Maternal Mortality in the United States: Are the High and Rising Rates Due to Changes in Obstetrical Factors, Maternal Medical Conditions, or Maternal Mortality Surveillance?

( Am J Obstet Gynecol. 2024;230:440.e1–440.e13. doi: 10.1016/j.ajog.2023.12.038) Maternal health concerns in the United States have intensified due to rising maternal mortality rates (MMR). However, there is skepticism about the accuracy of these estimates. Maternal mortality is often underreported, even in countries with reliable vital registration systems, as pregnancy status at the time of death can be overlooked. In 2003, adding a pregnancy checkbox to death certificates was recommended by the National Center for Health Statistics (NCHS). Although this led to an apparent increase in MMRs from 2003 to 2017, further analysis revealed that the increase was an artifact, with errors such as older women being incorrectly certified as pregnant at the time of death. Subsequently, NCHS introduced new guidelines restricting the use of the pregnancy checkbox to deaths among women aged 15 to 44 years to minimize errors.