The annual publication of the US maternal mortality rate leads to extensive, often alarmed, commentary from politicians, public health officials, and women’s health advocates. The official 2021 rate from the National Vital Statistics System (NVSS) was 32.9 maternal deaths per 100 000 births,1 which is the highest rate since 1964. The US rate, even accounting for COVID-19–related cases,2 remains higher than any other high-income country. [JAMA]
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There are currently 3 different government data sources on US maternal mortality: the NVSS, which provides official reports used for international comparisons (includes deaths related to pregnancy that occur during pregnancy and up to 42 days postpartum); the Centers for Disease Control and Prevention’s Pregnancy Related Mortality Surveillance System (PMSS), which reports the pregnancy-related mortality rate (pregnancy-related deaths that occur during pregnancy and up to 1 year postpartum); and state Maternal Mortality Review Committees (MMRCs), which report either or both of these rates for individual states, as well as a third category of pregnancy-associated deaths (deaths of pregnant/birthing people whether related to pregnancy or not). All 3 measures rely on state vital statistics systems to provide the initial data, which are then refined into mortality estimates using different approaches. These different sources typically yield inconsistent estimates of the magnitude of, and trends in, maternal mortality, with the NVSS system reporting a core national public health measure more than 50% higher than the PMSS. The NVSS system does have the considerable advantage of timeliness, having already produced a 2021 national estimate. In contrast, the most recent PMSS rate is for 2019, and most state MMRCs have not published rates past 2017.
It is challenging to identify deaths in those who were pregnant or recently pregnant and then make a judgment as to whether the pregnancy caused or contributed to the death.3 The World Health Organization has offered guidance on improving identification of pregnancy-related deaths, including adding a pregnancy checkbox to death certificates asking certifiers to identify whether the individual had been pregnant at the time of death or the death occurred within 42 days or 1 year of a birth.4 The US added the checkbox in a 2003 revision of the standard death certificate and all states adopted the pregnancy checkbox by 2018, although California opted to exclude the 42-day cutoff.5 Although the checkbox has improved identification of deaths during pregnancy, NVSS research identified numerous false-positive responses associated with the pregnancy checkbox, and steps have been taken to minimize this problem.5
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