title: Underreporting of pregnancy-related mortality in the United States and Europe.
abstract: OBJECTIVE
  Available maternal mortality statistics do not allow valid international comparisons. Our objective was to uniformly measure underreporting of mortality from pregnancy in official statistics from selected regions within the U.S. and Europe, and to provide comparable revised profiles of pregnancy-related mortality.
  
  
  METHODS
  We developed a standardized enhanced method to uniformly identify and classify pregnancy-associated deaths from 2 U.S. states, Massachusetts and North Carolina, and 2 European countries, Finland and France, for the years 1999-2000. Identification method included the use of all data available from the death certificate as well as computerized linkage of births and deaths registers. All cases were reviewed and classified by an international panel of experts.
  
  
  RESULTS
  Four-hundred-and-four pregnancy-associated deaths were identified and reviewed. Underestimation of mortality causally related to pregnancy based on International Classification of Diseases cause-of-death codes alone varied from 22% in France to 93% in Massachusetts. Underreporting was greater in the regions with lower initial maternal mortality ratios. The distribution of causes of pregnancy-related mortality was specific to each region. The leading causes of death were cardiovascular conditions in Massachusetts; hemorrhage, pregnancy-induced hypertension, and peripartum cardiomyopathy in North Carolina; noncardiovascular medical conditions in Finland; and hemorrhage in France.
  
  
  CONCLUSIONS
  This study shows the limitations of maternal mortality statistics based on International Classification of Diseases cause-of-death codes alone. Linkage of births and deaths registers should routinely be used in the ascertainment of pregnancy-related deaths. In addition, extension of the definition of a maternal death should be considered. Beyond pregnancy-related mortality ratios, considering the specific distribution of causes-of-death is important to define prevention strategies.
authors.affiliation: Institut National de la Santé et de la Recherche Medicale U 149, Epidemiological Research Unit on Perinatal and Women's Health, Paris, France. catherine.deneux@tnn.aphp.fr
authors.forename: Catherine
authors.initials: C
authors.lastname: Deneux-Tharaux
authors.forename: Cynthia
authors.initials: C
authors.lastname: Berg
authors.forename: Marie-Helene
authors.initials: MH
authors.lastname: Bouvier-Colle
authors.forename: Mika
authors.initials: M
authors.lastname: Gissler
authors.forename: Margaret
authors.initials: M
authors.lastname: Harper
authors.forename: Angela
authors.initials: A
authors.lastname: Nannini
authors.forename: Sophie
authors.initials: S
authors.lastname: Alexander
authors.forename: Katherine
authors.initials: K
authors.lastname: Wildman
authors.forename: Gerard
authors.initials: G
authors.lastname: Breart
authors.forename: Pierre
authors.initials: P
authors.lastname: Buekens
mesh_terms: D000328:Adult; D002423:Cause of Death; D005260:Female; D005387:Finland / Q000453:epidemiology; D005602:France / Q000453:epidemiology; D006801:Humans; D038801:International Classification of Diseases; D008404:Massachusetts / Q000453:epidemiology; D008428:Maternal Mortality; D009657:North Carolina / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D011256:Pregnancy Outcome / Q000453:epidemiology; D011996:Records