Checking the pregnancy checkbox: Evaluation of a four‐state quality assurance pilot

Abstract

Background:The 2003 revision of the standard United States death certificate included a set of "pregnancy checkboxes" to ascertain whether a woman was pregnant at the time of her death or within the preceding year. Studies validating the pregnancy checkbox have indicated a potentially high number of errors, resulting in inflated maternal mortality rates. In response to concerns about pregnancy checkbox data quality, four state health departments implemented a quality assurance pilot project examining the accuracy of the pregnancy checkbox for 2016 deaths. Methods: State staff conducted searches for birth or fetal death reports that matched a death certificate, within a year of death. If a pregnancy checkbox was marked, but no match was found between certificates, confirmation of the pregnancy was attempted through active follow-up with the death certifier. From December 2017 to January 2018, the quality assurance pilot was evaluated through three focus groups with key stakeholders. The evaluation aimed to describe opportunities and challenges to implementation, sustainability, and lessons learned. Results: Opportunities for implementing the pilot included written documentation of the quality assurance process, improved certifier response, improved data quality, and increased data timeliness for Maternal Mortality Review Committees. Challenges included initial delays in certifier response, staff turnover, high caseloads in relation to resources, and lack of pilot prioritization in the health department. All four pilot states plan to sustain the pregnancy checkbox quality assurance process in some capacity. Conclusions: Implementing quality assurance processes for the pregnancy checkbox may ultimately improve state and national maternal death data quality.

Identifying Deaths During and After Pregnancy: New Approaches to a Perennial Challenge

“…To reduce false positives, the Workgroup recommends confirming pregnancy status with the death certifier for all deaths identified based only on the checkbox and/or ICD-10 codes. 18,19 If certifier confirmation is not feasible, the Workgroup recommends searching obituaries, hospital and emergency department data, and media reports to confirm whether the decedent was in fact pregnant within 1 year of death. The best practice recommendations also include searching the death record literal cause of death fields for additional details and to capture deaths that may have been missed by other methods.…”

Documenting Maternal Deaths: Implications for National Statistics and Research

“…In response to concerns about the quality of the data collected via the pregnancy checkbox, Georgia, Louisiana, Michigan, and Ohio health departments reviewed every death certificate from 2016 that was marked with a pregnancy checkbox. An evaluation of this review reported that only one out of every five deaths for which a pregnancy checkbox was marked was found to be pregnancy related (Daymude, Catalano & Goodman, 2019).…”

Preventing Women’s Deaths From Pregnancy-Related Causes

“…However, by 2016, all but two states had done so (MacDorman et al, 2018). Unfortunately, despite the inclusion of the question to allow more accurate identification of potential pregnancy-related deaths, researchers found significant errors in the data provided by states (Daymude, Catalano, & Goodman, 2019).…”