title: Vital registration and under-reporting of maternal mortality in Jamaica.
abstract: OBJECTIVE
  To identify why vital registration under-reports maternal deaths in Jamaica.
  
  
  METHODS
  A cross-sectional study was undertaken to identify all maternal deaths (during pregnancy or ≤42 days after pregnancy ended) occurring in 2008. Data sources included vital registration, hospital records, forensic pathology records, and an independent maternal mortality surveillance system. Potential cases were cross-referenced to registered live births and stillbirths, and hospital records to confirm pregnancy status, when the pregnancy ended, and registration. Medical certificates were inspected for certification, transcription, and coding errors. Maternal mortality ratios (MMRs) for registered and/or unregistered deaths were calculated.
  
  
  RESULTS
  Of 50 maternal deaths identified, 10 (20%) were unregistered. Eight unregistered deaths were coroners' cases. Among 40 registered deaths, pregnancy was undocumented in 4 (10%). Among the other 36, 24 (67%) had been misclassified (59% direct and 89% indirect deaths). Therefore, only 12 (30%) registered maternal deaths had been coded as maternal deaths, yielding an MMR of 28.3 per 100 000 live births (95% confidence interval [CI] 12.3-48.3), which was 76% lower than the actual MMR of 117.8 (95% CI 85.2-150.4).
  
  
  CONCLUSIONS
  Under-reporting of maternal deaths in Jamaica in 2008 was attributable to delayed registration of coroners' cases and misclassification. Timely registration of coroners' cases and training of nosologists to recognize and code maternal deaths is needed.
authors.affiliation: Department of Community Health and Psychiatry, University of the West Indies, Kingston, Jamaica. Electronic address: affette.mccawbinns@uwimona.edu.jm.
authors.forename: Affette M
authors.initials: AM
authors.lastname: McCaw-Binns
authors.affiliation: Office of the Dean, Faculty of Medical Sciences, University of the West Indies, Kingston, Jamaica.
authors.forename: Jasneth A
authors.initials: JA
authors.lastname: Mullings
authors.affiliation: International Biostatistics and Information Services, Castries, Saint Lucia.
authors.forename: Yvette
authors.initials: Y
authors.lastname: Holder
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007563:Jamaica / Q000453:epidemiology; D050498:Live Birth; D063130:Maternal Death / Q000145:classification*; D008428:Maternal Mortality; D008499:Medical Records; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D012042:Registries / Q000592:standards*; D050497:Stillbirth
keywords: International Classification of Diseases-Maternal Mortality (ICD-MM); Jamaica; Maternal mortality; Misclassification; Surveillance; Under-reporting; Vital registration