How Are Maternal Deaths Counted and Investigated?
February 1, 2025
By Melinda Young
Determining a city, state, or country’s maternal mortality rate is challenging and can be a controversial process. It depends on the time frame measured, whether maternal deaths are considered only if there are biomedical causes, or when there are factors related to pregnancy, such as suicides and homicides that would have not occurred if the person had not had a pregnancy.
“We know we have exceedingly high maternal mortality rates in the United States, and we cannot find out the reason for that by just looking at death certificates and check boxes,” says Michael R. Kramer, PhD, MS, an epidemiologist and director of the Center for Rural Health and Health Disparities at Mercer University School of Medicine in Macon, GA.
“We want to get all the information available — autopsy and medical records and medical history — and we can convene a committee of experts like obstetricians and cardiologists and experts in the community,” he explains. “A diverse committee of experts look at all the information and see what went wrong and what we can do to prevent this in the future.”
That is where maternal mortality review committees (MMRCs) play a crucial role.MMRCs have existed since the 1930s, but they have grown in their role since 2018, when the U.S. Congress appropriated money to the Centers for Disease Control and Prevention (CDC) to be sent to states to fund MMRC work.1
“Grants from CDC lay some of the groundwork and support the staff who do preparation for these meetings,” Kramer says. “People have to request these medical records and scour hundreds of pages of information and synthesize it into a summary for the review.”
MMRCs have had bipartisan support previously, but it is uncertain if that will continue as more women are denied abortion procedures as standard miscarriage care since the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization allowed states to ban any and all abortions — both medication and procedural.
“I think one consequence of doing this holistic review is that questions come up about contributing factors to maternal deaths that are not solely biomedical factors,” he says. “The role of MMRCs is to identify factors above and beyond biomedical factors.”
Raising issues like the impact of anti-abortion legislation in maternal deaths creates a lightning rod and becomes political. “There is no guarantee MMRC funding will continue,” Kramer adds.
MMRCs use data collected by pregnancy mortality surveillance systems. Information comes from death certificates. Committees link data between births and deaths to find decedents who were pregnant, but the coroner did not know this fact, Kramer says. The committees look to see if the death was related to pregnancy and, if so, how it was related.
Some states renewed their interest in investigating maternal deaths after the COVID-19 pandemic years led to spikes in women dying during or shortly after pregnancy. There were 1,205 maternal deaths in 2021 compared with 754 in 2019 — a 60% increase, likely due to pregnant women who had not received the COVID-19 vaccine during pregnancy.2,3
Even as researchers are trying to make sense of the high maternal mortality rate in the United States, there are disputes over how the numbers are counted. The CDC’s estimates of maternal deaths show that the rate has tripled from 2001 to 2021 to reach 32.9 deaths per 100,000 live births. But a study published in The American Journal of Obstetrics and Gynecology (AJOG) reports a consistent death rate of about 10 maternal deaths per 100,000 live births.4,5
The AJOG research says the difference is that, when women die and a pregnancy check box is marked on the death certificate, that was counted as a maternal death. But this check box was sometimes marked erroneously. Even with changes that only counted that deaths of women from 15 to 44 years of age, investigators claim the pregnancy box created inaccurate information because the box could be checked if a pregnant woman dies in a car crash.4,5 The study found that Black women had the highest death rate of 23.8 per 100,000 live births in 2018-2021.4,5
Their revised way of determining maternal deaths does not show what has happened since the U.S. Supreme Court overturned Roe v. Wade with its decision in Dobbs v. Jackson Women’s Health Organization on June 24, 2022. Their data also does not capture the phenomenon of women being murdered, dying by suicide, or having a motor vehicle accident that occurred because of placental eruption — all of which could be preventable deaths that would not have occurred if the women had not been pregnant.5
The federal government revised its way of counting maternal deaths in 2003 by including the pregnancy checkbox on death certificates. It asks if the decedent was pregnant within the last year, Kramer says. “In the first few years, there was an issue of 70-year-olds being counted as maternal deaths because people were not good at handling forms and had checked them wrong,” he explains. “There were studies that picked up some increase of maternal mortality that included misreporting.” But it is not accurate to say that there was no problem with maternal mortality, he adds.
The recent study corrected for pregnancy-related causes that were not obstetric in nature. They did not include suicides and homicides, and omitting those deaths can obscure the big picture.5
The study separates obstetrical deaths into direct obstetrical death and indirect obstetrical deaths. Indirect obstetrical deaths are defined as a maternal death “resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy.”4
“Their argument is purely obstetric — direct pregnancy-related causes, and that is a narrow definition,” Kramer says. “It’s an important set, but it basically says those other social things or psychosocial things are too complicated, so we’re going to exclude them.”
It is possible in the current obstetric environment that is hostile to any health-preserving or life-saving procedures that could be labeled an abortion that some deaths of pregnant women will be overlooked. For instance, if a committee or investigators focus attention only on direct obstetrical deaths, they will miss maternal deaths in which a pregnant patient whose health is rapidly deteriorating during pregnancy is not advised by her physician about having an abortion to save her own health and life. This is what may have happened to Yeniifer Alvarez-Estrada Glick, a young, obese, married woman who died on July 10, 2022, in Luling, TX. She lived in a maternal desert with no labor-and-delivery unit in her town, and she developed pulmonary edema early in her first trimester of pregnancy. Her medical records showed no evidence that her doctors discussed a therapeutic termination of the pregnancy — even when she was hospitalized at 10 weeks because of high blood pressure and high glucose levels. She repeatedly visited emergency departments but was not given an abortion or early delivery. Glick and her fetus died at 31 weeks of gestation enroute to an emergency department.6
While data someday may show that maternal deaths like Glick’s have increased since the Dobbs decision, there already is evidence that maternal suicides and homicides are major factors in maternal mortality. Women in the United States are more likely to be murdered than to die from obstetric causes, and these homicides are linked to a combination of intimate partner violence (IPV) and easy access to guns. Moreover, the United States has a higher prevalence of IPV than comparable countries, and Black women have a substantially higher risk of being killed than white or Hispanic women.7
Murder of pregnant people is a public health crisis that should be addressed by MMRCs. The same is true of suicide. “When it comes to suicide, peripartum depression is a leading cause of suicide,” Kramer says. A recent study found that mothers with clinically diagnosed perinatal depression had a three times higher risk of suicidal behavior than mothers without perinatal depression.8
When there is clear evidence of deaths from a mental health issue related to pregnancy, then it also is something that MMRCs could address, analyze, and inform for public health solutions. The terms the CDC uses are “pregnancy-associated death” or “pregnancy-related death.”
A pregnancy-associated death means anyone who died within a year of pregnancy, without cause. Pregnancy-related deaths are when the cause of death is related to the pregnancy itself, and these deaths can include suicide and homicides that are related to the pregnancy, he explains.
MMRCs would need to interview law enforcement and others to determine whether a homicide or suicide is pregnancy-related. “Does it look like this is a homicide that might have occurred if there was not this new stressor in the relationship?” Kramer asks.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
- Analysis of Federal Bills to Strengthen Maternal Health Care. KFF, Women’s Health Policy. Dec. 21, 2020. https://www.kff.org/womens-health-policy/fact-sheet/analysis-of-federal-bills-to-strengthen-maternal-health-care/#:~:text=The%20115th%20Congress%20passed,in%20the%202019%2D2020%20session
- Davis D. State legislators are taking the maternal mortality crisis into their own hands. The 19th. April 26, 2024. https://19thnews.org/2024/04/state-legislators-maternal-mortality-review-committees/
- Wadman M. COVID-19 starkly increases pregnancy complications, including stillbirths, among the unvaccinated, Scottish study shows. Science. Jan. 14, 2022. https://www.science.org/content/article/covid-19-starkly-increases-pregnancy-complications-including-stillbirths-among
- Study: Maternal death rates in the U.S. may be overstated dure to faulty surveillance. News Medical Life Sciences. March 13, 2024. https://www.news-medical.net/news/20240313/Study-Maternal-death-rates-in-the-US-may-be-overstated-due-to-faulty-surveillance.aspx
- Joseph KS, Lisonkova S, Boutin A, et al. Maternal mortality in the United States: Are the high and rising rates due to changes in obstetric factors, maternal medical conditions, or maternal mortality surveillance. Am J Obstet Gynecol. 2024;230(4):P440.E1-440.E13.
- Taladrid S. Did an abortion ban cost a young Texas woman her life? The New Yorker. Jan. 8. 2024. https://www.newyorker.com/magazine/2024/01/15/abortion-high-risk-pregnancy-yeni-glick
- Homicide leading cause of death for pregnant women in U.S. Harvard T.H. Chan School of Public Health. Oct. 21, 2022. https://hsph.harvard.edu/news/homicide-leading-cause-of-death-for-pregnant-women-in-u-s/
- Yu H, Shen Q, Brann E, et al. Perinatal depression and risk of suicidal behavior. JAMA. 2024;7(1):e2350897.
Determining a city, state, or country’s maternal mortality rate is challenging and can be a controversial process. It depends on the time frame measured, whether maternal deaths are considered only if there are biomedical causes, or when there are factors related to pregnancy, such as suicides and homicides that would have not occurred if the person had not had a pregnancy.
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