Underreporting of pregnancy-related mortality in the United States and Europe.
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.
Deneux-Tharaux
Catherine
C
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
Berg
Cynthia
C
Bouvier-Colle
Marie-Helene
MH
Gissler
Mika
M
Harper
Margaret
M
Nannini
Angela
A
Alexander
Sophie
S
Wildman
Katherine
K
Breart
Gerard
G
Buekens
Pierre
P
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