Effectiveness of Pregnancy Check Boxes on Death Certificates in Identifying Pregnancy-Associated Mortality

Abstract

SYNOPSISObjectives. Information that would allow the identification of women who were pregnant at the time of death or within the year preceding death has historically been underreported on death certificates. As a result, the magnitude of the problem of pregnancy-associated mortality is underestimated. To improve the identification of these deaths, check boxes for reporting pregnancy status have been added to death certificates in a number of states. We used multiple external data sources to determine whether check boxes have been effective in identifying pregnancy-associated deaths.Methods. We collected data on deaths occurring among pregnant or recently pregnant women residing in Maryland during the years 2001-2008 using multiple data sources. We determined the percentage of these deaths that could be identified through check boxes placed on death certificates.Results. Overall, 64.5% of pregnancy-associated deaths were identified through pregnancy check boxes on death certificates, including 98.1% of maternal deaths-defined as deaths occurring during pregnancy or within 42 days of delivery from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes-and 46.7% of deaths from nonmaternal causes, such as homicide, suicide, accidents, and substance abuse.Conclusions. Check boxes on death certificates are effective in identifying pregnancy-associated deaths resulting from maternal causes. However, they are far less effective in identifying deaths resulting from nonmaternal causes, such as homicide, accidental death, and substance abuse, which represent three of the four leading causes of pregnancy-associated death in Maryland.

Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

“…This is the exact inverse of the USA where no nationally comprehensive confidential enquiries have been completed (although some states have established maternal mortality review boards). The USA has high MMR for a high-SDI country—and is one of the few where it is increasing—but following the lead of Mexico and much of Latin America, it is also one of the only countries that has proactively improved its civil registration system with addition of a pregnancy checkbox on the standard death certificate,62 so it is possible that at least a portion of the increase is related to enhanced case ascertainment 62. The USA should learn from the experiences of other countries and consider implementing regular, comprehensive confidential enquiries into drivers of maternal mortality.…”

Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance

“…21 Likewise, pregnancy-associated suicide ratios were the number of suicides among pregnant or postpartum women divided by the number of live births from states and years included in this analysis. Given documented underreporting of pregnancy status on death records, 22 we acknowledge that these mortality ratios are underestimates of the true rates of homicide and suicide in the peripartum period; however, their purpose is to illustrate the difference in risk across maternal demographic characteristics. Therefore we present rate ratios (and 95% confidence intervals [CI]) for pregnancy-associated homicide and suicide by demographic characteristic rather than absolute rates.…”

“…Fildes et al reviewed medical examiner records from 1986–1989 in Cook County, IL and found that 65% of the deaths to women who were pregnant or postpartum were not identified as such on the death record. 8 More recently, Horon and Cheng 22 quantified the underreporting of pregnancy/postpartum status on death certificates from 2001–2008 in Maryland. It is important to note that the Maryland Department of Health and Mental Hygiene implemented enhanced surveillance of pregnancy-associated death on death records beginning in 2001, and the Maryland Maternal Mortality Review Committee – established in 2000 – performs a detailed case review, including review of medical examiner records and linkage of the women’s death certificates with birth and fetal death certificates from the prior year to enhance the accuracy of reporting.…”

Perinatal suicide in Ontario, Canada: a 15-year population-based study

“…[7][8][9] Furthermore, these rates are based on whether the death certificate records pregnancy or recent childbirth. Data from Europe suggest that underreporting of perinatal suicide on death certificates is in the range of 26% to 56%, 10,11 given that the presence of a child, or perhaps a birth, does not always emerge during the investigation of a death. 1,4,9,12,13 Despite high-profile media attention and calls to increase knowledge, with the goal of encouraging policy change, little is known about the true extent of the problem in Canada or the steps that can be taken to prevent it.…”