09 February 2016
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Proposed revision of definitions
of maternal deaths
Contents
Rationale 5
Objectives 6
Proposed Definitions 6
1. Comprehensive definition (integrating) 6
2. Definitions derived from the comprehensive definition maternal death 7
I. Direct obstetric deaths 8
II. Indirect obstetric deaths 8
III. Late maternal death 9
IV. Maternal death from sequelae of obstetric causes 9
V. Pregnancy-related death not classified as maternal death 10
VI. Pregnancy-related death due to external causes 10
International reporting (Volume 2 of ICD-10) 11
Rationale
The certification and coding of the causes of maternal death has been an ongoing challenge, even in cases of confirmed or suspected causes of maternal death where clinical summaries or verbal autopsies are available.
This difficulty is one of the factors responsible for “misclassification,” which, along with incomplete reporting, accounts for the underreporting of maternal deaths in many countries. For this reason, the World Health Organization (WHO), in coordination with other international organizations, publishes internationally comparable maternal mortality estimates to periodically monitor the indicator’s behavior, rather than using figures reported by the countries.[1],[2],[3],[4]
Some of the problems responsible for misclassification have been identified by maternal mortality committees and researchers [5],[6],[7],[8]; these problems can be reduced through changes in the procedures of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)[9].
The main problems have been detected in some definitions that have had little changes since their incorporation in the ICD-9[10], while others are attributable to coding procedures, especially where indirect obstetric causes, late maternal death, or death due to sequelae are involved-phenomena that have been on the rise in recent years[11],[12],[13],[14],[15].
Objectives
To describe proposals for modifying certain definitions of maternal death as a means of facilitating better classification, and discuss the feasibility of approving and incorporating modifications to the ICD suggested by users.
The objective of this review is to request comments on the utility and clarity of these proposals for the purposes of improving documentation on maternal mortality. Please note that the final outcomes of this process will require further review by the International Classification of Diseases, Mortality Reference Group and Update and Revision Committee and will be implemented only upon approval by the ICD reference and review bodies.
Proposed Definitions
Proposal for definitions: provide an integrating definition and derived definitions
1. Comprehensive definition (integrating)
Current definition / Proposed definitionPregnancy-related death (death occurring during pregnancy, childbirth and puerperium)
is the death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the cause of death (obstetric and non-obstetric). / Pregnancy-related death
is the death of a woman while pregnant or within the 42 days of termination of the pregnancy (puerperium), irrespective of the cause of death (obstetric and non-obstetric), or when it occurs after the puerperium but is from complications or sequelae of direct or indirect obstetric causes.
Rationale:
· Unlike the current definition, this proposed definition encompasses all definitions and deaths that are related to maternal deaths, because it takes into account late obstetric deaths and those from sequelae of obstetric complications.
· All pregnancy-related deaths should be cause for surveillance and analysis, in order to determine their magnitude and establish preventive measures.
· In some cases, deaths occurring during pregnancy, childbirth, or puerperium are mistakenly classified as non-maternal and are omitted from analysis, leading to a lack of information on their magnitude and behavior.
· In order to provide a standardized definition of puerperium for the purposes of the ICD, it is defined as the 42-day period following the termination of pregnancy.
2. Definitions derived from the comprehensive definition maternal death
Current definition / Proposed definitionA maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. / A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration, site and form of ending, from any cause related to or aggravated by the pregnancy or its management, but not from external causes (V01-Y36, Y85-Y98), except for complications of medical and surgical care (Y40-Y84) of direct and indirect obstetric causes.
Rationale:
· This is equivalent to the current definition and will make it possible to monitor the traditional Maternal Mortality Ratio (MMR per 100 000 live birth) indicator.
· The terms accidental and incidental, whose interpretation causes confusion and leads to the exclusion of a proportion of maternal deaths, are eliminated.
· Some, but not all, external causes are excluded, since complications of medical and surgical care related to direct and indirect obstetric causes are part of the chain of events leading to death.
· Chapter XV currently contains only some of the complications of procedures, but not all those deriving from treatment related to direct and indirect obstetric causes (e.g., adverse effects of other drugs, blood and blood derivatives; errors or omissions in surgical procedures; foreign bodies left in the body cavity; etc.) that are sometimes responsible for erroneously classifying deaths as non-maternal. These should be classified as direct or indirect obstetric deaths, depending on the underlying cause being treated when the medical error or adverse reaction occurred.
· The term “incidental” is excluded because it refers to any event or cause that interrupts a process, and thus is inconsistent with the definition of death due to indirect obstetric causes, since many diseases that appear suddenly during pregnancy, childbirth, or puerperium are “incidental.”
I. Direct obstetric deaths
Current definition / Proposed definitionThose resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions or incorrect treatment, or from a chain of events resulting from any of the above. / Those resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from medical and surgical interventions to treat these complications, from omissions in treatment, from incorrect treatment, or from a chain of events resulting from any of the above.
Rationale:
· The added phrase referring to medical and surgical interventions provides precision, ensuring that deaths from these types of complications are not excluded from maternal deaths, since they are part of the chain of events, as it was explained in the definition of maternal death.
II. Indirect obstetric deaths
Current definition / Proposed definitionThose resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes, but that was aggravated by physiologic effects of pregnancy. / Those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes, but that was aggravated by physiological effects of pregnancy, childbirth or puerperium; these diseases may also affect the course of pregnancy, childbirth or puerperium.
Rationale:
· The inclusion notes in categories O98 and O99 refer to diseases that affect or may be affected by pregnancy, childbirth, or puerperium; thus, these categories should be included in the definition.
· The effect of a disease on pregnancy, childbirth, or puerperium is not always evident through a direct obstetric complication (for example, acute fetal disstress, preterm delivery, or abruptio placentae, among others); thus, the absence of these complications is not a reason to rule out a death as indirect obstetric death.
III. Late maternal death
Current definition / Proposed definitionThis definition does not require changes.
IV. Maternal death from sequelae of obstetric causes
Current definition / Proposed definitionThere is no definition. / Is the death of a woman from the residual effects of direct or indirect obstetric causes occurring a year or more after the termination of pregnancy.
Rationale:
· This definition does not currently exist in the ICD-10; it is supplementary to the derived definitions.
· There is a specific category in the ICD-10 for these deaths, as well as for late maternal deaths.
· Their frequency has been increasing, along with the frequency of late maternal deaths; these sequelae must be addressed in a timely fashion and their effects on the quality of life evaluated.
· The absence of this definition leads to such deaths not being included in maternal death statistics.
V. Pregnancy-related death not classified as maternal death
Current definition / Proposed definitionThere is no definition. / Is the death during pregnancy, childbirth, or puerperium not due to external causes or the interaction between pregnancy and the condition; such that the death is not classified as an indirect obstetric cause.
Rationale:
· This expands the spectrum of mortality related to pregnancy, childbirth, or puerperium where a cause could not be determined, or where indirect obstetric complications were identified as the cause.
· Pregnancy, childbirth, and puerperium may be factors associated with certain diseases, and should be evaluated.
VI. Pregnancy-related death due to external causes
Current definition / Proposed definitionThere is no definition. / Is the death during pregnancy, childbirth, or puerperium due to external causes, except for complications of medical and surgical care (Y40-Y84) of direct and indirect obstetric causes.
Rationale:
· This expands the spectrum of mortality related to pregnancy, childbirth, or puerperium where the death is due to external causes.
· Information would be provided to gauge magnitude, frequency, and trends, and particularly to expand preventive measures for causes of this type.
· Pregnancy, childbirth, and puerperium may be factors associated with certain external causes, and should be evaluated.
International reporting (Volume 2 of ICD-10)
Current note / Proposed noteFor the purpose of the international reporting of maternal mortality, only those maternal deaths occurring before the end of the 42-day reference period should be included in the calculation of the various ratios and rates, although the recording of later deaths is useful for national analytical purposes. / For the purpose of the international reporting of maternal mortality, in calculating of the various rates and ratios should separately include: (a) direct and indirect obstetric deaths occurring before the end of the 42-day reference period; and (b) late obstetric deaths and deaths from sequelae, so that the nature of these phenomena can be studied.
For purposes of national analysis, it is recommended that records of pregnancy-related deaths not classified as maternal deaths be maintained, as well as records of pregnancy-related deaths due to external causes.
Rationale:
· It is specified that indirect obstetric causes should not be omitted.
· The separate study, evaluation, and monitoring of late obstetric deaths and deaths from sequelae is also encouraged.
· The study of related deaths not classified as maternal is also encouraged.
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9
[1] World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), World Bank. Trends in maternal mortality: 1990 to 2008. Geneva: WHO; 2010.
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[8] Observations to the document: “The WHO Application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium: ICD MM”. Prepared by the Collaborating Centers for the WHO Family of International Classifications (FIC) in Brazil and Mexico and the Health Information and Analysis Project of the Pan American Health Organization (HA/PAHO).
[9] International Statistical Classification of Diseases and Related Health Problems. 10th revision. Geneva: World Health Organization; 2010.
[10] International Classification of Diseases. 9th Revision. Geneva: World Health Organization; 1978.
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[15] De Cosio FG, Jiwani SS, Sanhueza A, Soliz PN, Becerra-Posada F, Espinal MA. (2016) Late Maternal Deaths and Deaths from Sequelae Of Obstetric Causes in the Americas form 1999-2013: A Trend Analysis. PLOS ONE. 2016:11 (9); e0160642.