The epidemiology of traumatic injury-related fetal mortality in Pennsylvania, 1995–1997: the role of motor vehicle crashes

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Abstract

Methods: Rates and causes of traumatic injury-related fetal deaths in Pennsylvania were determined from a manual review of all fetal death certificates filed from 1995 to 1997 (7131 cases). Results: Thirty one traumatic injury cases were identified (6.5/100 000 live births). Most cases (94%) could be identified from the diagnosis code of 760.5 (maternal injury) and 87% contained narratives indicating specific injury mechanisms. Motor vehicles were the leading cause of injury (81%). Placental separation was the leading diagnosis (42%). Conclusions: The ICD-9-CM code 760.5 appears to be a specific indicator of traumatic fetal death, though it is not known how sensitive an indicator it is. Though not usually E-coded, the death certificates contained enough information to allow ascertainment of injury mechanism. These are very conservative estimates of the burden of the problem. The major role that motor vehicle injuries have on reported traumatic fetal injury deaths was shown and a significant new challenge for child passenger safety advocates is indicated.

Section snippets

Historical context

The effects of traumatic injury on pregnancy have been observed for millennia. While the oldest cases are lost in the fog of antiquity, known instances are referenced in the 15th century BCE Code of Hammurabi (Buchsbaum, 1976) and the Old Testament (Exodus 22:21).

In the medical literature of the late Nineteenth and mid-Twentieth centuries, the issue received increasingly detailed coverage, primarily in the forms of case reports and series. While the earliest of these papers described incidents

Modern scientific foundations

By the mid-1960s, within the trauma and obstetrics communities, the problems and challenges of pregnancy and automotive crashes were well recognized. Estimates of fetal mortality rates based on case series were increasingly reported (Elliott, 1966, Buchsbaum, 1968, Crosby and Costiloe, 1971). The first experimental (animal) studies investigating the forces and physiology of restrained pregnant women were initiated in 1968 (Crosby et al., 1968). Crosby was also the first to conduct a follow-up

Government statistics: fetal death registries and crash reporting systems

In contrast to the widespread awareness of the issue in the medical community, traumatic injury-related fetal mortality has received little attention from the public health vital statistics infrastructure or from modern traffic injury or crash data systems. In the former, coding conventions have limited examination of the cases to a grouping called ‘death due to maternal injury’. This subgroup is often combined into an even broader category of ‘maternal causes’. Thus, contributions of injuries

Methods

Fetal death certificates sent to the Pennsylvania State Health Department covering the years 1995–1997 were reviewed. Published reports indicated that there were 7131 fetal death certificates filed (among 442 705 live births) during this period. After internal review board approval and an approval for access to protected data from the state Health Department, arrangements were made to visit the Division of Vital Records for certificate review and data abstraction (without the use of identifiers

Results

Table 1 summarizes the major findings from this review. There was little difference between fetal gender (15 males, 12 females). The mean maternal age was 25 years, with the distribution skewed towards younger ages (Fig. 1). Seventy-seven percent of the mothers were white and 19% were black (blacks represented about 15% of all live births in Pennsylvania in 1995). Eleven of the deaths occurred in 1995, seven in 1996, and 13 in 1997. In three of the cases (10%), the fetal death certificate noted

Discussion

This study probably represents the largest reported population-based description of traumatic fetal injury-related deaths to date. By far, the leading cause of traumatic fetal injury death was motor vehicle crashes. Placental separation was the leading physiologic injury diagnosis. The rate of overall reported traumatic injury-related fetal death (≥16 weeks gestation) was 6.5/100 000 live births, slightly lower from the nine reported by Naey (which used a slightly different definition and drew

Recommendations

This study should be expanded to include examination of traumatic injury-related fetal deaths across the country to garner more numbers for analysis and better geographic representation. The author is currently engaged in such an effort and results from an analyses of birth certificates coded as 760.5 from states representing about 50% of the US population of women of childbearing age over a 3-year period (1995–1997) will be submitted for publication in the near future. About 240 fetal death

Acknowledgements

Partial funding for this project was supplied by the National Highway Traffic Safety Administration through a grant with the University of Pittsburgh Graduate School of Public Health Department of Biostatistics. I would like to thank my research assistant, Tony Fabio, for his help in data collection and abstraction and my colleagues at the Center for Injury Research and Control for their review and comments on manuscript drafts. This work was contingent upon the helpful cooperation of the

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    An earlier version of this paper entitled ‘The epidemiology of traumatic injury-related fetal mortality in Pennsylvania: the role of motor vehicle crashes’ was presented at the meeting of the Association for the Advancement of Automotive Medicine. Barcelona, Spain, September, 1999.

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