Introduction:

Maternal mortality seems like an issue that would no longer have a large-scale impact on modern American society. In fact, the Journal of the American Medical Association noted with pride in 1950 that the “maternal mortality rate for…the United States of America – has been pushed slightly below the apparently irreducible minimum of one maternal death per 1,000 live births.” Even after this declaration, maternal mortality continued to decline for a time. However, this celebration may have been premature, as maternal mortality has recently been on the rise.

According to the World Health Organization, maternal mortality or maternal death can be defined as: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. The American College of Obstetricians and Gynecologists (ACOG) expounds upon this idea, stating that the concept of maternal mortality encompasses both pregnancy-related and pregnancy associated deaths. Pregnancy-related deaths are those that occur during pregnancy or within a year of pregnancy due to causes related to the pregnancy or pregnancy management. In contrast, pregnancy-associated deaths are defined as deaths while pregnant or up to a year after pregnancy despite the cause.

The Center for Disease Control and Prevention (CDC) estimates that approximately 700 women die annually in the United States due to pregnancy-related or pregnancy-associated complications. This number is reflective of the United States’ ranking as 50^th in the world for its maternal death rate. Of the developed countries, it is the United States which has the most pregnancy-related deaths (per 100,000 live births). Looking at the situation from a quantitative angle further exemplifies this disconcerting trend. A 2015 Lancet article calculated that the U.S. maternal mortality rate was 26.4 deaths per every 100,000 live births, a number on par with that of Uzbekistan (26.2) and Kazakhstan (26.5) By comparison, the maternal mortality rates were 9.2 and 7.3 deaths per every 100,000 live births in the UK and Canada, respectively.

Background:

In 2003, the United States’ standard death certificate was modified to include a question regarding pregnancy. This change was instituted as an attempt to rectify the significant underreporting of maternal deaths, as found by studies in the 1980s and 1990s. In order to more accurately report rates of maternal mortality, the new standard death certificate provided several options regarding the time frame of pregnancy and death. The options were: pregnant at time of death, pregnancy within 42 days of death, pregnancy 43 days to one year before death, and not pregnant within the past year.

States have often lagged in adopting these changes. Only four states (California, Idaho, Montana, and New York) revised their death certificates in the intended year, 2003. By January 1, 2014, 44 states and Washington D.C. had revised their death certificates to include questions regarding pregnancy. The timeline for revision was not geographically based, as exemplified the New England States; Connecticut adopted checkboxes for pregnancy in 2005, but Massachusetts did not do so until 2014. Additionally, some states’ death certificates contained questions that were incompatible with the new U.S. standard, or completely lacked questions about pregnancy. Prior to the mandated revision, only 18 states had questions regarding pregnancy on their death certificate. Of those states, only 3 (Alabama, Maryland, and New Mexico), contained questions within the standardized 42-day timeframe. The other 15 states’ death certificates analyzed a varied time frame, often 3 to 18 months, postpartum.

This adoption lag has had significant effects on the reporting of maternal mortality statistics. In 2014, Robert Anderson, chief of the Mortality Statistics Branch at the  CDC stated, “We decided that the rates we were reporting were not accurate and not comparable year to year, because of the yearly increase in the number of states implementing the new certificate. Once all states are using the new certificate, we will begin reporting maternal mortality for the U.S. again.”

In an attempt to gap this data desert, 33 states have established Maternal Mortality Review Committees (MMRCs). These MMRCs include professionals from a variety of different fields, including: public health, obstetrics and gynecology, behavioral health, nursing and forensic pathology. According to ACOG, MMRCs are tasked with examining the underlying causes behind local maternal deaths and developing strategies to mitigate negative outcomes. From their analyses, MMRCs provide recommendations specific to their findings to relevant parties. Additionally, all cases that MMRCs determine are instances of maternal mortality are entered into a database by a MMRC representative. MMRC recommendations are based upon more than public records. While MMRCs have access to death and birth certificate data, they are also provided with additional information such as social service records, autopsy reports, hospital records, and prenatal care records.