Association of maternal chronic disease with risk of congenital heart disease in offspring.

BACKGROUND: Information about known risk factors for congenital heart disease is scarce. In this population-based study, we aimed to investigate the relation between maternal chronic disease and congenital heart disease in offspring. METHODS: The study cohort consisted of 1 387 650 live births from 2004 to 2010. We identified chronic disease in mothers and mild and severe forms of congenital heart disease in their offspring from Taiwan's National Health Insurance medical claims. We used multivariable logistic regression analysis to assess the associations of all cases and specific types of congenital heart disease with various maternal chronic diseases. RESULTS: For mothers with the following chronic diseases, the overall prevalence of congenital heart disease in their children was significantly higher than for mothers without these diseases: diabetes mellitus type 1 (adjusted odds ratio [OR] 2.32, 95% confidence interval [CI] 1.66-3.25), diabetes mellitus type 2 (adjusted OR 2.85, 95% CI 2.60-3.12), hypertension (adjusted OR 1.87, 95% CI 1.69-2.07), congenital heart defects (adjusted OR 3.05, 95% CI 2.45-3.80), anemia (adjusted OR 1.31, 95% CI 1.25-1.38), connective tissue disorders (adjusted OR 1.39, 95% CI 1.19-1.62), epilepsy (adjusted OR 1.37, 95% CI 1.08-1.74) and mood disorders (adjusted OR 1.25, 95% CI 1.11-1.41). The same pattern held for mild forms of congenital heart disease. A higher prevalence of severe congenital heart disease was seen only among offspring of mothers with congenital heart defects or type 2 diabetes. INTERPRETATION: The children of women with several kinds of chronic disease appear to be at risk for congenital heart disease. Preconception counselling and optimum treatment of pregnant women with chronic disease would seem prudent.

Pregnancy-associated mortality in Taiwan, 2004-2011.

OBJECTIVE: Pregnancy-associated death is defined by the American College of Obstetricians and Gynecologists as "a death of a woman while pregnant or within 1 year of termination of pregnancy, irrespective of the cause of death." We sought to determine pregnancy-associated mortality ratio (PAMR) in Taiwan and to compare the cause of death pattern with other countries to assess the national health status of Taiwanese women. MATERIALS AND METHODS: We linked four nationwide population-based data sets (birth registration, birth notification, National Health Insurance claims, and cause of death mortality) from 2004 to 2011 to identify women aged 15-49 years that died from pregnancy-associated deaths. We then calculated the PAMR and cause of death distribution by maternal age. RESULTS: A total of 559 pregnancy-associated deaths were identified with an overall PAMR of 36 (deaths per 100,000 live births). The J-shaped age-specific PAMR mortality pattern was noted, in which the PAMR was 32, 25, 24, 36, 71, 143, and 369 for women aged 15-19 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years, and 45-49 years, respectively. The age-standardized PAMR decreased drastically from 45 in 2004-2005 to 36 in 2006-2007 and 30 in 2008-2009, but leveled off to 33 in 2010-2011. The proportion of indirect causes increased from 2004-2007 to 2008-2011 among women aged 15-29 years and 35-49 years. CONCLUSION: Compared with previous studies, the PAMR of Taiwan is moderate. However, the proportion of external causes of pregnancy-associated deaths in Taiwan is the lowest compared with other regions. Further studies (such as death review) are needed to explore possible preventable factors.

International Ranking of Infant Mortality Rates: Taiwan Compared with European Countries.

BACKGROUND: Rankings of infant mortality rates are commonly cited international comparisons to assess the health status of individual countries. We compared the infant mortality rate of Taiwan with those of European countries for 2004 according to two definitions. METHODS: First, the countries were ranked on the basis of crude infant, neonatal, and postneonatal mortality rates. The countries were then ranked according to the mortality rates calculated after exclusion of live births with a known birth weight of <1000 g, which is the definition set by the World Health Organization. RESULTS: Taiwan was ranked 11(th), 12(th), and 15(th) among 26 high-income countries for crude infant, neonatal, and postneonatal mortality rates, respectively. The ranks were 12(th), 16(th), and 15(th), respectively, for mortality rates, excluding live births with a birth weight of <1000 g. However, in only seven, four, and 10 countries were the mortality rate ratios statistically significantly lower than Taiwan in infant, neonatal, and postneonatal mortality, respectively, according to the second definition. CONCLUSION: The ranking of Taiwan was similar (11(th) vs. 12(th)) according the two definitions. However, after consideration of the confidence interval, only six countries (Sweden, Finland, Czech Republic, Belgium, Austria, and Germany) had infant mortality rates statistically significantly lower than those of Taiwan in 2004.

Maternal Mortality in Taiwan: A Nationwide Data Linkage Study.

BACKGROUND: To examine the changes in the maternal mortality ratio (MMR) and causes of maternal death in Taiwan based on nationwide linked data sets. METHODS: We linked four population-based data sets (birth registration, birth notification, National Health Insurance inpatient claims, and cause of death mortality data) to identify maternal deaths for 2004-2011. Subsequently, we calculated the MMR (deaths per 100,000 live births) and the proportion of direct and indirect causes of maternal death by maternal age and year. FINDINGS: Based on the linked data sets, we identified 236 maternal death cases, of which only 102 were reported in officially published mortality data, with an underreporting rate of 57% [(236-102) × 100 / 236]. The age-adjusted MMR was 18.4 in 2004-2005 and decreased to 12.5 in 2008-2009; however, the MMR leveled off at 12.6 in 2010-2011. The MMR increased from 5.2 in 2008-2009 to 7.1 in 2010-2011 for patients aged 15-29 years. Women aged 15-29 years had relatively lower proportion in dying from direct causes (amniotic fluid embolism and obstetric hemorrhage) compared with their counterpart older women. CONCLUSIONS: Approximately two-thirds of maternal deaths were not reported in officially published mortality data. Routine surveillance of maternal mortality by using enhanced methods is necessary to monitor the health status of reproductive-age women. Furthermore, a comprehensive maternal death review is necessary to explore the preventability of these maternal deaths.

Counting injury deaths: a comparison of two definitions and two countries.

OBJECTIVES: This study sought to examine the discrepancy in counting injury deaths according to two definitions, that is, (a) external cause of injury as the underlying cause of death (UCOD), and (b) with mention of external cause of injury, and differences in certification practices between Taiwan and the USA. METHODS: We calculated the percentage (U/M%) in which external cause of injury was selected as the UCOD (U) among deaths with mention (M) of external cause of injury anywhere on the death certificate to assess the discrepancy between the two definitions in counting injury deaths. RESULTS: The discrepancy was small in Taiwan and in the USA for transport injuries (with U/M% 99% and 98%) and intentional self-harm (100% and 100%) and large for accidental suffocation (64% and 29%) as well as complications of medical and surgical care (61% and 10%). The magnitude of discrepancy was not consistent between countries in accidental falls (96% vs 81%) and accidental drowning (80% vs 97%). Certifiers in Taiwan were more likely to report an accidental fall in Part I of the death certificate and less likely to report medical conditions (such as stroke, Alzheimer's disease or Parkinson's disease, etc) with accidental suffocation than their counterpart US certifiers. CONCLUSIONS: The counting of injury deaths according to two definitions varied by external cause of injury as well as between countries. For some external causes of injury with high discrepancies, we suggest presenting the number of injury deaths according to two definitions.

Possible effect of implementing a national query program on site-specific cancer mortality rates in Taiwan.

BACKGROUND: This study aimed to examine possible effects of implementing a national query program on site-specific cancer mortality rates. MATERIALS AND METHODS: A total of 2,874 query letters were sent out by the Department of Statistics, Ministry of Health and Welfare of Taiwan between January 2009 and December 2011 to medical certifiers who reported "neoplasm with uncertain nature" on the death certificate asking for more detailed information for coding. RESULTS: Of the 2,571 responses, in 1,398 cases (54%) medical certifiers were still unable to determine the nature of the neoplasm. There were four neoplasm sites for which more than 50% of the responses changed the category to malignant, the gastrointestinal system (73%), urinary system (60%), stomach (55%) and rectum (53%). The liver was the cancer site that showed the largest absolute increase in the number of deaths after the query; however, the brain showed the largest relative increase, at 12%. CONCLUSIONS: Different neoplasm sites showed different magnitudes of change in nature after the query. Brain cancer mortality rates exhibited the largest increase.

Non-referral of unnatural deaths to coroners and non-reporting of unnatural deaths on death certificates in Taiwan: implications of using mortality data to monitor quality and safety in healthcare.

BACKGROUND: Mortality data has often been used to monitor the quality of cardiac care. OBJECTIVE: To investigate the under-reporting of unnatural deaths in mortality data. METHOD: All patients with a main discharge diagnosis of injury (ICD-9-CM code 800-999) who died in 2003 or 2004 were identified through record linkage between hospital discharge claims data and cause of death data in Taiwan. Percentages of unnatural deaths that had been referred to the coroner and in which injury-related information was reported on the death certificate were estimated. RESULTS: Of 4086 known or suspected unnatural deaths, only 57% (2346/4086) were referred to the coroner, and in 71% (2889/4086) injury-related information was reported on the death certificate. The percentages of referral and reporting were lowest for deaths related to complications in medical and surgical care. In deaths related to fracture of the femur and the effects of a foreign body, many doctors report injury-related information on the death certificate but do not refer the certification of cause of death to the coroner. CONCLUSIONS: The sensitivity of using mortality data alone to detect known or suspected unnatural deaths varied according to the types of injury and external causes. Monitoring cause of death data linked with hospital discharge record data could provide a better system for discovering these unnatural deaths.