title: Pitfalls of national routine death statistics for maternal mortality study.
abstract: BACKGROUND
  The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths.
  
  
  METHODS
  National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described.
  
  
  RESULTS
  Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians.
  
  
  CONCLUSIONS
  Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study.
authors.affiliation: Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.
authors.forename: Monica
authors.initials: M
authors.lastname: Saucedo
authors.forename: Marie-Hélène
authors.initials: MH
authors.lastname: Bouvier-Colle
authors.forename: Anne A
authors.initials: AA
authors.lastname: Chantry
authors.forename: Agathe
authors.initials: A
authors.lastname: Lamarche-Vadel
authors.forename: Grégoire
authors.initials: G
authors.lastname: Rey
authors.forename: Catherine
authors.initials: C
authors.lastname: Deneux-Tharaux
mesh_terms: D000328:Adult; D001699:Biometry; D002423:Cause of Death / Q000639:trends*; D003627:Data Interpretation, Statistical; D003644:Death Certificates; D005260:Female; D005602:France / Q000453:epidemiology; D006801:Humans; D008428:Maternal Mortality / Q000639:trends*; D011159:Population Surveillance; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D011634:Public Health; D015203:Reproducibility of Results
keywords: data accuracy; death statistics; maternal mortality; measurement