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Current Trends Maternal Mortality Surveillance -- Puerto Rico, 1989

Maternal mortality is substantially underreported in the United States and throughout the world (1,2). In Puerto Rico, the 1989 revised death certificate contained a new item that asked whether a decedent had been pregnant within the past year. This information enabled a panel of experts to identify and review all death certificates for females aged 10-49 years who had been pregnant within 1 year before death. This report describes how the new item on the birth certificate can be used to improve maternal mortality surveillance in Puerto Rico.

To classify and determine cause of death, the expert panel used the National Pregnancy Mortality Surveillance (3) classification of cause of death, developed by CDC in collaboration with the American College of Obstetricians and Gynecologists. A pregnancy-associated death was defined as a death from any cause during pregnancy or within 1 calendar year of termination of pregnancy, regardless of the duration or anatomical site of the pregnancy. A pregnancy-related death, a subset of pregnancy-associated deaths, was defined as a death resulting from: 1) complications of the pregnancy itself; 2) the chain of events initiated by the pregnancy that led to death; or 3) aggravation of an unrelated condition by the physiologic or pharmacologic effects of the pregnancy that subsequently caused death during pregnancy or within 1 calendar year of termination of pregnancy, regardless of the duration or anatomical site of the pregnancy.

For the 18 decedents whose pregnancies terminated in live births (Table 1), the panel used additional information from birth certificates that had been linked to the mother's death certificates. Of the 14 pregnancy-related deaths terminating in live births, five (36%) deaths were attributed to infection; two (14%) each to hemorrhage, pulmonary embolism, eclampsia, and other causes; and one (7%) to complications of anesthesia (Table 1). Birth certificates could not be matched to eight pregnancy-related deaths; complications of pregnancy-induced hypertension accounted for six (75%) of these deaths.

Based on the review, the number of deaths classified as pregnancy-related in 1989 increased 69% (from the 13 deaths that would have been reported by vital statistics to 22 deaths identified from the new death certificate item). This item identified 46 of the 47 pregnancy-associated deaths in Puerto Rico for 1989. Reported by: A Comas, MD, Dept of Obstetrics and Gynecology, Univ of Puerto Rico School of Medicine; A Navarro, MD, Univ of Puerto Rico Graduate School of Public Health; A Carrera, MD, R Castellanos, MD, N Perez, MS, J Saliceti, PhD, R Reyes, PhD, L Diaz, MS, C Ayoroa, MS, Puerto Rico Dept of Health. Pregnancy and Infant Health Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: A previous study in Puerto Rico based on reviews of death certificates and medical records indicated that, for 1978-1979, 17 (27%) of 62 pregnancy-related deaths were identified by the usual registration of vital events (4). Of the 45 additional pregnancy-related deaths identified in that study, 13 (21%) could have been ascertained by review of death certificates that were selected on the basis of suspected misclassification of pregnancy-related causes of death (4).

The findings in this report suggest that modification of the death certificate can substantially enhance reporting of pregnancy-related deaths. In Puerto Rico, in 34 of the 47 cases, the new item provided the only basis for determining that a death occurred during pregnancy or within 1 year of termination of pregnancy; however, the sensitivity and specificity of this approach was not assessed.

The national health objectives for the year 2000 have specified as a target a maternal mortality ratio (MMR) of 3.3 per 100,000 live births (5). Accurate documentation of the magnitude of pregnancy-related mortality is important for formulating prevention measures and other interventions. Based on a total of 66,692 live births in Puerto Rico for 1989, the actual MMR probably ranged from 33 to 51 per 100,000 live births, consistent with estimates for 1978-1979 (42 per 100,000 live births) (4) and 1982 (40 per 100,000) (6).

As a result of this assessment, the Puerto Rico Department of Health is establishing active surveillance of pregnancy-related deaths in Puerto Rico. In addition, hospital medical records of the 47 deaths identified as pregnancy-associated are being reviewed to assess the sensitivity and specificity of the initial process involving the expert panel review. Finally, death certificates of females aged 10-49 years will be matched with birth and fetal death certificates to assess the sensitivity and specificity of the new death certificate item in identifying pregnancy-associated deaths among mothers whose pregnancies terminated in a live birth or fetal death.


  1. Rochat RW, Koonin LM, Atrash HK, Jewett JF. Maternal mortality in the United States: report from the Maternal Mortality Collaborative. Obstet Gynecol 1988;72:91-7.

  2. Rosenfield A. Maternal mortality in developing countries. JAMA 1989;262:376-9.

  3. Ellerbrock TV, Atrash HK, Hogue CJ, Smith JC. Pregnancy mortality surveillance: a new initiative. Contemporary OB/GYN 1988;June:23-34.

  4. Speckhard ME, Comas-Urrutia AC, Rigau-Perez JG, Adamson K. Intensive surveillance of pregnancy-related deaths, Puerto Rico, 1978-1979. Bol Asoc Med P R 1985;77:508-13.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (PHS)91-50213.

  6. Comas A, Navarro A, Conde J, Blasini I, Adamsons K. Misreporting of maternal mortality in Puerto Rico. Bol Asoc Med P R 1990;82:343-6.

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