gestation pregnancies are likely to complicate efforts to reduce maternal mortality.