title: Maternal mortality revisited: the application of the new ICD-MM classification system in reference to maternal deaths in Sri Lanka.
abstract: BACKGROUND
  The recently published WHO guidelines on applications of ICD-10 to deaths during pregnancy, childbirth, and the puerperium (ICD-MM) aimed at enabling a comprehensive framework for international comparison of maternal deaths, which includes maternal suicides as a direct cause of maternal deaths. At present, most developing countries do not include suicide as a maternal death.
  
  
  METHODS
  We extracted and analysed data from the maternal death surveillance system in North Central Province of Sri Lanka for the period of 2005 to 2011, in order to identify the implications of this new classification on maternal mortality estimates. All reported deaths of pregnant women and women within 12 months of termination of pregnancy were included in this study. Causes of deaths were extracted and coded using ICD-10 reclassified according to new ICD-MM for maternal deaths.
  
  
  RESULTS
  Of the 118 deaths analysed, the maternal death investigation system had classified 53 (44.9%) deaths as maternal deaths. These 53 maternal deaths included one deaths due to suicied, out of 21 (17.8%) suicide deaths among 118 reported deaths. Application of the new ICD-MM showed 83 maternal deaths which resulted in a 56.6% increase of number of maternal deaths in the province. Detailed analysis of all individual causes by ICD 10 codes showed that intentional self-poisoning by an exposure to pesticide (ICD code X63) as the leading cause of maternal deaths in NCP (n = 11, 13.3% of all maternal deaths) during this period. The estimated MMR in the study area based on the new classification in years 2009, 2010 and 2011 was 115, 103 and 88 per 100,000 live births respectively.
  
  
  CONCLUSIONS
  The new classification system may have an immediate effect in raising maternal mortality thresholds, making the MDG Goal 5A more elusive for many countries. However, this new approach may ultimately lead to a more accurate understanding of maternal mortality, as well as the real number of maternal deaths attributed to suicide. This more accurate accounting has implications for policymakers andpractitioners globally as they strive to meet women's needs during pregnancy, including attention to detection and treatment for maternal depression, given its close correlation with maternal suicide.
authors.affiliation: Maternal and Child Health Research Unit, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka. sunethagampodi@yahoo.com.
authors.forename: Suneth
authors.initials: S
authors.lastname: Agampodi
authors.forename: Kolitha
authors.initials: K
authors.lastname: Wickramage
authors.forename: Thilini
authors.initials: T
authors.lastname: Agampodi
authors.forename: Upuli
authors.initials: U
authors.lastname: Thennakoon
authors.forename: Nirasha
authors.initials: N
authors.lastname: Jayathilaka
authors.forename: Dhammika
authors.initials: D
authors.lastname: Karunarathna
authors.forename: Sasanka
authors.initials: S
authors.lastname: Alagiyawanna
mesh_terms: D005260:Female; D006801:Humans; D008428:Maternal Mortality; D008429:Maternal Welfare / Q000706:statistics & numerical data; D011247:Pregnancy; D013188:Sri Lanka / Q000453:epidemiology; D014944:World Health Organization