Maternal mortality in the United States: where are we going and how will we get there?

M aternal mortality is considered a basic health indicator that reflects the adequacy of health care (1). Although the maternal mortality rate (MMR) in the United States (US) is approximately 7.5 per 100,000, most studies suggest that the actual number of maternal deaths is larger because of the continuing problem of under reporting (2). Unfortunately, the goal of reducing the MMR to 5 per 100,000 suggested by the Surgeon General in 1980 has not been attained. Maternal mortality has decreased over the last half of the 20th century but preventable cases continue to occur. Thus, despite numerous improvements in health care, poor outcome in the parturient remains a major public health concern that follows us into the 21st century. Although the majority of the approximately 600,000 annual maternal deaths takes place in third-world countries, western Europe and the US are not immune. As we enter the new millennium, we should ask why these deaths continue and what can be done individually and as a profession to decrease the incidence? In this issue, Panchal et al. (3) review 13 yr of maternal mortality in the State of Maryland using a state-maintained database. By analyzing patient demographics and diagnosis and procedure codes for women who died during their admission for childbirth, these authors identified some medical and demographic risks associated with maternal mortality in their state. This is useful information for physicians and hospitals in Maryland and may also provide a model for other states to examine their maternal mortality data and thus help in efforts to develop important preventative intervention strategies. Panchal et al. (3) found a state delivery mortality ratio (maternal deaths per 100,000 live births) of 16.4, with marked year-to-year variability ranging from 5.9 to 29.6. This compares with the Centers for Disease Control and Prevention (CDC) estimate of a national maternal mortality of 7.5. Other risk factors identified for maternal mortality in their study were AfricanAmerican race (odds ratio [OR], 5.4), racial category other than African-American or White (OR, 12.2), Cesarean delivery (OR, 5.3), delivering in a “minor teaching hospital” (OR, 3.1), and being transferred from another hospital (OR, 6.2). As has been reported in other series, the MMR for women aged ,34 yr was 13.9 as compared with 23.9 with advanced maternal age. The five most common diagnoses associated with maternal mortality were preeclampsia/eclampsia, postpartum hemorrhage, pulmonary complications, cerebrovascular event, and embolism. Anesthesiarelated complications, although not on the top of the list, still accounted for more than 5% of the deaths. The Ninth Revision of the International Classification of Diseases (ICD-9), commonly used in similar studies, defined maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Recently, the tenth revision (ICD-10) has revised that definition to include “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.” It was hoped that the introduction of this new definition would allow better classification, especially in cases in which the cause of death in a pregnant patient was uncertain. Unfortunately, multiple definitions increase the confusion and have helped turn this subject into a quagmire. Results from studies using different definitions cannot be compared and incomplete databases provide information that is at best inaccurate and at worst wrong. When evaluating maternal deaths, under-reporting is the rule, rather than the exception, and may reach as much as 75% (4). Even in the UK, which has the best system for collecting this data, it has been suggested that underestimates are approximately 30% (5). Despite the importance of collecting and analyzing data regarding maternal mortality, in the US this data Accepted for publication February 27, 2001. Address correspondence to David J. Birnbach, MD, Department of Anesthesiology, St. Luke’s-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, Hospital Center, 1000 Tenth Avenue, New York, NY 10019.