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The Impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017
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January 2020
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[PDF-5.53 MB]
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Description:Background: National maternal mortality rates (MMRs) using mortality data from the National Vital Statistics System have not been reported since 2007 due to the staggered implementation of the 2003 U.S. Standard Certificate of Death between 2003 and 2017, which added a checkbox to determine pregnancy status at the time of death. This report evaluates the impact of the staggered implementation of the pregnancy checkbox and potential outcome misclassification on MMRs and related trends from 1999 through 2017.
Methods: Log-binomial regression models were used to examine the impact of the staggered implementation of the pregnancy checkbox by states over time and to predict MMRs under two alternative scenarios: (1) assuming that no states had the checkbox at any point, and (2) assuming that all states had the checkbox from 1999 through 2017. The impact of the checkbox and related trends over time were examined by age, race and Hispanic origin, state of occurrence, and causes of maternal death. Sensitivity analyses examined the impact of outcome misclassification.
Results: The implementation of the checkbox was associated with an increased identification of maternal deaths. Averaging over the period 2003–2017, the checkbox resulted in an MMR increase of 9.6 deaths per 100,000 live births (95% confidence interval: 8.6–10.6). The average impact of the checkbox adoption was greater for women aged 40 and over, non-Hispanic black women, and for certain causes of death. Accounting for the checkbox, predicted MMRs did not change significantly from 1999 through 2017, although trends varied by subgroup (age, race and Hispanic origin, cause of death).
Conclusions: Estimated trends suggest that the observed increases in MMRs from 1999 through 2017 reported in the literature were largely due to the staggered implementation of the checkbox. Potential misclassification of pregnancy status using the pregnancy checkbox likely also contributed, which disproportionately inflated MMRs among women aged 40 and over.
Suggested citation: Rossen LM, Womack LS, Hoyert DL, Anderson RN, Uddin SFG. The impact of the pregnancy checkbox and misclassification on maternal mortality trends in the United States, 1999–2017. National Center for Health Statistics. Vital Health Stat 3(44). 2020.
CS313703
sr03_044-508.pdf
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