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