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Perspectives in Disease Prevention and Health Promotion Maternal Mortality: Pilot Surveillance in Seven States

As part of a collaborative effort to improve the quality of maternal mortality data, maternal mortality committees in seven states* and CDC have jointly developed a confidential pilot surveillance system. For 1983, this system reported 39 maternal deaths among residents of the participating states, compared to 28 maternal deaths reported through state vital statistics systems; this is a 39% increase in ascertainment of maternal deaths. One state committee reported one less maternal death than did the vital statistics system.

The estimated rate was 9.6 maternal deaths per 100,000 live births, compared to 6.9/100,000 when vital records data alone were used. The surveillance system revealed a maternal mortality rate for blacks and others of 16.6/100,000, compared to 7.6/100,000 for whites (RR = 2.2; 95% confidence limits = 1.2-4.1). Embolism, peripartum cardiomyopathy, and cerebrovascular accident together accounted for 49% of the maternal deaths (Table 1). In four (10%) of 39 cases, data were insufficient to arrive at a cause of death more specific than "cardiopulmonary arrest." This degree of specificity of cause of death was in part attributable to the fact that 60% of the reports were supplemented by information not available from death certificates (e.g., clinical summaries and autopsy reports). Reported by State Maternal Mortality Committees represented by SB Berry, Shreveport, Louisiana, SR DePersio, MD, Oklahoma City, Oklahoma, WH Deschner, MD, Billings, Montana, EM Gold, MD, Providence, Rhode Island, JF Jewett, MD, Boston, Massachusetts, WJ May, MD, Winston-Salem, North Carolina, WD Ragan, MD, Indianapolis, Indiana; RW Rochat, MD, Emory University, Atlanta, Georgia; Pregnancy Epidemiology Br, Research and Statistics Br, Div of Reproductive Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The U.S. Public Health Service 1990 objective for maternal mortality is a maternal death rate not to exceed 5/100,000 live births for any county or for any ethnic group (e.g., black, Hispanic, American Indian) (1). The relatively slow decline in the maternal mortality rate for blacks and others suggests that the 1990 objective may not be met for this group (Figure 1). The development of strategies to reduce the maternal mortality rate may be facilitated by the availability of timely, complete, and accurate data on maternal deaths.

To identify maternal deaths, the participating maternal mortality committees generally augment reviews of death certificates with clinical information obtained from an informal network of participating obstetricians. By contrast, vital statistics depend on death certificates alone for identification of maternal deaths. Four special investigations have found that vital records classify 17%-73% of maternal deaths as nonmaternal deaths (2,3). The discrepancy between the committees' counts and those of state vital records probably has two sources. First, some deaths may not be classified as maternal deaths because information on the death certificate may not indicate that the death was related to pregnancy. Second, classification rules that determine the underlying cause of death from the "causes of death" and "other significant conditions" listed on the death certificate do not necessarily identify deaths related to pregnancy as maternal deaths. For example, preliminary evidence suggests that two of five cases of peripartum cardiomyopathy (4) reported through the surveillance system were not classified as maternal deaths by the state vital statistics system.

Because the maternal mortality committees provided clinical descriptions, it was possible to determine the underlying cause of death according to a previously described method (5). The finding that embolism was the most common cause of maternal death is consistent with a recent review of causes of maternal mortality during 1974-1978 (5). In addition, clinical summaries were used to identify lack of prenatal care, extreme obesity, multiparity, and maternal age over 35 years as possible risk factors. In addition to demographic data (96%-100% complete), the surveillance system collected data on the woman's prior reproductive history (62% complete) and on the current pregnancy's gestational age (65% complete) and outcome (77% complete); data on education were not routinely available (20% complete).

Results from this voluntary pilot surveillance system suggest that active maternal mortality surveillance can yield timely data and that counts of maternal deaths may be more complete than those available from vital records alone. Moreover, the surveillance data were more detailed, allowing a more precise determination of the cause of death. Even more complete counts of maternal deaths could be obtained from the routine linkage of birth and fetal death certificates to the death certificates of women of reproductive age (6). State or local maternal mortality committees, and others who wish to participate in this confidential surveillance system for 1983 and subsequent years should contact J. F. Jewett, M.D., Committee on Maternal Welfare, Massachusetts Medical Society, 319 Longwood Avenue, Boston, Massachusetts, 02115; Emory University MPH Program, 735 Gatewood Road, Atlanta, Georgia, 30322; or the Division of Reproductive Health, Center for Health Promotion and Education, CDC.

References

  1. U.S. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, 1980:17.

  2. Friede AM, Rochat RW. Maternal mortality and perinatal mortality: an epidemiologic perspective. In: Sachs B, ed. Clinical obstetrics: a public health perspective. Littleton, Massachusetts: PSG, Inc., 1985.

  3. Smith JC, Hughes JM, Pekow PS, Rochat RW. An assessment of the incidence of maternal mortality in the United States. Am J Public Health 1984;74:780-3.

  4. Homans DC. Peripartum cardiomyopathy. N Engl J Med 1985;312:1432-7.

  5. Kaunitz AM, Hughes JM, Grimes DA, Smith JC, Rochat RW, Kafrissen ME. Causes of maternal mortality in the United States. Obstet Gynecol 1985;65:605-12.

  6. Rubin G, McCarthy B, Shelton J, Rochat RW, Terry J. The risk of childbearing re-evaluated. Am J Public Health 1981;71:712-6. *Indiana, Louisiana, Massachusetts, Montana, North Carolina, Oklahoma, and Rhode Island.



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