Maternal death at an inner-city hospital, 1949–2000

Abstract

To the Editors: With great interest we read the article by Ho et al1.Ho E.M. Brown J. Graves W. Lindsay M.K. Maternal death at an inner-city hospital, 1949–2000.Am J Obstet Gynecol. 2002; 187: 1213-1216Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar on maternal mortality in Atlanta. We have, however, some reservations:1.When one aims to generate data on the maternal mortality ratio (MMR), it is important to use internationally accepted definitions as provided by the World Health Organization (WHO) in the International Classification of Diseases (at present in its 10th revision: ICD-10). Otherwise any comparison will lack consistency. The authors, however, did use definitions from 1957 from the American Medical Association, indicating that a maternal death is the death of a woman from any cause that occurs during pregnancy or within 90 days after delivery. This definition does not comply with ICD-10. ICD-10 only recognizes direct and indirect causes as maternal deaths. Deaths that are not related to pregnancy or its complications or management are not included in the MMR in ICD-10. Also, ICD-10 only considers direct and indirect deaths within 42 days after delivery as maternal deaths. When such deaths occur after 42 days and before 365 days after birth, ICD-10 speaks of “late maternal deaths.” In the international literature, reference will never be found to 90 days after delivery.2.The classification of the causes of maternal death is the second issue of concern. Vascular disease (defined as hypertensive vascular disease and vascular embolism) is classified as an indirect cause, and only air and amniotic fluid embolism as direct causes. Everywhere in this world, however, thromboembolism is classified as a direct cause. Also, hepatic disease is classified as an indirect cause in this study, but acute yellow liver atrophy of pregnancy is normally considered to be a direct cause. Human immunodeficiency virus and hepatitis are even classified as unrelated deaths. In the other known confidential inquiries into the causes of maternal deaths from the United Kingdom, the Netherlands, South Africa, Ethiopia, and Surinam, these are classified as indirect causes.2.Why mothers die 1997–1999: the confidential enquiries into maternal deaths in the United Kingdom. RCOG Press, London2001Google Scholar, 3.Schuitemaker N.E.W. van Roosmalen J. Dekker G.A. van Dongen P.W.J. van Geijn H.P. Bennebroek Gravenhorst J. Confidential enquiry into maternal deaths in The Netherlands 1983–1992.Eur J Obstet Gynecol Reprod Biol. 1998; 79: 57-62Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 4.Moodley J, Pattinson B. Saving mothers: report on confidential enquiries into maternal deaths in South Africa 1999-2001 on CD-ROM. Pretoria: 2003.Google ScholarAlso, homicide and suicide in this study are classified as unrelated medical, although some cases of homicide and suicide are indirect causes of maternal deaths in the United Kingdom confidential inquiries.2.Why mothers die 1997–1999: the confidential enquiries into maternal deaths in the United Kingdom. RCOG Press, London2001Google Scholar3.A systematic review of maternal deaths is by nature a retrospective review and this is not a limitation, as the authors state. In conclusion, we recommend the use of universal definitions and classifications when reviewing causes of maternal deaths. There are good reasons to make use of ICD-10 issued by WHO. It will help meaningful worldwide comparison and interpretation.