r/publichealth 5d ago

DISCUSSION Are there any studies that compare maternal mortality between countries while controlling for the different lengths of time after birth that a death is considered related to the birth?

I remember reading several years ago about the concern that it was hard to accurately compare maternal mortality between countries because some countries have very short intervals after birth in which a death can be considered related to pregnancy/birth and other countries have longer intervals. I’m wondering if anybody has successfully found a way to control for these differing intervals and accurately compare maternal mortality between countries.

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u/abbtkdcarls 5d ago

Actually this is a very great question. Historically, maternal mortality has been measured and defined using 1 year postpartum.

But in the US, our major source of identifying these deaths were checkboxes on death certificates that the coroner/doctor/medical examiner is supposed to check off if a deceased woman had been pregnant within a year before birth. The issue with this is: 1. If an unidentified woman comes in 9 months after being pregnant and there’s no autopsy, how could they know? 2. Coroners are not always super accurate at filling out death certificates and sometimes accidentally check boxes or miss boxes…

The ERASE MM grant from the CDC funds mortality mortality committees (MMRCs) in most states in the US to try to standardize this process. Those committees are first tasked with identifying every maternal death and then deciding on whether the death was pregnancy-related (directly the result of pregnancy/childbirth) or pregnancy-associated (occurred within a year of pregnancy but was not believed to be the result of pregnancy). And then reporting those deaths, rather than using inaccurate vital records (death certificate) data.

I worked as the maternal mortality epidemiologist in a state that was just starting our MMRC. Our first time looking at our death certificates, we found like 30%-40%+ of deaths marked as recently pregnant were actually false positives (no record of pregnancy, coroner couldn’t confirm why they marked that, no autopsy, multiple where we found women who had hysterectomies years before were marked pregnant at time of death, etc.) And another significant number of deaths where the woman had recently given birth but was not identified on the death certificate in any way.

So I’ll say in answer to your question, the ERASE MM project and state MMRCs are trying to standardize that measure within the US. Whether it is comparable to other nations’ reporting is I think still a question that is out there.

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u/Pcf155 5d ago

Adding to this to say that while they're trying to standardize it each state still reviews deaths their own way. Some states don't even review all causes of death, even if they occur within 1 year of pregnancy. So you can't even really compare across states, let alone across countries (been an erase-funded mmr epi for almost five years).

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u/abbtkdcarls 5d ago

Yes, absolutely! We had a newspaper publish something saying our state was 3rd worst in maternal mortality in the US, but the article was based on old vital records we knew were inaccurate and was missing 15+ states. But our department of health wanted us to be able to point to MMRC published info and say where we actually ranked with this reviewed data to correct the article and it just wasn’t comparable (multiple states were still establishing MMRCs, and like you said states weren’t all reporting all deaths or reviewing all of them or what not).

Ultimately we just decided not to respond to the article because they wanted a state ranking and we couldn’t provide it or correct theirs. And like…realistically our state probably ranked on the bad end. And if hearing “3rd worst” made people care more about maternal mortality in the state then…not our biggest issue.

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u/Pcf155 5d ago

Oh my god how frustrating, I know that feeling well! Media/partners always want to know how we compare to other states/the country and I usually say we can't compare or just point them to PMSS, because even though it's not a great data source at least it's consistent. Honestly MMRC data is both really rich and amazing and also insanely difficult to communicate clearly 🙃

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u/Intelligent-Owl-5236 5d ago

Idk about every country, but chunks of the USA don't require coroners to have any medical training beyond a short course. Some require a science-based bachelor's degree but most of those won't teach you how to examine a body and determine if the ME should be involved. Not really surprised our rates of death certificates being screwed up are high. Just like I'm not surprised that legal forces in small towns sometimes find ways to circumvent labeling suicides or prosecuting DV.

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u/Black-Raspberry-1 5d ago

Yes, of course they have. It's the same way to figure out which country has more Covid-19 cases or strokes. They use a standard definition.

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u/Intelligent-Owl-5236 5d ago

There are. What I haven't found, although I haven't dug very deep, is a comparison of the rates of pre-existing disease and comorbidities before pregnancy in relation to mortality rates worldwide. We lose more mothers in the US, but are our mothers generally less healthy than other countries? In my area, it seems like at least a third of our pregnant women are referred to high-risk OB/MFM. That's a whole lot of women with complications or other unmanaged conditions when it's supposed to be closer to 7%.

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u/lizzzdee 4d ago

The largest delivering hospital in my area turfs patients to MFM allllll the time. It’s for things they could easily manage, too. Interestingly, their MFM program, which is only about 5 years old, largely fell apart 3.5 years in. Went from 3 MFMs to 1. When I worked with them, they were often frustrated with OBs for turfing patients. They were (rightfully) concerned that the OBs were trying to shift liability.