Underreporting of Maternal Deaths on Death Certificates and the Magnitude of the Problem of Maternal Mortality

Vital Statistics Administration, Maryland Department of Health and Mental Hygiene, 201 West Preston Street, Baltimore, MD 21201, USA.
American Journal of Public Health (Impact Factor: 4.55). 04/2005; 95(3):478-82. DOI: 10.2105/AJPH.2004.040063
Source: PubMed


I studied the extent to which maternal deaths are underreported on death certificates.
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.
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.
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.

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    • "Researchers in Ghana [2] attributed just 7% (2/27) of unreported cases of maternal death to certification errors, similar to the 8% (4/50) identified in the present study, whereas Brazilian investigators concluded that doctors were responsible for 46% of their errors [24]. The duration of illness was not recorded on 77% of the MCCDs, limiting the ability to distinguish between maternal and late maternal deaths. "
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    ABSTRACT: Objective To identify why vital registration under-reports maternal deaths in Jamaica. Methods A cross-sectional study was undertaken to identify all maternal deaths (during pregnancy or ≤ 42 days after pregnancy ended) occurring in 2008. Data sources included vital registration, hospital records, forensic pathology records, and an independent maternal mortality surveillance system. Potential cases were cross-referenced to registered live births and stillbirths, and hospital records to confirm pregnancy status, when the pregnancy ended, and registration. Medical certificates were inspected for certification, transcription, and coding errors. Maternal mortality ratios (MMRs) for registered and/or unregistered deaths were calculated. Results Of 50 maternal deaths identified, 10 (20%) were unregistered. Eight unregistered deaths were coroners’ cases. Among 40 registered deaths, pregnancy was undocumented in 4 (10%). Among the other 36, 24 (67%) had been misclassified (59% direct and 89% indirect deaths). Therefore, only 12 (30%) registered maternal deaths had been coded as maternal deaths, yielding an MMR of 28.3 per 100 000 live births (95% confidence interval [CI] 12.3–48.3), which was 76% lower than the actual MMR of 117.8 (95% CI 85.2–150.4). Conclusion Under-reporting of maternal deaths in Jamaica in 2008 was attributable to delayed registration of coroners’ cases and misclassification. Timely registration of coroners’ cases and training of nosologists to recognize and code maternal deaths is needed.
    Full-text · Article · Sep 2014 · International Journal of Gynecology & Obstetrics
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    • "The extent of late maternal deaths (those occurring >42 days after delivery and up to one year of birth) is reported to be underestimated by up to 50% in most studies conducted which utilised multiple collection means to calculate rates [3, 4, 6–8]. Late maternal deaths are not included in the standard World Health Organisation (WHO) MMR estimates but it has been reported that the relative risk (RR) of death for a woman within 91 days of birth in developing nations is 2.8 when compared to baseline reproductive years' mortality, with the RR returning to baseline at one year postpartum [9]. "
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    ABSTRACT: Introduction: Trauma, including suicide, accidental injury, motor traffic accidents, and homicides, accounts for 73% of all maternal deaths (early and late) in NSW annually. Late maternal deaths are underreported and are not as well documented or acknowledged as early deaths. Methods: Linked population datasets from births, hospital admissions, and death registrations were analysed for the period from 1 July 2000 to 31 December 2007. Results: There were 552,901 births and a total of 129 maternal deaths. Of these deaths, 37 were early deaths (early MMR of 6.7/100,000) and 92 occurred late (late MMR of 16.6/100,000). Sixty-seven percent of deceased women had a mental health diagnosis and/or a mental health issue related to substance abuse noted. A notable peak in deaths appeared to occur from 9 to 12 months following birth with the odds ratio of a woman dying of nonmedical causes within 9-12 months of birth being 3.8 (95% CI 1.55-9.01) when compared to dying within the first 3 months following birth. Conclusion: Perinatal services are often constructed to provide short-term support. Long-term identification and support of women at particular risk of maternal death due to suicide and trauma in the first year following birth may help lower the incidence of late maternal deaths.
    Full-text · Article · Aug 2013
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    • "Only first birth within the time period was included to avoid intraperson correlation. The proportional hazards assumption was tested using Schoenfeld residuals which were plotted against each covariate and the graphs inspected for any trend in the residuals [22,23]. Interactions between the log of gestational age and each covariate were created and added to the model individually to test for any departure from the proportional hazards assumption [24]. "
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    ABSTRACT: Background Maternal age is a known risk factor for stillbirth and delayed childbearing is a societal norm in developed country settings. The timing and reasons for age being a risk factor are less clear. This study aimed to document the gestational specific risk of maternal age throughout pregnancy and whether the underlying causes of stillbirth differ for older women. Methods Using linkage of state maternity and perinatal death data collections the authors assessed risk factors for antepartum stillbirth in New South Wales Australia for births between 2002 – 2006 (n = 327,690) using a Cox proportional hazards model. Gestational age specific risk was calculated for different maternal age groups. Deaths were classified according to the Perinatal Mortality Classifications of the Perinatal Society of Australia and New Zealand. Results Maternal age was a significant independent risk factor for antepartum stillbirth (35 – 39 years HR 1.4 95% CI 1.12 – 1.75; ≥ 40 years HR 2.41 95% CI 1.8 – 3.23). Other significant risk factors were smoking HR 1.82 (95% CI 1.56 –2.12) nulliparity HR 1.23 (95% CI 1.08 – 1.40), pre-existing hypertension HR 2.77 (95% CI 1.94 – 3.97) and pre-existing diabetes HR 2.65 (95% CI 1.63 – 4.32). For women aged 40 or over the risk of antepartum stillbirth beyond 40 weeks was 1 in 455 ongoing pregnancies compared with 1 in 1177 ongoing pregnancies for those under 40. This risk was increased in nulliparous women to 1 in 247 ongoing pregnancies. Unexplained stillbirths were the most common classification for all women, stillbirths classified as perinatal infection were more common in the women aged 40 or above. Conclusions Women aged 35 or older in a first pregnancy should be counselled regarding stillbirth risk at the end of pregnancy to assist with informed decision making regarding delivery. For women aged 40 or older in their first pregnancy it would be reasonable to offer induction of labour by 40 weeks gestation.
    Full-text · Article · Jan 2013 · BMC Pregnancy and Childbirth
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