posts_gdocs: 1xdTt6o9OWxJ9RJAQ1DiyfTuFZGPfGnHUFq5AA86sBOg

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id	slug	type	content	published	createdAt	publishedAt	updatedAt	publicationContext	revisionId	breadcrumbs	markdown	title
1xdTt6o9OWxJ9RJAQ1DiyfTuFZGPfGnHUFq5AA86sBOg	rise-us-maternal-mortality-rates-measurement	article	{ "toc": [], "body": [ { "type": "text", "value": [ { "text": "Look at reported maternal mortality rates in the United States, and you\u2019ll see an alarming rise since the early 2000s.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This rise has been widely covered in the media. See a 2023 article on Scientific American: \u201c", "spanType": "span-simple-text" }, { "url": "https://www.scientificamerican.com/article/why-maternal-mortality-rates-are-getting-worse-across-the-u-s/", "children": [ { "text": "Why Maternal Mortality Rates Are Getting Worse across the U.S.", "spanType": "span-simple-text" } ], "spanType": "span-link" }, { "text": "\u201d Or a report on National Public Radio (NPR): \u201c", "spanType": "span-simple-text" }, { "url": "https://www.npr.org/sections/health-shots/2023/07/04/1185904749/u-s-maternal-deaths-keep-rising-heres-who-is-most-at-risk", "children": [ { "text": "The number of people dying in the U.S. from pregnancy-related causes has more than doubled in the last 20 years.", "spanType": "span-simple-text" } ], "spanType": "span-link" }, { "text": "\u201d It has, understandably, been a big concern among the public.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "But researchers have shown that this rise does not represent an actual increase in the number of women dying in childbirth. Rather, it is the result of a change in measurement that was gradually introduced in the US between 2003 and 2017.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This change wasn\u2019t adopted at a national level in a single moment; that would have led to a single step-wise change in mortality rates. Instead, the measurement change was adopted state by state, which led to a ", "spanType": "span-simple-text" }, { "children": [ { "text": "gradual", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " rise over 14 years.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This measurement change has helped to identify more deaths that meet the criteria for maternal deaths, but has also led to some misclassification.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The process of ", "spanType": "span-simple-text" }, { "url": "https://ourworldindata.org/how-are-causes-of-death-registered-around-the-world", "children": [ { "text": "determining the cause of death", "spanType": "span-simple-text" } ], "spanType": "span-link" }, { "text": " can be complicated, and in many countries, national statistics from death certificates tend to miss some maternal deaths. To tackle this, some countries have used additional systems to identify maternal deaths that would otherwise be unreported.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In this article, I explain how a change in measurement in the United States led to an apparent rising trend in maternal deaths.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "text": [ { "text": "The recent rise in reported US maternal mortality looks alarming", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "id": "maternal-mortality", "children": [ { "text": "Maternal mortality", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " refers to the death of mothers from pregnancy, childbirth, abortion, or related causes.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The chart below shows trends in reported maternal mortality rates between different countries. Rates are measured as the number of maternal deaths per 100,000 women in the population. It shows the statistics as reported to the World Health Organization.", "spanType": "span-simple-text" }, { "url": "#note-1", "children": [ { "children": [ { "text": "1", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "You can see that the maternal mortality rate has fallen across all of these countries since 1950.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "But in the last two decades, the rate appears to have risen steeply in the United States. Between 2003 and 2017, it has more than doubled, from 0.4 to 0.8 deaths per 100,000 women.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In other countries such as France, Canada, and the United Kingdom the rates were stable or slightly falling.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "size": "wide", "type": "image", "filename": "reported-maternal-mortality-rate-us-canada-france-uk.png", "hasOutline": false, "parseErrors": [] }, { "text": [ { "text": "Maternal deaths had previously been underestimated", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "text": "According to the ", "spanType": "span-simple-text" }, { "id": "icd", "children": [ { "text": "International Classification of Diseases", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ", which is the international system to classify causes of death, a maternal death is counted if pregnancy or related causes are listed as the \u201c", "spanType": "span-simple-text" }, { "id": "underlying-cause-of-death", "children": [ { "text": "underlying cause of death", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": "\u201d on a death certificate.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This cause of death is filled into the field of the death certificate by doctors and nurses, based on the circumstances of death and medical records, according to their medical knowledge. The cause of death is then reported in the country\u2019s ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registry", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ".", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "You can read more about how causes of death are determined in my article:", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "url": "https://docs.google.com/document/d/13dQWV1hDG1I0bf0HLvYGrgGxlW-7l1ci6rhL9Wf2XQc/edit", "type": "prominent-link", "parseErrors": [] }, { "type": "text", "value": [ { "text": "But research has found that data from death certificates often underestimates maternal deaths.", "spanType": "span-simple-text" }, { "url": "#note-2", "children": [ { "children": [ { "text": "2", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "One reason is that some maternal deaths are missed and attributed to other causes. This can happen because pregnancy can worsen pre-existing conditions, such as ", "spanType": "span-simple-text" }, { "id": "hiv_aids", "children": [ { "text": "HIV/AIDS", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " and ", "spanType": "span-simple-text" }, { "id": "cvd", "children": [ { "text": "cardiovascular diseases", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ", and thereby indirectly lead to a woman\u2019s death.", "spanType": "span-simple-text" }, { "url": "#note-3", "children": [ { "children": [ { "text": "3", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" }, { "text": " In these cases, it can be difficult for doctors to make a judgment call on whether the woman would have died if she had not been pregnant.", "spanType": "span-simple-text" }, { "url": "#note-4", "children": [ { "children": [ { "text": "4", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "To complicate the situation further, sometimes medical records are lacking or inaccessible, and many deceased women don\u2019t have linked hospital records or undergo an autopsy to confirm whether they were pregnant at the time of death.", "spanType": "span-simple-text" }, { "url": "#note-5", "children": [ { "children": [ { "text": "5", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "There can also be social, cultural, or legal issues around reporting whether women were pregnant when they died.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "To address these problems, which can lead to the underestimation of maternal deaths, the ", "spanType": "span-simple-text" }, { "id": "icd", "children": [ { "text": "International Classification of Diseases (ICD)", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " expanded its definition of maternal deaths and recommended that countries collect additional data on whether deceased women had been pregnant before their death.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In the ninth edition, known as ICD-9 (published in 1979), the definition of maternal mortality was very narrow: it focused only on deaths ", "spanType": "span-simple-text" }, { "children": [ { "text": "during childbirth or the postpartum period", "spanType": "span-simple-text" } ], "spanType": "span-bold" }, { "text": ", and considered any causes related to, or aggravated by, the pregnancy or its management.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The updated ICD-10 (published in 1994) expanded the definition. It considered all those deaths as maternal which happened ", "spanType": "span-simple-text" }, { "children": [ { "text": "during pregnancy, childbirth, or within 42 days of the end of pregnancy", "spanType": "span-simple-text" } ], "spanType": "span-bold" }, { "text": ", from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.", "spanType": "span-simple-text" }, { "url": "#note-6", "children": [ { "children": [ { "text": "6", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The ICD-10 also recommended that a \u201cpregnancy checkbox\u201d be included in national death certificates, which would help flag these deaths for further investigation to understand if they were caused by pregnancy.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The checkbox asked if the deceased woman was pregnant or had been recently pregnant. You can see an example below, which is used in death certificates in the United States.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This checkbox was introduced to reduce underestimation and to capture maternal mortality more accurately.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "size": "narrow", "type": "image", "caption": [ { "text": "The \u201cpregnancy checkbox\u201d section of death certificates in the United States. This section was added to death certificates in some states in 2003, and was then gradually adopted across all other US states. The figure is adapted from Catalano et al. (2020).", "spanType": "span-simple-text" }, { "url": "#note-7", "children": [ { "children": [ { "text": "7", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "filename": "checkbox-explanation.png", "hasOutline": false, "parseErrors": [] }, { "text": [ { "text": "As the checkbox was gradually implemented in the United States, more maternal deaths were reported", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "text": "To follow the ICD-10 definition and make sure that maternal deaths weren\u2019t going uncounted, the United States added the \u201cpregnancy checkbox\u201d to death certificates, starting in 2003.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The US used an automated system to code deaths as maternal deaths if the checkbox was ticked for women between the ages of 10 and 54, for deaths caused by medical conditions, regardless of other information on the death certificate.", "spanType": "span-simple-text" }, { "url": "#note-8", "children": [ { "children": [ { "text": "8", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In 2003, four states had implemented the pregnancy checkbox \u2014\u00a0Idaho, Maryland, Montana, and New York state.", "spanType": "span-simple-text" }, { "url": "#note-9", "children": [ { "children": [ { "text": "9", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In the following years, more and more states added the checkbox. It wasn\u2019t until 2017 that every state included it on death certificates. You can see this in the chart below.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "As more and more states included the pregnancy checkbox, more deaths were identified as related to pregnancy, and the reported maternal mortality rate increased.", "spanType": "span-simple-text" }, { "url": "#note-10", "children": [ { "children": [ { "text": "10", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "size": "wide", "type": "image", "filename": "pregnancy-checkbox-maternal-mortality-usa.png", "hasOutline": false, "parseErrors": [] }, { "type": "text", "value": [ { "text": "To understand the impact of the measurement change, we can also examine what happened to maternal mortality ", "spanType": "span-simple-text" }, { "children": [ { "text": "within", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " states.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This is shown in the chart below, which plots the average maternal mortality ratio before and after the change.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The chart comes from reports from the National Center for Health Statistics and the National Vital Statistics System, which is part of the Centers for Disease Control and Prevention.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "You can see that once the checkbox was implemented, the reported maternal mortality ratio suddenly increased \u2014\u00a0on average, it ", "spanType": "span-simple-text" }, { "children": [ { "text": "doubled", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " from 10 to 20 deaths per 100,000 births \u2014 and then remained stable.", "spanType": "span-simple-text" }, { "url": "#note-11", "children": [ { "children": [ { "text": "11", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "size": "wide", "type": "image", "caption": [ { "text": "The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017.", "spanType": "span-simple-text" }, { "url": "#note-12", "children": [ { "children": [ { "text": "12", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "filename": "pregnancy-checkbox-average-change.png", "hasOutline": false, "parseErrors": [] }, { "type": "text", "value": [ { "text": "The researchers also estimated what the maternal mortality ratio from 2003 to 2017 would have looked like under two hypothetical scenarios: (a) if all states adopted the checkbox simultaneously, or (b) if none of them did.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In both scenarios, they estimate that there would have been no change in maternal mortality ratios between 2003 and 2017.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In other words, the rise in maternal mortality is largely explained by the staggered adoption of the checkbox.", "spanType": "span-simple-text" }, { "url": "#note-13", "children": [ { "children": [ { "text": "13", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" }, { "text": " The researchers also noted that the impact of the change in measurement was greatest among older women and non-Hispanic black women.", "spanType": "span-simple-text" }, { "url": "#note-14", "children": [ { "children": [ { "text": "14", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The checkbox increased the ability to detect pregnancy-related deaths that would have been missed otherwise, but in some cases, it also resulted in ", "spanType": "span-simple-text" }, { "children": [ { "text": "overcounting", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " deaths from other causes.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In a quality assurance study of four US states, researchers found that around 21% of death certificates with the checkbox ticked were confirmed to be false positives\u00a0\u2014\u00a0data from other health systems confirmed they had not been pregnant, and this was especially the case in girls aged under 15 and women aged over 45.", "spanType": "span-simple-text" }, { "url": "#note-15", "children": [ { "children": [ { "text": "15", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" }, { "text": " One reason for these false positives is that the box was ticked accidentally in some cases.", "spanType": "span-simple-text" }, { "url": "#note-16", "children": [ { "children": [ { "text": "16", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "To reduce these false positives, another change in measurement has been made in US statistics: from 2018 onwards, the checkbox is disregarded for women and girls aged under 10 or over 45.", "spanType": "span-simple-text" }, { "url": "#note-17", "children": [ { "children": [ { "text": "17", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Researchers also recommended further quality assurance processes \u2014\u00a0such as conducting follow-ups to verify ticked checkboxes and improving training for death certifiers \u2014 to be conducted in other states in the US ", "spanType": "span-simple-text" }, { "children": [ { "text": "before", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " sending data to the ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registry", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ", to improve the accuracy of national data on maternal deaths.", "spanType": "span-simple-text" }, { "url": "#note-18", "children": [ { "children": [ { "text": "18", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "text": [ { "text": "Maternal mortality is underreported in national statistics in many countries", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "text": "While the United States has used the checkbox to automatically code deaths as maternal if it is ticked", "spanType": "span-simple-text" }, { "url": "#note-19", "children": [ { "children": [ { "text": "19", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" }, { "text": ", this practice is not followed in several other countries.", "spanType": "span-simple-text" }, { "url": "#note-20", "children": [ { "children": [ { "text": "20", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "There is strong evidence that maternal mortality, as defined in the ", "spanType": "span-simple-text" }, { "id": "icd", "children": [ { "text": "ICD", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ", is underreported in national statistics in many countries.", "spanType": "span-simple-text" }, { "url": "#note-21", "children": [ { "children": [ { "text": "21", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "One reason is that some countries do not use data from the checkbox to identify potential maternal deaths, or do not routinely conduct additional investigations to identify unreported maternal deaths.", "spanType": "span-simple-text" }, { "url": "#note-20", "children": [ { "children": [ { "text": "20", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Some countries ", "spanType": "span-simple-text" }, { "children": [ { "text": "have", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": " implemented systems separate from their ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registries", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " to investigate potential maternal deaths further.", "spanType": "span-simple-text" }, { "url": "#note-22", "children": [ { "children": [ { "text": "22", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" }, { "text": " These systems include \u201cenhanced surveillance\u201d, which involves an additional system for more detailed monitoring, and \u201cconfidential inquiries\u201d, which are private investigations into individual cases.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "These investigations have been conducted infrequently, and the maternal deaths identified through these systems are not necessarily counted in vital registries for national statistics and given to the WHO.", "spanType": "span-simple-text" }, { "url": "#note-23", "children": [ { "children": [ { "text": "23", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Research finds that the number of maternal deaths from ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registries", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " tend to be lower than equivalent definitions from these other surveillance systems.", "spanType": "span-simple-text" }, { "url": "#note-24", "children": [ { "children": [ { "text": "24", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In low- and middle-income countries \u2014 where death certificates and ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registries", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " are often lacking \u2014 other sources of data are used to determine maternal deaths, including hospital records, and ", "spanType": "span-simple-text" }, { "id": "verbal-autopsy", "children": [ { "text": "verbal autopsies", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": ".", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Maternal mortality data from these sources can also include women who have died from incidental or accidental causes of death that are unrelated to their pregnancy, because data to identify the specific causes of death may be lacking.", "spanType": "span-simple-text" }, { "url": "#note-25", "children": [ { "children": [ { "text": "25", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "text": [ { "text": "International statistics on maternal mortality are adjusted for underreporting, but uncertainties remain", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "text": "To address this problem \u2014 of underreported maternal deaths in ", "spanType": "span-simple-text" }, { "id": "crvs", "children": [ { "text": "vital registries", "spanType": "span-simple-text" } ], "spanType": "span-dod" }, { "text": " \u2014 the United Nations Maternal Mortality Estimation Inter-agency Group (MMEIG) uses other data sources and expert knowledge to adjust for underreporting.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In countries that lack other surveillance systems for maternal deaths, the number of maternal deaths are adjusted upwards.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In countries that have enhanced surveillance data, different adjustment factors are used to adjust for incompleteness and misclassification.", "spanType": "span-simple-text" }, { "url": "#note-26", "children": [ { "children": [ { "text": "26", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Unfortunately, this adjustment can be imprecise because many countries lack comprehensive data on causes of death, or have not conducted national investigations into unreported maternal deaths, which could be used to understand the degree of underreporting in each country and improve adjustment factors.", "spanType": "span-simple-text" }, { "url": "#note-27", "children": [ { "children": [ { "text": "27", "spanType": "span-simple-text" } ], "spanType": "span-superscript" } ], "spanType": "span-ref" } ], "parseErrors": [] }, { "text": [ { "text": "Conclusion", "spanType": "span-simple-text" } ], "type": "heading", "level": 1, "parseErrors": [] }, { "type": "text", "value": [ { "text": "To prevent avoidable maternal deaths, it\u2019s crucial to have accurate data on deaths caused by pregnancy and related causes.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Unfortunately, maternal deaths are often underreported in official statistics due to a range of reasons, such as missing medical records and poor training of death certifiers.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "To help identify missed deaths, the United States introduced a \u201cpregnancy checkbox\u201d on death certificates, and deaths of women with this box ticked would be coded as maternal deaths in most age groups.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "While this helped identify maternal deaths that would have been missed, it also led to some misclassification and false positives from women who had not been pregnant or had died from other incidental causes.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Because of this, the US changed its coding system in 2018 to disregard the checkbox for deaths of patients under 10 or over 45 years old.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Researchers have also recommended that additional quality-assurance measures are used to verify potential maternal deaths before they are compiled in US national statistics.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In other high-income countries, there is strong evidence that maternal mortality is underreported in national statistics.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Some countries rely on additional systems to uncover unreported maternal deaths, but these tend to be conducted infrequently and are not necessarily considered in national statistics.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "In contrast, data from low- and middle-income countries \u2014\u00a0which tend to lack death certificates, hospital records, and vital registries \u2014\u00a0are less precise.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "International organizations try to adjust for these problems of underreporting and misclassification, but without better surveillance in each country, the adjustments can be imprecise.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "By improving data collection and surveillance of maternal deaths further, the world can have a better understanding of where and why mothers are dying, mobilize resources and policies to save lives, and reduce maternal mortality further.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "text": [ { "type": "text", "value": [ { "text": "On June 27th 2024, this article was updated to clarify that the automated coding system in the US was used to classify deaths as maternal, if the checkbox was ticked in certain demographics, only for deaths where the \u2018underlying cause of death\u2019 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M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017. National Center for Health Statistics. Vital Health Stat 3(44). ", "spanType": "span-simple-text" }, { "url": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "children": [ { "text": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "19bde67f78eb5c73d59de4fc7f67fbde9030fb76": { "id": "19bde67f78eb5c73d59de4fc7f67fbde9030fb76", "index": 4, "content": [ { "type": "text", "value": [ { "text": "Joseph, K. S., Boutin, A., Lisonkova, S., Muraca, G. M., Razaz, N., John, S., Mehrabadi, A., Sabr, Y., Ananth, C. V., & Schisterman, E. (2021). Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. 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", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/j.tjog.2019.07.017", "children": [ { "text": "https://doi.org/10.1016/j.tjog.2019.07.017", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada\u2019s maternal mortality statistics. Obstetric Medicine, 16(4), 211\u2013216. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1177/1753495X231178405", "children": [ { "text": "https://doi.org/10.1177/1753495X231178405", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany \u2013 discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1515/jpm-2023-0403", "children": [ { "text": "https://doi.org/10.1515/jpm-2023-0403", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "245e79279617c0e127be12cb93cad7badababfe2": { "id": "245e79279617c0e127be12cb93cad7badababfe2", "index": 15, "content": [ { "type": "text", "value": [ { "text": "Daymude, A. E. C., Catalano, A., & Goodman, D. (2019). Checking the pregnancy checkbox: Evaluation of a four\u2010state quality assurance pilot. Birth, 46(4), 648\u2013655. 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", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1097/AOG.0000000000004361", "children": [ { "text": "https://doi.org/10.1097/AOG.0000000000004361", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "44c77b63e62370a9cf88b8521265e66988b58ca3": { "id": "44c77b63e62370a9cf88b8521265e66988b58ca3", "index": 10, "content": [ { "type": "text", "value": [ { "text": "In this study, the researchers made estimates using the maternal mortality ratio.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The maternal mortality ratio is slightly different from the maternal mortality rate, but both measure the frequency of maternal deaths.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The maternal mortality rate is typically calculated as the number of deaths per 100,000 women, while the maternal mortality ratio is calculated as the number of deaths per 100,000 live births.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017. ", "spanType": "span-simple-text" }, { "url": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "children": [ { "text": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "46b336856ff8f753bbdb298871a79302f29372e0": { "id": "46b336856ff8f753bbdb298871a79302f29372e0", "index": 14, "content": [ { "type": "text", "value": [ { "text": "Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. American Journal of Obstetrics and Gynecology, 222(3), 269.e1-269.e8. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/j.ajog.2019.10.005", "children": [ { "text": "https://doi.org/10.1016/j.ajog.2019.10.005", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "46c3260ad153c6cfdfe3e685cb7f1fabcff62bf3": { "id": "46c3260ad153c6cfdfe3e685cb7f1fabcff62bf3", "index": 23, "content": [ { "type": "text", "value": [ { "text": "Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., B\u00f8dker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1136/bmj-2022-070621", "children": [ { "text": "https://doi.org/10.1136/bmj-2022-070621", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Bouvier\u2010Colle, M., Mohangoo, A., Gissler, M., Novak\u2010Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro\u2010Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880\u2013890. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1111/j.1471-0528.2012.03330.x", "children": [ { "text": "https://doi.org/10.1111/j.1471-0528.2012.03330.x", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700\u2013705. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/0029-7844(95)00200-B", "children": [ { "text": "https://doi.org/10.1016/0029-7844(95)00200-B", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "4c9372c5e6ed1941bce62a976182d49e8a7353c4": { "id": "4c9372c5e6ed1941bce62a976182d49e8a7353c4", "index": 7, "content": [ { "type": "text", "value": [ { "text": "Maternal death data in the US from the NCHS excludes deaths from injuries and other external causes (such as accidents, suicides, and homicides).", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "For other causes, i.e. medical conditions, death certificate data is processed through an automated system, sometimes with manual intervention, especially for complex cases. All maternal deaths also undergo a final manual check for accurate coding.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The definition of maternal death excludes accidental or incidental causes unrelated to pregnancy, though due to coding practices and lack of detailed guidelines, some deaths may incorrectly receive a maternal classification if pregnancy is mentioned on the certificate.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "The NCHS explains that: \u201cBecause coders are instructed to assign a maternal code to all certificates with a mention of pregnancy, including just a checkbox indicating pregnancy in the past year, it is possible that some deaths are assigned a maternal code when the medical conditions reported on the death certificate are incidental (e.g., neither caused nor complicated by pregnancy) to the pregnancy.\u201d", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "For women aged above 55, the coding instructions were to not rely only on the checkbox item, but use other information in the cause of death certificate about pregnancy or obstetric causes of death.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Hoyert, D. L., Uddin, S. F., & Mini\u00f1o, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. ", "spanType": "span-simple-text" }, { "url": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf", "children": [ { "text": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "663bee134e7584534294a43b9c0d731e4a4553c7": { "id": "663bee134e7584534294a43b9c0d731e4a4553c7", "index": 12, "content": [ { "type": "text", "value": [ { "text": "Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017. National Center for Health Statistics. Vital Health Stat 3(44). ", "spanType": "span-simple-text" }, { "url": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "children": [ { "text": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "See also:", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Davis, N. L., Hoyert, D. L., Goodman, D. A., Hirai, A. H., & Callaghan, W. M. (2017). Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978\u20132012. American Journal of Obstetrics and Gynecology, 217(3), 352.e1-352.e7. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/j.ajog.2017.04.042", "children": [ { "text": "https://doi.org/10.1016/j.ajog.2017.04.042", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "848c051fb45722952359c9c69226ceb86eb2152f": { "id": "848c051fb45722952359c9c69226ceb86eb2152f", "index": 24, "content": [ { "type": "text", "value": [ { "text": "Gazeley, U., Reniers, G., Eilerts-Spinelli, H., Prieto, J. R., Jasseh, M., Khagayi, S., & Filippi, V. (2022). Women\u2019s risk of death beyond 42 days post partum: A pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa. The Lancet Global Health, 10(11), e1582\u2013e1589. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/S2214-109X(22)00339-4", "children": [ { "text": "https://doi.org/10.1016/S2214-109X(22)00339-4", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "866035d77d002f6a7313fe631cd8272938985881": { "id": "866035d77d002f6a7313fe631cd8272938985881", "index": 16, "content": [ { "type": "text", "value": [ { "text": "Hoyert, D. L., & Mini\u00f1o, A. M. (2020). Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. ", "spanType": "span-simple-text" }, { "url": "https://stacks.cdc.gov/view/cdc/84769", "children": [ { "text": "https://stacks.cdc.gov/view/cdc/84769", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "8cdf58bf9c9f72c61d34271ae7b45c23cd2f1f78": { "id": "8cdf58bf9c9f72c61d34271ae7b45c23cd2f1f78", "index": 18, "content": [ { "type": "text", "value": [ { "text": "For women aged above 55, the coding instructions were to not rely only on the checkbox item, but use other information in the cause of death certificate about pregnancy or obstetric causes of death.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Hoyert, D. L., Uddin, S. F., & Mini\u00f1o, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. ", "spanType": "span-simple-text" }, { "url": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf", "children": [ { "text": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "8d41121cd1daaffbdc8dc07b98202ba30cde2636": { "id": "8d41121cd1daaffbdc8dc07b98202ba30cde2636", "index": 6, "content": [ { "type": "text", "value": [ { "text": "Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. ", "spanType": "span-simple-text" }, { "children": [ { "text": "American Journal of Obstetrics and Gynecology", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": ", ", "spanType": "span-simple-text" }, { "children": [ { "text": "222", "spanType": "span-simple-text" } ], "spanType": "span-italic" }, { "text": "(3), 269.e1-269.e8.", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/j.ajog.2019.10.005", "children": [ { "text": " ", "spanType": "span-simple-text" } ], "spanType": "span-link" }, { "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/", "children": [ { "text": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "a3602cdfdb76881c29640cee6e2965b48a742e5c": { "id": "a3602cdfdb76881c29640cee6e2965b48a742e5c", "index": 25, "content": [ { "type": "text", "value": [ { "text": "The 2023 UN MMEIG estimates have not adjusted for the change in the measurement of maternal mortality in the US.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "This is because the inclusion criteria of the UN MMEIG\u2019s model uses data on false positive and false negative rates from a national-level inquiry into individual-level data, using multiple sources via a review process, where one of the sources needs to be the national Civil Registry and Vital Statistics (CRVS) system.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "There has not yet been a national-level inquiry using data from the CRVS in the United States to investigate the false-positive and false-negative rates of maternal deaths across the country.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Instead, inquiries into individual data in the US have been conducted in a selection of states so far, and the National Center for Health Statistics (NCHS) has used other approaches to understand the impact of the checkbox, and simulate the trends with and without the checkbox.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "These approaches aren\u2019t included in the UN MMEIG\u2019s models currently.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "World Health Organization. (2023). Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. ", "spanType": "span-simple-text" }, { "url": "https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1", "children": [ { "text": "https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Ahmed, S. M. A., Cresswell, J. A., & Say, L. (2023). Incompleteness and misclassification of maternal death recording: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 23(1), 794. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1186/s12884-023-06077-4", "children": [ { "text": "https://doi.org/10.1186/s12884-023-06077-4", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "aa7fc0f6aab551dae43c289f2a2810dec2c902c6": { "id": "aa7fc0f6aab551dae43c289f2a2810dec2c902c6", "index": 21, "content": [ { "type": "text", "value": [ { "text": "Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., B\u00f8dker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1136/bmj-2022-070621", "children": [ { "text": "https://doi.org/10.1136/bmj-2022-070621", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "bf7ea208ee21e523215536521dcdb81b41334317": { "id": "bf7ea208ee21e523215536521dcdb81b41334317", "index": 3, "content": [ { "type": "text", "value": [ { "text": "Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700\u2013705. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/0029-7844(95)00200-B", "children": [ { "text": "https://doi.org/10.1016/0029-7844(95)00200-B", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "c88fef693430284687cf7501009c32f9494ca157": { "id": "c88fef693430284687cf7501009c32f9494ca157", "index": 2, "content": [ { "type": "text", "value": [ { "text": "Lumbiganon, P., Laopaiboon, M., Intarut, N., Vogel, J., Souza, J., G\u00fclmezoglu, A., & Mori, R. (2014). Indirect causes of severe adverse maternal outcomes: A secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology, 121(s1), 32\u201339. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1111/1471-0528.12647", "children": [ { "text": "https://doi.org/10.1111/1471-0528.12647", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "d0c22570e11c1a05eff851409dbe20ef37212f31": { "id": "d0c22570e11c1a05eff851409dbe20ef37212f31", "index": 26, "content": [ { "type": "text", "value": [ { "text": "World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. ", "spanType": "span-simple-text" }, { "url": "https://www.who.int/publications/i/item/9789240052376", "children": [ { "text": "https://www.who.int/publications/i/item/9789240052376", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] }, "d0cdb706673351a6d28e700d6e99f855891e2f2d": { "id": "d0cdb706673351a6d28e700d6e99f855891e2f2d", "index": 13, "content": [ { "type": "text", "value": [ { "text": "Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017. National Center for Health Statistics. Vital Health Stat 3(44). ", "spanType": "span-simple-text" }, { "url": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "children": [ { "text": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "It\u2019s important to note that racial disparities are visible regardless of the change in measurement, which is shown in Figure 14 in the report. In other words, with or without the checkbox, the maternal mortality rate was higher among black women than white women. At the same time, the measurement change is estimated to have had a larger impact on maternal mortality rates of black women than white women.", "spanType": "span-simple-text" } ], "parseErrors": [] } ], "parseErrors": [] }, "f4da9c0388bb4177fe7f9b8df91f456f5f26380a": { "id": "f4da9c0388bb4177fe7f9b8df91f456f5f26380a", "index": 5, "content": [ { "type": "text", "value": [ { "text": "This definition continues in the most recent manual:", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "According to the ICD-11, maternal deaths are defined as the deaths of women while pregnant or within 42 days of termination of pregnancy, from pregnancy-related causes, but excluding accidental or incidental causes of death.", "spanType": "span-simple-text" } ], "parseErrors": [] } ], "parseErrors": [] }, "fa6071aac3f44629ca6c19b398d9242257c29b8b": { "id": "fa6071aac3f44629ca6c19b398d9242257c29b8b", "index": 22, "content": [ { "type": "text", "value": [ { "text": "One exception is the United Kingdom\u2019s Confidential Enquiry into Maternal Deaths (CEMD) \u2014 which is a long-running program that requires the reporting of maternal deaths from diverse sources such as health workers, coroners, family members, and media reports \u2014 and verifies maternal mortality data to enhances its quality and completeness.", "spanType": "span-simple-text" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680\u2013683. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1016/j.tjog.2019.07.017", "children": [ { "text": "https://doi.org/10.1016/j.tjog.2019.07.017", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada\u2019s maternal mortality statistics. Obstetric Medicine, 16(4), 211\u2013216. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1177/1753495X231178405", "children": [ { "text": "https://doi.org/10.1177/1753495X231178405", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany \u2013 discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1515/jpm-2023-0403", "children": [ { "text": "https://doi.org/10.1515/jpm-2023-0403", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] }, { "type": "text", "value": [ { "text": "Bouvier\u2010Colle, M., Mohangoo, A., Gissler, M., Novak\u2010Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro\u2010Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880\u2013890. ", "spanType": "span-simple-text" }, { "url": "https://doi.org/10.1111/j.1471-0528.2012.03330.x", "children": [ { "text": "https://doi.org/10.1111/j.1471-0528.2012.03330.x", "spanType": "span-simple-text" } ], "spanType": "span-link" } ], "parseErrors": [] } ], "parseErrors": [] } } }, "type": "article", "title": "The rise in reported maternal mortality rates in the US is largely due to a change in measurement", "authors": [ "Saloni Dattani" ], "excerpt": "Maternal mortality rates appear to have risen in the last 20 years in the US. But this reflects a change in measurement rather than an actual rise in mortality.", "subtitle": "Maternal mortality rates appear to have risen in the last 20 years in the US. But this reflects a change in measurement rather than an actual rise in mortality.", "featured-image": "maternal-mortality-checkbox-thumbnail-edit.png" }	1	2024-03-13 17:17:04	2024-05-13 08:03:00	2024-05-09 11:56:02	listed	ALBJ4Lvwb_fqZJVG0npYw-039izMLv4NmxVDAIpCJPCb62CNukiwfiN-9vqa3eUH_ozZSSwyoM8sqD8DsVYVtg		Look at reported maternal mortality rates in the United States, and you’ll see an alarming rise since the early 2000s. This rise has been widely covered in the media. See a 2023 article on Scientific American: “[Why Maternal Mortality Rates Are Getting Worse across the U.S.](https://www.scientificamerican.com/article/why-maternal-mortality-rates-are-getting-worse-across-the-u-s/)” Or a report on National Public Radio (NPR): “[The number of people dying in the U.S. from pregnancy-related causes has more than doubled in the last 20 years.](https://www.npr.org/sections/health-shots/2023/07/04/1185904749/u-s-maternal-deaths-keep-rising-heres-who-is-most-at-risk)” It has, understandably, been a big concern among the public. But researchers have shown that this rise does not represent an actual increase in the number of women dying in childbirth. Rather, it is the result of a change in measurement that was gradually introduced in the US between 2003 and 2017. This change wasn’t adopted at a national level in a single moment; that would have led to a single step-wise change in mortality rates. Instead, the measurement change was adopted state by state, which led to a _gradual_ rise over 14 years. This measurement change has helped to identify more deaths that meet the criteria for maternal deaths, but has also led to some misclassification. The process of [determining the cause of death](https://ourworldindata.org/how-are-causes-of-death-registered-around-the-world) can be complicated, and in many countries, national statistics from death certificates tend to miss some maternal deaths. To tackle this, some countries have used additional systems to identify maternal deaths that would otherwise be unreported. In this article, I explain how a change in measurement in the United States led to an apparent rising trend in maternal deaths. # The recent rise in reported US maternal mortality looks alarming Maternal mortality refers to the death of mothers from pregnancy, childbirth, abortion, or related causes. The chart below shows trends in reported maternal mortality rates between different countries. Rates are measured as the number of maternal deaths per 100,000 women in the population. It shows the statistics as reported to the World Health Organization.1 You can see that the maternal mortality rate has fallen across all of these countries since 1950. But in the last two decades, the rate appears to have risen steeply in the United States. Between 2003 and 2017, it has more than doubled, from 0.4 to 0.8 deaths per 100,000 women. In other countries such as France, Canada, and the United Kingdom the rates were stable or slightly falling. <Image filename="reported-maternal-mortality-rate-us-canada-france-uk.png"/> # Maternal deaths had previously been underestimated According to the International Classification of Diseases, which is the international system to classify causes of death, a maternal death is counted if pregnancy or related causes are listed as the “underlying cause of death” on a death certificate. This cause of death is filled into the field of the death certificate by doctors and nurses, based on the circumstances of death and medical records, according to their medical knowledge. The cause of death is then reported in the country’s vital registry. You can read more about how causes of death are determined in my article: ### undefined undefined https://docs.google.com/document/d/13dQWV1hDG1I0bf0HLvYGrgGxlW-7l1ci6rhL9Wf2XQc/edit But research has found that data from death certificates often underestimates maternal deaths.2 One reason is that some maternal deaths are missed and attributed to other causes. This can happen because pregnancy can worsen pre-existing conditions, such as HIV/AIDS and cardiovascular diseases, and thereby indirectly lead to a woman’s death.3 In these cases, it can be difficult for doctors to make a judgment call on whether the woman would have died if she had not been pregnant.4 To complicate the situation further, sometimes medical records are lacking or inaccessible, and many deceased women don’t have linked hospital records or undergo an autopsy to confirm whether they were pregnant at the time of death.5 There can also be social, cultural, or legal issues around reporting whether women were pregnant when they died. To address these problems, which can lead to the underestimation of maternal deaths, the International Classification of Diseases (ICD) expanded its definition of maternal deaths and recommended that countries collect additional data on whether deceased women had been pregnant before their death. In the ninth edition, known as ICD-9 (published in 1979), the definition of maternal mortality was very narrow: it focused only on deaths during childbirth or the postpartum period, and considered any causes related to, or aggravated by, the pregnancy or its management. The updated ICD-10 (published in 1994) expanded the definition. It considered all those deaths as maternal which happened during pregnancy, childbirth, or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.6 The ICD-10 also recommended that a “pregnancy checkbox” be included in national death certificates, which would help flag these deaths for further investigation to understand if they were caused by pregnancy. The checkbox asked if the deceased woman was pregnant or had been recently pregnant. You can see an example below, which is used in death certificates in the United States. This checkbox was introduced to reduce underestimation and to capture maternal mortality more accurately. <Image filename="checkbox-explanation.png"/> # As the checkbox was gradually implemented in the United States, more maternal deaths were reported To follow the ICD-10 definition and make sure that maternal deaths weren’t going uncounted, the United States added the “pregnancy checkbox” to death certificates, starting in 2003. The US used an automated system to code deaths as maternal deaths if the checkbox was ticked for women between the ages of 10 and 54, regardless of other information on the death certificate.8 In 2003, four states had implemented the pregnancy checkbox — Idaho, Maryland, Montana, and New York state.9 In the following years, more and more states added the checkbox. It wasn’t until 2017 that every state included it on death certificates. You can see this in the chart below. As more and more states included the pregnancy checkbox, more deaths were identified as related to pregnancy, and the reported maternal mortality rate increased.10 <Image filename="pregnancy-checkbox-maternal-mortality-usa.png"/> To understand the impact of the measurement change, we can also examine what happened to maternal mortality rates _within_ states. This is shown in the chart below, which plots the average maternal mortality rate before and after the change. The chart comes from reports from the National Center for Health Statistics and the National Vital Statistics System, which is part of the Centers for Disease Control and Prevention. You can see that once the checkbox was implemented, the reported maternal mortality ratio suddenly increased — on average, it _doubled_ from 10 to 20 deaths per 100,000 births — and then remained stable.11 <Image filename="pregnancy-checkbox-average-change.png"/> The researchers also estimated what the maternal mortality ratio from 2003 to 2017 would have looked like under two hypothetical scenarios: (a) if all states adopted the checkbox simultaneously, or (b) if none of them did. In both scenarios, they estimate that there would have been no change in maternal mortality ratios between 2003 and 2017. In other words, the rise in maternal mortality is largely explained by the staggered adoption of the checkbox.13 The researchers also noted that the impact of the change in measurement was greatest among older women and non-Hispanic black women. The checkbox increased the ability to detect pregnancy-related deaths that would have been missed otherwise, but in some cases, it also resulted in _overcounting_ deaths from other causes. In a quality assurance study of four US states, researchers found that around 21% of death certificates with the checkbox ticked were confirmed to be false positives — data from other health systems confirmed they had not been pregnant, and this was especially the case in girls aged under 15 and women aged over 45. One reason for these false positives is that the box was ticked accidentally in some cases. To reduce these false positives, another change in measurement has been made in US statistics: from 2018 onwards, the checkbox is disregarded for women and girls aged under 10 or over 54.14 Researchers also recommended further quality assurance processes — such as conducting follow-ups to verify ticked checkboxes and improving training for death certifiers — to be conducted in other states in the US _before_ sending data to the vital registry, to improve the accuracy of national data on maternal deaths.15 # Maternal mortality is underreported in national statistics in many countries While the United States has used the checkbox to automatically code deaths as maternal if it is ticked8, this practice is not followed in several other countries.16 There is strong evidence that maternal mortality, as defined in the ICD, is underreported in national statistics in many countries.17 One reason is that some countries do not use data from the checkbox to identify potential maternal deaths, or do not routinely conduct additional investigations to identify unreported maternal deaths.16 Some countries _have_ implemented systems separate from their vital registries to investigate potential maternal deaths further.18 These systems include “enhanced surveillance”, which involves an additional system for more detailed monitoring, and “confidential inquiries”, which are private investigations into individual cases. These investigations have been conducted infrequently, and the maternal deaths identified through these systems are not necessarily counted in vital registries for national statistics and given to the WHO.19 Research finds that the number of maternal deaths from vital registries tend to be lower than equivalent definitions from these other surveillance systems.20 In low- and middle-income countries — where death certificates and vital registries are often lacking — other sources of data are used to determine maternal deaths, including hospital records, and verbal autopsies. Maternal mortality data from these sources can also include women who have died from incidental or accidental causes of death that are unrelated to their pregnancy, because data to identify the specific causes of death may be lacking.21 # International statistics on maternal mortality are adjusted for underreporting, but uncertainties remain To address this problem — of underreported maternal deaths in vital registries — the United Nations Maternal Mortality Estimation Inter-agency Group (MMEIG) uses other data sources and expert knowledge to adjust for underreporting. In countries that lack other surveillance systems for maternal deaths, the number of maternal deaths are adjusted upwards. In countries that have enhanced surveillance data, different adjustment factors are used to adjust for incompleteness and misclassification.22 Unfortunately, this adjustment can be imprecise because many countries lack comprehensive data on causes of death, or have not conducted national investigations into unreported maternal deaths, which could be used to understand the degree of underreporting in each country and improve adjustment factors.23 # Conclusion To prevent avoidable maternal deaths, it’s crucial to have accurate data on deaths caused by pregnancy and related causes. Unfortunately, maternal deaths are often underreported in official statistics due to a range of reasons, such as missing medical records and poor training of death certifiers. To help identify missed deaths, the United States introduced a “pregnancy checkbox” on death certificates, and deaths of women with this box ticked would be coded as maternal deaths in most age groups. While this helped identify maternal deaths that would have been missed, it also led to some misclassification and false positives from women who had not been pregnant or had died from other incidental causes. Because of this, the US changed its coding system in 2018 to disregard the checkbox for deaths of patients under 10 or over 54 years old. Researchers have also recommended that additional quality-assurance measures are used to verify potential maternal deaths before they are compiled in US national statistics. In other high-income countries, there is strong evidence that maternal mortality is underreported in national statistics. Some countries rely on additional systems to uncover unreported maternal deaths, but these tend to be conducted infrequently and are not necessarily considered in national statistics. In contrast, data from low- and middle-income countries — which tend to lack death certificates, hospital records, and vital registries — are less precise. International organizations try to adjust for these problems of underreporting and misclassification, but without better surveillance in each country, the adjustments can be imprecise. By improving data collection and surveillance of maternal deaths further, the world can have a better understanding of where and why mothers are dying, mobilize resources and policies to save lives, and reduce maternal mortality further. The World Health Organization’s Mortality Database publishes national statistics as they have been reported by countries, without further adjustment except to replace non-standard ICD codes, if they have been used, with standard ICD codes. Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. American Journal of Obstetrics and Gynecology, 222(3), 269.e1-269.e8. [https://pubmed.ncbi.nlm.nih.gov/31639369/](https://pubmed.ncbi.nlm.nih.gov/31639369/) Lumbiganon, P., Laopaiboon, M., Intarut, N., Vogel, J., Souza, J., Gülmezoglu, A., & Mori, R. (2014). Indirect causes of severe adverse maternal outcomes: A secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology, 121(s1), 32–39. [https://doi.org/10.1111/1471-0528.12647](https://doi.org/10.1111/1471-0528.12647) Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Joseph, K. S., Boutin, A., Lisonkova, S., Muraca, G. M., Razaz, N., John, S., Mehrabadi, A., Sabr, Y., Ananth, C. V., & Schisterman, E. (2021). Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. Obstetrics & Gynecology, 137(5), 763–771. [https://doi.org/10.1097/AOG.0000000000004361](https://doi.org/10.1097/AOG.0000000000004361) This definition continues in the most recent manual: According to the ICD-11, maternal deaths are defined as the deaths of women while pregnant or within 42 days of termination of pregnancy, from pregnancy-related causes, but excluding accidental or incidental causes of death. Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. _American Journal of Obstetrics and Gynecology_, _222_(3), 269.e1-269.e8.[ ](https://doi.org/10.1016/j.ajog.2019.10.005)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/) For women aged above 55, the coding instructions were to not rely only on the checkbox item, but use other information in the cause of death certificate about pregnancy or obstetric causes of death. Hoyert, D. L., Uddin, S. F., & Miniño, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. [https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf) Hoyert, D. L., Uddin, S. F., & Miniño, A. M. (2020). _Evaluation of the pregnancy status checkbox on the identification of maternal deaths_.[ ](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf)[https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf) Joseph, K. S., Boutin, A., Lisonkova, S., Muraca, G. M., Razaz, N., John, S., Mehrabadi, A., Sabr, Y., Ananth, C. V., & Schisterman, E. (2021). Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. Obstetrics & Gynecology, 137(5), 763–771. [https://doi.org/10.1097/AOG.0000000000004361](https://doi.org/10.1097/AOG.0000000000004361) In this study, the researchers made estimates using the maternal mortality ratio. The maternal mortality ratio is slightly different from the maternal mortality rate, but both measure the frequency of maternal deaths. The maternal mortality rate is typically calculated as the number of deaths per 100,000 women, while the maternal mortality ratio is calculated as the number of deaths per 100,000 live births. Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. National Center for Health Statistics. Vital Health Stat 3(44). [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. National Center for Health Statistics. Vital Health Stat 3(44). [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) See also: Davis, N. L., Hoyert, D. L., Goodman, D. A., Hirai, A. H., & Callaghan, W. M. (2017). Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978–2012. American Journal of Obstetrics and Gynecology, 217(3), 352.e1-352.e7. [https://doi.org/10.1016/j.ajog.2017.04.042](https://doi.org/10.1016/j.ajog.2017.04.042) Hoyert, D. L., & Miniño, A. M. (2020). Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. [https://stacks.cdc.gov/view/cdc/84769](https://stacks.cdc.gov/view/cdc/84769) Daymude, A. E. C., Catalano, A., & Goodman, D. (2019). Checking the pregnancy checkbox: Evaluation of a four‐state quality assurance pilot. Birth, 46(4), 648–655. [https://doi.org/10.1111/birt.12425](https://doi.org/10.1111/birt.12425) Berg, C. J. (2012). From Identification and Review to Action—Maternal Mortality Review in the United States. Seminars in Perinatology, 36(1), 7–13. [https://doi.org/10.1053/j.semperi.2011.09.003](https://doi.org/10.1053/j.semperi.2011.09.003) Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680–683. [https://doi.org/10.1016/j.tjog.2019.07.017](https://doi.org/10.1016/j.tjog.2019.07.017) Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada’s maternal mortality statistics. Obstetric Medicine, 16(4), 211–216. [https://doi.org/10.1177/1753495X231178405](https://doi.org/10.1177/1753495X231178405) Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). [https://doi.org/10.1515/jpm-2023-0403](https://doi.org/10.1515/jpm-2023-0403) World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. [https://iris.who.int/bitstream/handle/10665/360576/9789240052376-eng.pdf?sequence=1](https://iris.who.int/bitstream/handle/10665/360576/9789240052376-eng.pdf?sequence=1) Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., Bødker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. [https://doi.org/10.1136/bmj-2022-070621](https://doi.org/10.1136/bmj-2022-070621) One exception is the United Kingdom’s Confidential Enquiry into Maternal Deaths (CEMD) — which is a long-running program that requires the reporting of maternal deaths from diverse sources such as health workers, coroners, family members, and media reports — and verifies maternal mortality data to enhances its quality and completeness. Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680–683. [https://doi.org/10.1016/j.tjog.2019.07.017](https://doi.org/10.1016/j.tjog.2019.07.017) Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada’s maternal mortality statistics. Obstetric Medicine, 16(4), 211–216. [https://doi.org/10.1177/1753495X231178405](https://doi.org/10.1177/1753495X231178405) Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). [https://doi.org/10.1515/jpm-2023-0403](https://doi.org/10.1515/jpm-2023-0403) Bouvier‐Colle, M., Mohangoo, A., Gissler, M., Novak‐Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro‐Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880–890. [https://doi.org/10.1111/j.1471-0528.2012.03330.x](https://doi.org/10.1111/j.1471-0528.2012.03330.x) Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., Bødker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. [https://doi.org/10.1136/bmj-2022-070621](https://doi.org/10.1136/bmj-2022-070621) Bouvier‐Colle, M., Mohangoo, A., Gissler, M., Novak‐Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro‐Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880–890. [https://doi.org/10.1111/j.1471-0528.2012.03330.x](https://doi.org/10.1111/j.1471-0528.2012.03330.x) Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Gazeley, U., Reniers, G., Eilerts-Spinelli, H., Prieto, J. R., Jasseh, M., Khagayi, S., & Filippi, V. (2022). Women’s risk of death beyond 42 days post partum: A pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa. The Lancet Global Health, 10(11), e1582–e1589. [https://doi.org/10.1016/S2214-109X(22)00339-4](https://doi.org/10.1016/S2214-109X(22)00339-4) The 2023 UN MMEIG estimates have not adjusted for the change in the measurement of maternal mortality in the US. This is because the inclusion criteria of the UN MMEIG’s model uses data on false positive and false negative rates from a national-level inquiry into individual-level data, using multiple sources via a review process, where one of the sources needs to be the national Civil Registry and Vital Statistics (CRVS) system. There has not yet been a national-level inquiry using data from the CRVS in the United States to investigate the false-positive and false-negative rates of maternal deaths across the country. Instead, inquiries into individual data in the US have been conducted in a selection of states so far, and the National Center for Health Statistics (NCHS) has used other approaches to understand the impact of the checkbox, and simulate the trends with and without the checkbox. These approaches aren’t included in the UN MMEIG’s models currently. World Health Organization. (2023). Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. [https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1](https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1) Ahmed, S. M. A., Cresswell, J. A., & Say, L. (2023). Incompleteness and misclassification of maternal death recording: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 23(1), 794. [https://doi.org/10.1186/s12884-023-06077-4](https://doi.org/10.1186/s12884-023-06077-4) World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. [https://www.who.int/publications/i/item/9789240052376](https://www.who.int/publications/i/item/9789240052376)	The rise in reported maternal mortality rates in the US is largely due to a change in measurement

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1xdTt6o9OWxJ9RJAQ1DiyfTuFZGPfGnHUFq5AA86sBOg

rise-us-maternal-mortality-rates-measurement

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    "body": [
        {
            "type": "text",
            "value": [
                {
                    "text": "Look at reported maternal mortality rates in the United States, and you\u2019ll see an alarming rise since the early 2000s.",
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                }
            ],
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        },
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            "value": [
                {
                    "text": "This rise has been widely covered in the media. See a 2023 article on Scientific American: \u201c",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "https://www.scientificamerican.com/article/why-maternal-mortality-rates-are-getting-worse-across-the-u-s/",
                    "children": [
                        {
                            "text": "Why Maternal Mortality Rates Are Getting Worse across the U.S.",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-link"
                },
                {
                    "text": "\u201d Or a report on National Public Radio (NPR): \u201c",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "https://www.npr.org/sections/health-shots/2023/07/04/1185904749/u-s-maternal-deaths-keep-rising-heres-who-is-most-at-risk",
                    "children": [
                        {
                            "text": "The number of people dying in the U.S. from pregnancy-related causes has more than doubled in the last 20 years.",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-link"
                },
                {
                    "text": "\u201d It has, understandably, been a big concern among the public.",
                    "spanType": "span-simple-text"
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            "type": "text",
            "value": [
                {
                    "text": "But researchers have shown that this rise does not represent an actual increase in the number of women dying in childbirth. Rather, it is the result of a change in measurement that was gradually introduced in the US between 2003 and 2017.",
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            "value": [
                {
                    "text": "This change wasn\u2019t adopted at a national level in a single moment; that would have led to a single step-wise change in mortality rates. Instead, the measurement change was adopted state by state, which led to a ",
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                    "children": [
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                            "text": "gradual",
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                    "text": " rise over 14 years.",
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            "value": [
                {
                    "text": "This measurement change has helped to identify more deaths that meet the criteria for maternal deaths, but has also led to some misclassification.",
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            "value": [
                {
                    "text": "The process of ",
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                },
                {
                    "url": "https://ourworldindata.org/how-are-causes-of-death-registered-around-the-world",
                    "children": [
                        {
                            "text": "determining the cause of death",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-link"
                },
                {
                    "text": " can be complicated, and in many countries, national statistics from death certificates tend to miss some maternal deaths. To tackle this, some countries have used additional systems to identify maternal deaths that would otherwise be unreported.",
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            "value": [
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                    "text": "In this article, I explain how a change in measurement in the United States led to an apparent rising trend in maternal deaths.",
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            "text": [
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                    "text": "The recent rise in reported US maternal mortality looks alarming",
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            "type": "heading",
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            "value": [
                {
                    "id": "maternal-mortality",
                    "children": [
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                            "text": "Maternal mortality",
                            "spanType": "span-simple-text"
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                    ],
                    "spanType": "span-dod"
                },
                {
                    "text": " refers to the death of mothers from pregnancy, childbirth, abortion, or related causes.",
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                    "text": "The chart below shows trends in reported maternal mortality rates between different countries. Rates are measured as the number of maternal deaths per 100,000 women in the population. It shows the statistics as reported to the World Health Organization.",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-1",
                    "children": [
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                            "children": [
                                {
                                    "text": "1",
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            "value": [
                {
                    "text": "You can see that the maternal mortality rate has fallen across all of these countries since 1950.",
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            "value": [
                {
                    "text": "But in the last two decades, the rate appears to have risen steeply in the United States. Between 2003 and 2017, it has more than doubled, from 0.4 to 0.8 deaths per 100,000 women.",
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            "value": [
                {
                    "text": "In other countries such as France, Canada, and the United Kingdom the rates were stable or slightly falling.",
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            "size": "wide",
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            "filename": "reported-maternal-mortality-rate-us-canada-france-uk.png",
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            "text": [
                {
                    "text": "Maternal deaths had previously been underestimated",
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                    "text": "According to the ",
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                    "id": "icd",
                    "children": [
                        {
                            "text": "International Classification of Diseases",
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                {
                    "text": ", which is the international system to classify causes of death, a maternal death is counted if pregnancy or related causes are listed as the \u201c",
                    "spanType": "span-simple-text"
                },
                {
                    "id": "underlying-cause-of-death",
                    "children": [
                        {
                            "text": "underlying cause of death",
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                    ],
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                },
                {
                    "text": "\u201d on a death certificate.",
                    "spanType": "span-simple-text"
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        {
            "type": "text",
            "value": [
                {
                    "text": "This cause of death is filled into the field of the death certificate by doctors and nurses, based on the circumstances of death and medical records, according to their medical knowledge. The cause of death is then reported in the country\u2019s ",
                    "spanType": "span-simple-text"
                },
                {
                    "id": "crvs",
                    "children": [
                        {
                            "text": "vital registry",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-dod"
                },
                {
                    "text": ".",
                    "spanType": "span-simple-text"
                }
            ],
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            "value": [
                {
                    "text": "You can read more about how causes of death are determined in my article:",
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                }
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            "url": "https://docs.google.com/document/d/13dQWV1hDG1I0bf0HLvYGrgGxlW-7l1ci6rhL9Wf2XQc/edit",
            "type": "prominent-link",
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            "value": [
                {
                    "text": "But research has found that data from death certificates often underestimates maternal deaths.",
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                },
                {
                    "url": "#note-2",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "2",
                                    "spanType": "span-simple-text"
                                }
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            "value": [
                {
                    "text": "One reason is that some maternal deaths are missed and attributed to other causes. This can happen because pregnancy can worsen pre-existing conditions, such as ",
                    "spanType": "span-simple-text"
                },
                {
                    "id": "hiv_aids",
                    "children": [
                        {
                            "text": "HIV/AIDS",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-dod"
                },
                {
                    "text": " and ",
                    "spanType": "span-simple-text"
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                {
                    "id": "cvd",
                    "children": [
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                            "text": "cardiovascular diseases",
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                    "spanType": "span-dod"
                },
                {
                    "text": ", and thereby indirectly lead to a woman\u2019s death.",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-3",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "3",
                                    "spanType": "span-simple-text"
                                }
                            ],
                            "spanType": "span-superscript"
                        }
                    ],
                    "spanType": "span-ref"
                },
                {
                    "text": " In these cases, it can be difficult for doctors to make a judgment call on whether the woman would have died if she had not been pregnant.",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-4",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "4",
                                    "spanType": "span-simple-text"
                                }
                            ],
                            "spanType": "span-superscript"
                        }
                    ],
                    "spanType": "span-ref"
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            ],
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            "type": "text",
            "value": [
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                    "text": "To complicate the situation further, sometimes medical records are lacking or inaccessible, and many deceased women don\u2019t have linked hospital records or undergo an autopsy to confirm whether they were pregnant at the time of death.",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-5",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "5",
                                    "spanType": "span-simple-text"
                                }
                            ],
                            "spanType": "span-superscript"
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                    "spanType": "span-ref"
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            "type": "text",
            "value": [
                {
                    "text": "There can also be social, cultural, or legal issues around reporting whether women were pregnant when they died.",
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                }
            ],
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        },
        {
            "type": "text",
            "value": [
                {
                    "text": "To address these problems, which can lead to the underestimation of maternal deaths, the ",
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                },
                {
                    "id": "icd",
                    "children": [
                        {
                            "text": "International Classification of Diseases (ICD)",
                            "spanType": "span-simple-text"
                        }
                    ],
                    "spanType": "span-dod"
                },
                {
                    "text": " expanded its definition of maternal deaths and recommended that countries collect additional data on whether deceased women had been pregnant before their death.",
                    "spanType": "span-simple-text"
                }
            ],
            "parseErrors": []
        },
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            "type": "text",
            "value": [
                {
                    "text": "In the ninth edition, known as ICD-9 (published in 1979), the definition of maternal mortality was very narrow: it focused only on deaths ",
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                },
                {
                    "children": [
                        {
                            "text": "during childbirth or the postpartum period",
                            "spanType": "span-simple-text"
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                    ],
                    "spanType": "span-bold"
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                {
                    "text": ", and considered any causes related to, or aggravated by, the pregnancy or its management.",
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                }
            ],
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        },
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            "type": "text",
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                    "text": "The updated ICD-10 (published in 1994) expanded the definition. It considered all those deaths as maternal which happened ",
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                {
                    "children": [
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                            "text": "during pregnancy, childbirth, or within 42 days of the end of pregnancy",
                            "spanType": "span-simple-text"
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                    ],
                    "spanType": "span-bold"
                },
                {
                    "text": ", from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.",
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                },
                {
                    "url": "#note-6",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "6",
                                    "spanType": "span-simple-text"
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                            ],
                            "spanType": "span-superscript"
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            "type": "text",
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                    "text": "The ICD-10 also recommended that a \u201cpregnancy checkbox\u201d be included in national death certificates, which would help flag these deaths for further investigation to understand if they were caused by pregnancy.",
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                }
            ],
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            "type": "text",
            "value": [
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                    "text": "The checkbox asked if the deceased woman was pregnant or had been recently pregnant. You can see an example below, which is used in death certificates in the United States.",
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                    "text": "This checkbox was introduced to reduce underestimation and to capture maternal mortality more accurately.",
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                {
                    "text": "The \u201cpregnancy checkbox\u201d section of death certificates in the United States. This section was added to death certificates in some states in 2003, and was then gradually adopted across all other US states. The figure is adapted from Catalano et al. (2020).",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-7",
                    "children": [
                        {
                            "children": [
                                {
                                    "text": "7",
                                    "spanType": "span-simple-text"
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                            "spanType": "span-superscript"
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            "text": [
                {
                    "text": "As the checkbox was gradually implemented in the United States, more maternal deaths were reported",
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                    "text": "To follow the ICD-10 definition and make sure that maternal deaths weren\u2019t going uncounted, the United States added the \u201cpregnancy checkbox\u201d to death certificates, starting in 2003.",
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            ],
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            "type": "text",
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                    "text": "The US used an automated system to code deaths as maternal deaths if the checkbox was ticked for women between the ages of 10 and 54, for deaths caused by medical conditions, regardless of other information on the death certificate.",
                    "spanType": "span-simple-text"
                },
                {
                    "url": "#note-8",
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                            "children": [
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                                    "text": "8",
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                    "text": "In 2003, four states had implemented the pregnancy checkbox \u2014\u00a0Idaho, Maryland, Montana, and New York state.",
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                },
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                    "url": "#note-9",
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                            "children": [
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                                    "text": "9",
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                    "text": "In the following years, more and more states added the checkbox. It wasn\u2019t until 2017 that every state included it on death certificates. You can see this in the chart below.",
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                    "text": "As more and more states included the pregnancy checkbox, more deaths were identified as related to pregnancy, and the reported maternal mortality rate increased.",
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                    "url": "#note-10",
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                            "children": [
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                                    "text": "10",
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                    "text": "To understand the impact of the measurement change, we can also examine what happened to maternal mortality ",
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                            "text": "within",
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                    "text": " states.",
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                    "text": "This is shown in the chart below, which plots the average maternal mortality ratio before and after the change.",
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                    "text": "The chart comes from reports from the National Center for Health Statistics and the National Vital Statistics System, which is part of the Centers for Disease Control and Prevention.",
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                    "text": "You can see that once the checkbox was implemented, the reported maternal mortality ratio suddenly increased \u2014\u00a0on average, it ",
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                    "children": [
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                            "text": "doubled",
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                    "text": " from 10 to 20 deaths per 100,000 births \u2014 and then remained stable.",
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                    "url": "#note-11",
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                            "children": [
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                                    "text": "11",
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                    "text": "The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017.",
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                    "url": "#note-12",
                    "children": [
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                            "children": [
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                                    "text": "12",
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                    "text": "The researchers also estimated what the maternal mortality ratio from 2003 to 2017 would have looked like under two hypothetical scenarios: (a) if all states adopted the checkbox simultaneously, or (b) if none of them did.",
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                    "text": "In both scenarios, they estimate that there would have been no change in maternal mortality ratios between 2003 and 2017.",
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                    "text": "In other words, the rise in maternal mortality is largely explained by the staggered adoption of the checkbox.",
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                    "url": "#note-13",
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                            "children": [
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                                    "text": "13",
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                    "text": " The researchers also noted that the impact of the change in measurement was greatest among older women and non-Hispanic black women.",
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                    "url": "#note-14",
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                                    "text": "14",
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                    "text": "The checkbox increased the ability to detect pregnancy-related deaths that would have been missed otherwise, but in some cases, it also resulted in ",
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                    "children": [
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                            "text": "overcounting",
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                    "text": " deaths from other causes.",
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                    "text": "In a quality assurance study of four US states, researchers found that around 21% of death certificates with the checkbox ticked were confirmed to be false positives\u00a0\u2014\u00a0data from other health systems confirmed they had not been pregnant, and this was especially the case in girls aged under 15 and women aged over 45.",
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                {
                    "url": "#note-15",
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                                    "text": "15",
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                    "text": " One reason for these false positives is that the box was ticked accidentally in some cases.",
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                    "url": "#note-16",
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                            "children": [
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                                    "text": "16",
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                    "text": "To reduce these false positives, another change in measurement has been made in US statistics: from 2018 onwards, the checkbox is disregarded for women and girls aged under 10 or over 45.",
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                    "url": "#note-17",
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                                    "text": "17",
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                    "text": "Researchers also recommended further quality assurance processes \u2014\u00a0such as conducting follow-ups to verify ticked checkboxes and improving training for death certifiers \u2014 to be conducted in other states in the US ",
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                    "children": [
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                            "text": "before",
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                    "text": " sending data to the ",
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                            "text": "vital registry",
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                    "text": ", to improve the accuracy of national data on maternal deaths.",
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                    "url": "#note-18",
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                                    "text": "18",
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            "text": [
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                    "text": "Maternal mortality is underreported in national statistics in many countries",
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                    "text": "While the United States has used the checkbox to automatically code deaths as maternal if it is ticked",
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                    "url": "#note-19",
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                                    "text": "19",
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                    "text": ", this practice is not followed in several other countries.",
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                    "url": "#note-20",
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                                    "text": "20",
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                    "text": "There is strong evidence that maternal mortality, as defined in the ",
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                            "text": "ICD",
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                    "text": ", is underreported in national statistics in many countries.",
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                    "url": "#note-21",
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                            "children": [
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                                    "text": "21",
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                    "text": "One reason is that some countries do not use data from the checkbox to identify potential maternal deaths, or do not routinely conduct additional investigations to identify unreported maternal deaths.",
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                    "url": "#note-20",
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                    "text": " implemented systems separate from their ",
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                    "text": " to investigate potential maternal deaths further.",
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                    "url": "#note-22",
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                                    "text": "22",
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                    "text": " These systems include \u201cenhanced surveillance\u201d, which involves an additional system for more detailed monitoring, and \u201cconfidential inquiries\u201d, which are private investigations into individual cases.",
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                    "text": "These investigations have been conducted infrequently, and the maternal deaths identified through these systems are not necessarily counted in vital registries for national statistics and given to the WHO.",
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                    "url": "#note-23",
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                                    "text": "23",
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                    "text": "Research finds that the number of maternal deaths from ",
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                            "text": "vital registries",
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                    "text": " tend to be lower than equivalent definitions from these other surveillance systems.",
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                    "url": "#note-24",
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                                    "text": "24",
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                    "text": "In low- and middle-income countries \u2014 where death certificates and ",
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                    "text": " are often lacking \u2014 other sources of data are used to determine maternal deaths, including hospital records, and ",
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                {
                    "id": "verbal-autopsy",
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                            "text": "verbal autopsies",
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                    "text": ".",
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                    "text": "Maternal mortality data from these sources can also include women who have died from incidental or accidental causes of death that are unrelated to their pregnancy, because data to identify the specific causes of death may be lacking.",
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                    "url": "#note-25",
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                                    "text": "25",
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                    "text": " \u2014 the United Nations Maternal Mortality Estimation Inter-agency Group (MMEIG) uses other data sources and expert knowledge to adjust for underreporting.",
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                                "text": "Bouvier\u2010Colle, M., Mohangoo, A., Gissler, M., Novak\u2010Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro\u2010Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880\u2013890. ",
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                                "text": "Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700\u2013705. ",
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                                "text": "Maternal death data in the US from the NCHS excludes deaths from injuries and other external causes (such as accidents, suicides, and homicides).",
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                                "text": "The definition of maternal death excludes accidental or incidental causes unrelated to pregnancy, though due to coding practices and lack of detailed guidelines, some deaths may incorrectly receive a maternal classification if pregnancy is mentioned on the certificate.",
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                                "text": "The NCHS explains that: \u201cBecause coders are instructed to assign a maternal code to all certificates with a mention of pregnancy, including just a checkbox indicating pregnancy in the past year, it is possible that some deaths are assigned a maternal code when the medical conditions reported on the death certificate are incidental (e.g., neither caused nor complicated by pregnancy) to the pregnancy.\u201d",
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                                "text": "Hoyert, D. L., Uddin, S. F., & Mini\u00f1o, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. ",
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                                "url": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf",
                                "children": [
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                                "text": "Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017.  National Center for Health Statistics. Vital Health Stat 3(44). ",
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                                        "text": "https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf",
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                                "text": "See also:",
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                                "text": "Davis, N. L., Hoyert, D. L., Goodman, D. A., Hirai, A. H., & Callaghan, W. M. (2017). Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978\u20132012. American Journal of Obstetrics and Gynecology, 217(3), 352.e1-352.e7. ",
                                "spanType": "span-simple-text"
                            },
                            {
                                "url": "https://doi.org/10.1016/j.ajog.2017.04.042",
                                "children": [
                                    {
                                        "text": "https://doi.org/10.1016/j.ajog.2017.04.042",
                                        "spanType": "span-simple-text"
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                            {
                                "text": "Gazeley, U., Reniers, G., Eilerts-Spinelli, H., Prieto, J. R., Jasseh, M., Khagayi, S., & Filippi, V. (2022). Women\u2019s risk of death beyond 42 days post partum: A pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa. The Lancet Global Health, 10(11), e1582\u2013e1589. ",
                                "spanType": "span-simple-text"
                            },
                            {
                                "url": "https://doi.org/10.1016/S2214-109X(22)00339-4",
                                "children": [
                                    {
                                        "text": "https://doi.org/10.1016/S2214-109X(22)00339-4",
                                        "spanType": "span-simple-text"
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                                "spanType": "span-link"
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                        "value": [
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                                "text": "Hoyert, D. L., & Mini\u00f1o, A. M. (2020). Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. ",
                                "spanType": "span-simple-text"
                            },
                            {
                                "url": "https://stacks.cdc.gov/view/cdc/84769",
                                "children": [
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                                        "text": "https://stacks.cdc.gov/view/cdc/84769",
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                                "text": "For women aged above 55, the coding instructions were to not rely only on the checkbox item, but use other information in the cause of death certificate about pregnancy or obstetric causes of death.",
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                                "text": "Hoyert, D. L., Uddin, S. F., & Mini\u00f1o, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. ",
                                "spanType": "span-simple-text"
                            },
                            {
                                "url": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf",
                                "children": [
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                                        "text": "https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf",
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                                "text": "Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. ",
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                            {
                                "children": [
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                                        "text": "American Journal of Obstetrics and Gynecology",
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                                "text": ", ",
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                                        "text": "222",
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                            {
                                "text": "(3), 269.e1-269.e8.",
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                                "url": "https://doi.org/10.1016/j.ajog.2019.10.005",
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                                "text": "The 2023 UN MMEIG estimates have not adjusted for the change in the measurement of maternal mortality in the US.",
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                                "text": "This is because the inclusion criteria of the UN MMEIG\u2019s model uses data on false positive and false negative rates from a national-level inquiry into individual-level data, using multiple sources via a review process, where one of the sources needs to be the national Civil Registry and Vital Statistics (CRVS) system.",
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                                "text": "Instead, inquiries into individual data in the US have been conducted in a selection of states so far, and the National Center for Health Statistics (NCHS) has used other approaches to understand the impact of the checkbox, and simulate the trends with and without the checkbox.",
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                                "text": "World Health Organization. (2023). Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. ",
                                "spanType": "span-simple-text"
                            },
                            {
                                "url": "https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1",
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                                "text": "Ahmed, S. M. A., Cresswell, J. A., & Say, L. (2023). Incompleteness and misclassification of maternal death recording: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 23(1), 794. ",
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                                "url": "https://doi.org/10.1186/s12884-023-06077-4",
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                                "text": "Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700\u2013705. ",
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                                "text": "Lumbiganon, P., Laopaiboon, M., Intarut, N., Vogel, J., Souza, J., G\u00fclmezoglu, A., & Mori, R. (2014). Indirect causes of severe adverse maternal outcomes: A secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology, 121(s1), 32\u201339. ",
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                                "text": "World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. ",
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                                "url": "https://www.who.int/publications/i/item/9789240052376",
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                                "text": "Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999\u20132017.  National Center for Health Statistics. Vital Health Stat 3(44). ",
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                                "text": "It\u2019s important to note that racial disparities are visible regardless of the change in measurement, which is shown in Figure 14 in the report. In other words, with or without the checkbox, the maternal mortality rate was higher among black women than white women. At the same time, the measurement change is estimated to have had a larger impact on maternal mortality rates of black women than white women.",
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                                "text": "This definition continues in the most recent manual:",
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                                "text": "According to the ICD-11, maternal deaths are defined as the deaths of women while pregnant or within 42 days of termination of pregnancy, from pregnancy-related causes, but excluding accidental or incidental causes of death.",
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                                "text": "One exception is the United Kingdom\u2019s Confidential Enquiry into Maternal Deaths (CEMD) \u2014 which is a long-running program that requires the reporting of maternal deaths from diverse sources such as health workers, coroners, family members, and media reports \u2014 and verifies maternal mortality data to enhances its quality and completeness.",
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                                "text": "Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680\u2013683. ",
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                                "url": "https://doi.org/10.1016/j.tjog.2019.07.017",
                                "children": [
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    "type": "article",
    "title": "The rise in reported maternal mortality rates in the US is largely due to a change in measurement",
    "authors": [
        "Saloni Dattani"
    ],
    "excerpt": "Maternal mortality rates appear to have risen in the last 20 years in the US. But this reflects a change in measurement rather than an actual rise in mortality.",
    "subtitle": "Maternal mortality rates appear to have risen in the last 20 years in the US. But this reflects a change in measurement rather than an actual rise in mortality.",
    "featured-image": "maternal-mortality-checkbox-thumbnail-edit.png"
}

2024-03-13 17:17:04

2024-05-13 08:03:00

2024-05-09 11:56:02

listed

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Look at reported maternal mortality rates in the United States, and you’ll see an alarming rise since the early 2000s. This rise has been widely covered in the media. See a 2023 article on Scientific American: “[Why Maternal Mortality Rates Are Getting Worse across the U.S.](https://www.scientificamerican.com/article/why-maternal-mortality-rates-are-getting-worse-across-the-u-s/)” Or a report on National Public Radio (NPR): “[The number of people dying in the U.S. from pregnancy-related causes has more than doubled in the last 20 years.](https://www.npr.org/sections/health-shots/2023/07/04/1185904749/u-s-maternal-deaths-keep-rising-heres-who-is-most-at-risk)” It has, understandably, been a big concern among the public. But researchers have shown that this rise does not represent an actual increase in the number of women dying in childbirth. Rather, it is the result of a change in measurement that was gradually introduced in the US between 2003 and 2017. This change wasn’t adopted at a national level in a single moment; that would have led to a single step-wise change in mortality rates. Instead, the measurement change was adopted state by state, which led to a _gradual_ rise over 14 years. This measurement change has helped to identify more deaths that meet the criteria for maternal deaths, but has also led to some misclassification. The process of [determining the cause of death](https://ourworldindata.org/how-are-causes-of-death-registered-around-the-world) can be complicated, and in many countries, national statistics from death certificates tend to miss some maternal deaths. To tackle this, some countries have used additional systems to identify maternal deaths that would otherwise be unreported. In this article, I explain how a change in measurement in the United States led to an apparent rising trend in maternal deaths. # The recent rise in reported US maternal mortality looks alarming Maternal mortality refers to the death of mothers from pregnancy, childbirth, abortion, or related causes. The chart below shows trends in reported maternal mortality rates between different countries. Rates are measured as the number of maternal deaths per 100,000 women in the population. It shows the statistics as reported to the World Health Organization.1 You can see that the maternal mortality rate has fallen across all of these countries since 1950. But in the last two decades, the rate appears to have risen steeply in the United States. Between 2003 and 2017, it has more than doubled, from 0.4 to 0.8 deaths per 100,000 women. In other countries such as France, Canada, and the United Kingdom the rates were stable or slightly falling. <Image filename="reported-maternal-mortality-rate-us-canada-france-uk.png"/> # Maternal deaths had previously been underestimated According to the International Classification of Diseases, which is the international system to classify causes of death, a maternal death is counted if pregnancy or related causes are listed as the “underlying cause of death” on a death certificate. This cause of death is filled into the field of the death certificate by doctors and nurses, based on the circumstances of death and medical records, according to their medical knowledge. The cause of death is then reported in the country’s vital registry. You can read more about how causes of death are determined in my article: ### undefined undefined https://docs.google.com/document/d/13dQWV1hDG1I0bf0HLvYGrgGxlW-7l1ci6rhL9Wf2XQc/edit But research has found that data from death certificates often underestimates maternal deaths.2 One reason is that some maternal deaths are missed and attributed to other causes. This can happen because pregnancy can worsen pre-existing conditions, such as HIV/AIDS and cardiovascular diseases, and thereby indirectly lead to a woman’s death.3 In these cases, it can be difficult for doctors to make a judgment call on whether the woman would have died if she had not been pregnant.4 To complicate the situation further, sometimes medical records are lacking or inaccessible, and many deceased women don’t have linked hospital records or undergo an autopsy to confirm whether they were pregnant at the time of death.5 There can also be social, cultural, or legal issues around reporting whether women were pregnant when they died. To address these problems, which can lead to the underestimation of maternal deaths, the International Classification of Diseases (ICD) expanded its definition of maternal deaths and recommended that countries collect additional data on whether deceased women had been pregnant before their death. In the ninth edition, known as ICD-9 (published in 1979), the definition of maternal mortality was very narrow: it focused only on deaths **during childbirth or the postpartum period**, and considered any causes related to, or aggravated by, the pregnancy or its management. The updated ICD-10 (published in 1994) expanded the definition. It considered all those deaths as maternal which happened **during pregnancy, childbirth, or within 42 days of the end of pregnancy**, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.6 The ICD-10 also recommended that a “pregnancy checkbox” be included in national death certificates, which would help flag these deaths for further investigation to understand if they were caused by pregnancy. The checkbox asked if the deceased woman was pregnant or had been recently pregnant. You can see an example below, which is used in death certificates in the United States. This checkbox was introduced to reduce underestimation and to capture maternal mortality more accurately. <Image filename="checkbox-explanation.png"/> # As the checkbox was gradually implemented in the United States, more maternal deaths were reported To follow the ICD-10 definition and make sure that maternal deaths weren’t going uncounted, the United States added the “pregnancy checkbox” to death certificates, starting in 2003. The US used an automated system to code deaths as maternal deaths if the checkbox was ticked for women between the ages of 10 and 54, regardless of other information on the death certificate.8 In 2003, four states had implemented the pregnancy checkbox — Idaho, Maryland, Montana, and New York state.9 In the following years, more and more states added the checkbox. It wasn’t until 2017 that every state included it on death certificates. You can see this in the chart below. As more and more states included the pregnancy checkbox, more deaths were identified as related to pregnancy, and the reported maternal mortality rate increased.10 <Image filename="pregnancy-checkbox-maternal-mortality-usa.png"/> To understand the impact of the measurement change, we can also examine what happened to maternal mortality rates _within_ states. This is shown in the chart below, which plots the average maternal mortality rate before and after the change. The chart comes from reports from the National Center for Health Statistics and the National Vital Statistics System, which is part of the Centers for Disease Control and Prevention. You can see that once the checkbox was implemented, the reported maternal mortality ratio suddenly increased — on average, it _doubled_ from 10 to 20 deaths per 100,000 births — and then remained stable.11 <Image filename="pregnancy-checkbox-average-change.png"/> The researchers also estimated what the maternal mortality ratio from 2003 to 2017 would have looked like under two hypothetical scenarios: (a) if all states adopted the checkbox simultaneously, or (b) if none of them did. In both scenarios, they estimate that there would have been no change in maternal mortality ratios between 2003 and 2017. In other words, the rise in maternal mortality is largely explained by the staggered adoption of the checkbox.13 The researchers also noted that the impact of the change in measurement was greatest among older women and non-Hispanic black women. The checkbox increased the ability to detect pregnancy-related deaths that would have been missed otherwise, but in some cases, it also resulted in _overcounting_ deaths from other causes. In a quality assurance study of four US states, researchers found that around 21% of death certificates with the checkbox ticked were confirmed to be false positives — data from other health systems confirmed they had not been pregnant, and this was especially the case in girls aged under 15 and women aged over 45. One reason for these false positives is that the box was ticked accidentally in some cases. To reduce these false positives, another change in measurement has been made in US statistics: from 2018 onwards, the checkbox is disregarded for women and girls aged under 10 or over 54.14 Researchers also recommended further quality assurance processes — such as conducting follow-ups to verify ticked checkboxes and improving training for death certifiers — to be conducted in other states in the US _before_ sending data to the vital registry, to improve the accuracy of national data on maternal deaths.15 # Maternal mortality is underreported in national statistics in many countries While the United States has used the checkbox to automatically code deaths as maternal if it is ticked8, this practice is not followed in several other countries.16 There is strong evidence that maternal mortality, as defined in the ICD, is underreported in national statistics in many countries.17 One reason is that some countries do not use data from the checkbox to identify potential maternal deaths, or do not routinely conduct additional investigations to identify unreported maternal deaths.16 Some countries _have_ implemented systems separate from their vital registries to investigate potential maternal deaths further.18 These systems include “enhanced surveillance”, which involves an additional system for more detailed monitoring, and “confidential inquiries”, which are private investigations into individual cases. These investigations have been conducted infrequently, and the maternal deaths identified through these systems are not necessarily counted in vital registries for national statistics and given to the WHO.19 Research finds that the number of maternal deaths from vital registries tend to be lower than equivalent definitions from these other surveillance systems.20 In low- and middle-income countries — where death certificates and vital registries are often lacking — other sources of data are used to determine maternal deaths, including hospital records, and verbal autopsies. Maternal mortality data from these sources can also include women who have died from incidental or accidental causes of death that are unrelated to their pregnancy, because data to identify the specific causes of death may be lacking.21 # International statistics on maternal mortality are adjusted for underreporting, but uncertainties remain To address this problem — of underreported maternal deaths in vital registries — the United Nations Maternal Mortality Estimation Inter-agency Group (MMEIG) uses other data sources and expert knowledge to adjust for underreporting. In countries that lack other surveillance systems for maternal deaths, the number of maternal deaths are adjusted upwards. In countries that have enhanced surveillance data, different adjustment factors are used to adjust for incompleteness and misclassification.22 Unfortunately, this adjustment can be imprecise because many countries lack comprehensive data on causes of death, or have not conducted national investigations into unreported maternal deaths, which could be used to understand the degree of underreporting in each country and improve adjustment factors.23 # Conclusion To prevent avoidable maternal deaths, it’s crucial to have accurate data on deaths caused by pregnancy and related causes. Unfortunately, maternal deaths are often underreported in official statistics due to a range of reasons, such as missing medical records and poor training of death certifiers. To help identify missed deaths, the United States introduced a “pregnancy checkbox” on death certificates, and deaths of women with this box ticked would be coded as maternal deaths in most age groups. While this helped identify maternal deaths that would have been missed, it also led to some misclassification and false positives from women who had not been pregnant or had died from other incidental causes. Because of this, the US changed its coding system in 2018 to disregard the checkbox for deaths of patients under 10 or over 54 years old. Researchers have also recommended that additional quality-assurance measures are used to verify potential maternal deaths before they are compiled in US national statistics. In other high-income countries, there is strong evidence that maternal mortality is underreported in national statistics. Some countries rely on additional systems to uncover unreported maternal deaths, but these tend to be conducted infrequently and are not necessarily considered in national statistics. In contrast, data from low- and middle-income countries — which tend to lack death certificates, hospital records, and vital registries — are less precise. International organizations try to adjust for these problems of underreporting and misclassification, but without better surveillance in each country, the adjustments can be imprecise. By improving data collection and surveillance of maternal deaths further, the world can have a better understanding of where and why mothers are dying, mobilize resources and policies to save lives, and reduce maternal mortality further. The World Health Organization’s Mortality Database publishes national statistics as they have been reported by countries, without further adjustment except to replace non-standard ICD codes, if they have been used, with standard ICD codes. Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. American Journal of Obstetrics and Gynecology, 222(3), 269.e1-269.e8. [https://pubmed.ncbi.nlm.nih.gov/31639369/](https://pubmed.ncbi.nlm.nih.gov/31639369/) Lumbiganon, P., Laopaiboon, M., Intarut, N., Vogel, J., Souza, J., Gülmezoglu, A., & Mori, R. (2014). Indirect causes of severe adverse maternal outcomes: A secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology, 121(s1), 32–39. [https://doi.org/10.1111/1471-0528.12647](https://doi.org/10.1111/1471-0528.12647) Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Joseph, K. S., Boutin, A., Lisonkova, S., Muraca, G. M., Razaz, N., John, S., Mehrabadi, A., Sabr, Y., Ananth, C. V., & Schisterman, E. (2021). Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. Obstetrics & Gynecology, 137(5), 763–771. [https://doi.org/10.1097/AOG.0000000000004361](https://doi.org/10.1097/AOG.0000000000004361) This definition continues in the most recent manual: According to the ICD-11, maternal deaths are defined as the deaths of women while pregnant or within 42 days of termination of pregnancy, from pregnancy-related causes, but excluding accidental or incidental causes of death. Catalano, A., Davis, N. L., Petersen, E. E., Harrison, C., Kieltyka, L., You, M., Conrey, E. J., Ewing, A. C., Callaghan, W. M., & Goodman, D. A. (2020). Pregnant? Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors. _American Journal of Obstetrics and Gynecology_, _222_(3), 269.e1-269.e8.[ ](https://doi.org/10.1016/j.ajog.2019.10.005)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056489/) For women aged above 55, the coding instructions were to not rely only on the checkbox item, but use other information in the cause of death certificate about pregnancy or obstetric causes of death. Hoyert, D. L., Uddin, S. F., & Miniño, A. M. (2020). Evaluation of the pregnancy status checkbox on the identification of maternal deaths. [https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf) Hoyert, D. L., Uddin, S. F., & Miniño, A. M. (2020). _Evaluation of the pregnancy status checkbox on the identification of maternal deaths_.[ ](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf)[https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf](https://stacks.cdc.gov/view/cdc/84768/cdc_84768_DS1.pdf) Joseph, K. S., Boutin, A., Lisonkova, S., Muraca, G. M., Razaz, N., John, S., Mehrabadi, A., Sabr, Y., Ananth, C. V., & Schisterman, E. (2021). Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations. Obstetrics & Gynecology, 137(5), 763–771. [https://doi.org/10.1097/AOG.0000000000004361](https://doi.org/10.1097/AOG.0000000000004361) In this study, the researchers made estimates using the maternal mortality ratio. The maternal mortality ratio is slightly different from the maternal mortality rate, but both measure the frequency of maternal deaths. The maternal mortality rate is typically calculated as the number of deaths per 100,000 women, while the maternal mortality ratio is calculated as the number of deaths per 100,000 live births. Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. National Center for Health Statistics. Vital Health Stat 3(44). [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) Rossen, L. M., Womack, L. S., Hoyert, D. L., Anderson, R. N., & Uddin, S. F. (2020). The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. National Center for Health Statistics. Vital Health Stat 3(44). [https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf](https://www.cdc.gov/nchs/data/series/sr_03/sr03_044-508.pdf) See also: Davis, N. L., Hoyert, D. L., Goodman, D. A., Hirai, A. H., & Callaghan, W. M. (2017). Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978–2012. American Journal of Obstetrics and Gynecology, 217(3), 352.e1-352.e7. [https://doi.org/10.1016/j.ajog.2017.04.042](https://doi.org/10.1016/j.ajog.2017.04.042) Hoyert, D. L., & Miniño, A. M. (2020). Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. [https://stacks.cdc.gov/view/cdc/84769](https://stacks.cdc.gov/view/cdc/84769) Daymude, A. E. C., Catalano, A., & Goodman, D. (2019). Checking the pregnancy checkbox: Evaluation of a four‐state quality assurance pilot. Birth, 46(4), 648–655. [https://doi.org/10.1111/birt.12425](https://doi.org/10.1111/birt.12425) Berg, C. J. (2012). From Identification and Review to Action—Maternal Mortality Review in the United States. Seminars in Perinatology, 36(1), 7–13. [https://doi.org/10.1053/j.semperi.2011.09.003](https://doi.org/10.1053/j.semperi.2011.09.003) Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680–683. [https://doi.org/10.1016/j.tjog.2019.07.017](https://doi.org/10.1016/j.tjog.2019.07.017) Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada’s maternal mortality statistics. Obstetric Medicine, 16(4), 211–216. [https://doi.org/10.1177/1753495X231178405](https://doi.org/10.1177/1753495X231178405) Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). [https://doi.org/10.1515/jpm-2023-0403](https://doi.org/10.1515/jpm-2023-0403) World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. [https://iris.who.int/bitstream/handle/10665/360576/9789240052376-eng.pdf?sequence=1](https://iris.who.int/bitstream/handle/10665/360576/9789240052376-eng.pdf?sequence=1) Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., Bødker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. [https://doi.org/10.1136/bmj-2022-070621](https://doi.org/10.1136/bmj-2022-070621) One exception is the United Kingdom’s Confidential Enquiry into Maternal Deaths (CEMD) — which is a long-running program that requires the reporting of maternal deaths from diverse sources such as health workers, coroners, family members, and media reports — and verifies maternal mortality data to enhances its quality and completeness. Lin, C.-Y., Tsai, P.-Y., Wang, L.-Y., Chen, G., Kuo, P.-L., Lee, M.-C., & Lu, T.-H. (2019). Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan. Taiwanese Journal of Obstetrics and Gynecology, 58(5), 680–683. [https://doi.org/10.1016/j.tjog.2019.07.017](https://doi.org/10.1016/j.tjog.2019.07.017) Aflaki, K., & Ray, J. G. (2023). How other countries can improve Canada’s maternal mortality statistics. Obstetric Medicine, 16(4), 211–216. [https://doi.org/10.1177/1753495X231178405](https://doi.org/10.1177/1753495X231178405) Callaghan, J., Dudenhausen, J., Paulson, L., Hellmeyer, L., Vetter, K., Ziegert, M., Braun, T., & Koenigbauer, J. T. (2023). Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration. Journal of Perinatal Medicine, 0(0). [https://doi.org/10.1515/jpm-2023-0403](https://doi.org/10.1515/jpm-2023-0403) Bouvier‐Colle, M., Mohangoo, A., Gissler, M., Novak‐Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro‐Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880–890. [https://doi.org/10.1111/j.1471-0528.2012.03330.x](https://doi.org/10.1111/j.1471-0528.2012.03330.x) Diguisto, C., Saucedo, M., Kallianidis, A., Bloemenkamp, K., Bødker, B., Buoncristiano, M., Donati, S., Gissler, M., Johansen, M., Knight, M., Korbel, M., Kristufkova, A., Nyflot, L. T., & Deneux-Tharaux, C. (2022). Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ, e070621. [https://doi.org/10.1136/bmj-2022-070621](https://doi.org/10.1136/bmj-2022-070621) Bouvier‐Colle, M., Mohangoo, A., Gissler, M., Novak‐Antolic, Z., Vutuc, C., Szamotulska, K., Zeitlin, J., & for The Euro‐Peristat Scientific Committee. (2012). What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG: An International Journal of Obstetrics & Gynaecology, 119(7), 880–890. [https://doi.org/10.1111/j.1471-0528.2012.03330.x](https://doi.org/10.1111/j.1471-0528.2012.03330.x) Atrash, H., Alexander, S., & Berg, C. (1995). Maternal mortality in developed countries: Not just a concern of the past. Obstetrics & Gynecology, 86(4), 700–705. [https://doi.org/10.1016/0029-7844(95)00200-B](https://doi.org/10.1016/0029-7844(95)00200-B) Gazeley, U., Reniers, G., Eilerts-Spinelli, H., Prieto, J. R., Jasseh, M., Khagayi, S., & Filippi, V. (2022). Women’s risk of death beyond 42 days post partum: A pooled analysis of longitudinal Health and Demographic Surveillance System data in sub-Saharan Africa. The Lancet Global Health, 10(11), e1582–e1589. [https://doi.org/10.1016/S2214-109X(22)00339-4](https://doi.org/10.1016/S2214-109X(22)00339-4) The 2023 UN MMEIG estimates have not adjusted for the change in the measurement of maternal mortality in the US. This is because the inclusion criteria of the UN MMEIG’s model uses data on false positive and false negative rates from a national-level inquiry into individual-level data, using multiple sources via a review process, where one of the sources needs to be the national Civil Registry and Vital Statistics (CRVS) system. There has not yet been a national-level inquiry using data from the CRVS in the United States to investigate the false-positive and false-negative rates of maternal deaths across the country. Instead, inquiries into individual data in the US have been conducted in a selection of states so far, and the National Center for Health Statistics (NCHS) has used other approaches to understand the impact of the checkbox, and simulate the trends with and without the checkbox. These approaches aren’t included in the UN MMEIG’s models currently. World Health Organization. (2023). Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. [https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1](https://iris.who.int/bitstream/handle/10665/366225/9789240068759-eng.pdf?sequence=1) Ahmed, S. M. A., Cresswell, J. A., & Say, L. (2023). Incompleteness and misclassification of maternal death recording: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 23(1), 794. [https://doi.org/10.1186/s12884-023-06077-4](https://doi.org/10.1186/s12884-023-06077-4) World Health Organization. (2022). Maternal mortality measurement: Guidance to improve national reporting. [https://www.who.int/publications/i/item/9789240052376](https://www.who.int/publications/i/item/9789240052376)

The rise in reported maternal mortality rates in the US is largely due to a change in measurement

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