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From the 1Institut National de la Santé et de la Recherche Medicale U 149, Epidemiological Research Unit on Perinatal and Women’s Health, Paris, France; 2Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; 3STAKES (National Research and Development Centre for Welfare and Health), Helsinki, Finland; 4Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; 5Massachusetts Department of Public Health, Boston, Massachusetts; 6Reproductive Health Unit, School of Public Health, Universite Libre de Bruxelles, Belgium; and 7School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana.
OBJECTIVE: Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality.
METHODS: We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999–2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts.
RESULTS: Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France.
CONCLUSION: This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies.
LEVEL OF EVIDENCE: II-2
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