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Case Identification

Case Identification Wheel

The first task in pregnancy mortality surveillance is comprehensively identifying pregnancy-associated deaths. Typically, pregnancy-associated deaths are identified by a state’s Office of Vital Records (the official name of this office varies by state). Vital records (birth and death certificates) are the primary sources for identifying pregnancy-associated deaths.


The Office of Vital Records identifies maternal death cases using birth and death certificates in the following ways:

In 2003, the CDC National Center for Health Statistics released revised standards for live birth, death, and fetal death certificates. The revision of the standard death certificate included a set of pregnancy-status checkboxes with five options: Not pregnant within the past year, pregnant at time of death, not pregnant but pregnant within 42 days of death, not pregnant but pregnant between 43 days and one year before death, and unknown.

Vital records offices use the options selected by death registrars on death certificates. From there, death registrars identify potential pregnancy-associated deaths for review by the committee. States are in various stages of implementation of the pregnancy checkboxes. Additionally, some jurisdictions have reported inaccurate use of the checkboxes among death registrars. Therefore, maternal mortality review committees (MMRCs) are encouraged to partner with their Office of Vital Records to use additional means of identifying pregnancy-associated deaths to ensure no deaths are missed.

The cause-of-death section on the death certificate is intended to record immediate and underlying causes of death. Death registrars use International Classification of Diseases (ICD) codes to describe causes of death. If used, there are specific ICD codes that indicate an obstetric cause of death. Vital records offices can search for death certificates that use these specific obstetric cause of death codes to identify potential pregnancy-associated deaths. Vital records offices shouldn’t rely solely on these codes to identify all pregnancy-related deaths, as some jurisdictions have reported inadequate training for physicians or other death registrars on the specific rules that govern coding.

Vital records offices, along with maternal and child health epidemiologists, can link death certificates of reproductive-aged women with other vital records, such as birth certificates and fetal death certificates. These records are linked by common information that is found on both the death certificate of the woman and the birth certificate of the baby (e.g. the name on the death certificate for the reproductive-aged woman and the name of the mother on an infant birth certificate that was registered within one year of the woman’s death). Vital records offices or epidemiologists can maintain an ongoing linked dataset through computerized databases. This method is perhaps the highest quality method for identifying deaths of women during the childbirth hospitalization or in the year after having a live birth or fetal death.


In addition to identifying maternal deaths through vital records, MMRCs may use additional methods for case identification.

  • Newspaper obituaries and other media outlets

    In smaller states, MMRC staff can identify potential cases through newspaper obituaries or news reports.

  • Direct report from hospitals, providers, medical examiners, and coroners

    Based on legislation or statutory authority in some states, some MMRCs have relationships with hospitals and medical providers to support mandatory or voluntary reporting of deaths that take place in maternity units. In these states, the death is reported directly to the MMRC coordinator at a state health department. Additionally, MMRCs may have relationships in place with professionals responsible for investigating and certifying deaths (e.g. medical examiners, the state Medical Examiner’s Office, coroners, etc.). These relationships facilitate direct reporting to the MMRC when those professionals receive cases of pregnant women or women who were pregnant within the past year.