The check box - Determining pregnancy status to improve maternal mortality surveillance

Objective: More than half of pregnancy-related deaths are not identified through routine surveillance methods. The purpose of this study was to evaluate the effectiveness of the pregnancy check box on death certificates in ascertaining pregnancy-related deaths. Methods: Data derived from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System were used to identify states that included a check box on the death certificate in 1991 and 1992. Death certificates from those states were evaluated to determine the number and proportion of pregnancy-related deaths identified by a marked check box. Characteristics of death were also examined. Results: Sixteen states and New York City included a check box or question specifically asking about pregnancy of the decedent. Of the 425 pregnancy-related deaths identified in the 17 reporting areas, 124 (29%) were determined to be pregnancy-related deaths only because of the pregnancy status information provided in the check box. The proportion of deaths identified only by a marked check box ranged from less than 5% for four states to 40% or more for seven states. Conclusions: The availability of pregnancy status information on death certificates is a simple and effective aid in ascertaining a pregnancy-related death, when no other indicators of pregnancy appear on the death certificate. Routine use of the pregnancy check box for all states would lead to substantially increased classification of maternal deaths and more accurate classification of the causes of and risk factors for maternal deaths.