Proposed revision of definitions
of maternal deaths
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Contents
Rationale ............................................................................................................................................. 5
Objectives ............................................................................................................................................ 6
Proposed Definitions ........................................................................................................................... 6
1. Comprehensive definition (integrating) ...................................................................................... 6
2. Definitions derived from the comprehensive definition maternal death ..................................... 7
I. Direct obstetric deaths.............................................................................................................. 8
II. Indirect obstetric deaths .......................................................................................................... 8
III. Late maternal death ............................................................................................................... 9
IV. Maternal death from sequelae of obstetric causes ................................................................. 9
V. Pregnancy-related death not classified as maternal death ..................................................... 10
VI. Pregnancy-related death due to external causes .................................................................. 10
International reporting (Volume 2 of ICD-10) .................................................................................. 11
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Rationale
The certification and coding of the causes of maternal death has been an ongoing challenge, even
in cases of confirmed or suspected causes of maternal death where clinical summaries or verbal
autopsies are available.
This difficulty is one of the factors responsible for “misclassification,” which, along with incomplete
reporting, accounts for the underreporting of maternal deaths in many countries. For this reason,
the World Health Organization (WHO), in coordination with other international organizations,
publishes internationally comparable maternal mortality estimates to periodically monitor the
indicator’s behavior, rather than using figures reported by the countries.1,2,3,4
Some of the problems responsible for misclassification have been identified by maternal mortality
committees and researchers
5,6,7,8
; these problems can be reduced through changes in the
procedures of the International Statistical Classification of Diseases and Related Health Problems
(ICD-10)9.
The main problems have been detected in some definitions that have had little changes since their
incorporation in the ICD-910, while others are attributable to coding procedures, especially where
indirect obstetric causes, late maternal death, or death due to sequelae are involved-phenomena
that have been on the rise in recent years11,12,13,14,15.
World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund
(UNFPA), World Bank. Trends in maternal mortality: 1990 to 2008. Geneva: WHO; 2010.
2 World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund
(UNFPA), World Bank. Trends in maternal mortality: 1990 to 2010. Geneva: WHO; 2012.
3 World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund
(UNFPA), World Bank, United Nations Population Division. Trends in maternal mortality: 1990 to 2013. Estimates by
WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division. Geneva: WHO; 2014.
4 WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Trends in maternal mortality:
1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.
Geneva: World Health Organization; 2015.
5
Berg C, Danel I, Atrash H, Zane S, Bartlett L (Editors). Strategies to reduce pregnancy-related deaths: from
identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001.
6 Laurenti R, Buchalla CM, Lolio CA, Santo, AH, Mello J. Mortalidade de mulheres em edade fértil no Municipio de Sao
Paulo (Brasil), 1986. II Mortes por causas maternas. Rev Saude Publica 1990; 24(6):468-72.
7
Mortalidad Materna en México durante 2009. El efecto de las infecciones respiratorias agudas (neumonía e influenza).
México: Secretaría de Salud. 2011.
8
Observations to the document: “The WHO Application of ICD-10 to deaths during pregnancy, childbirth, and the
puerperium: ICD MM”. Prepared by the Collaborating Centers for the WHO Family of International Classifications (FIC)
in Brazil and Mexico and the Health Information and Analysis Project of the Pan American Health Organization
(HA/PAHO).
9
International Statistical Classification of Diseases and Related Health Problems. 10th revision. Geneva: World Health
Organization; 2010.
10
International Classification of Diseases. 9th Revision. Geneva: World Health Organization; 1978.
11
Cross S. Bel J. Graham W. What you count is what you target: the implications of maternal death classification for
tracking progress towards reducing maternal mortality in developing countries. Bull World Health Organ 2010; 88: 147153.
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Objectives
To describe proposals for modifying certain definitions of maternal death as a means of facilitating
better classification, and discuss the feasibility of approving and incorporating modifications to the
ICD suggested by users.
The objective of this review is to request comments on the utility and clarity of these proposals for
the purposes of improving documentation on maternal mortality. Please note that the final
outcomes of this process will require further review by the International Classification of Diseases,
Mortality Reference Group and Update and Revision Committee and will be implemented only
upon approval by the ICD reference and review bodies.
Proposed Definitions
Proposal for definitions: provide an integrating definition and derived definitions
1. Comprehensive definition (integrating)
Current definition
Proposed definition
Pregnancy-related death (death occurring
during pregnancy, childbirth and
puerperium)
is the death of a woman while pregnant or
within 42 days of termination of the
pregnancy, irrespective of the cause of
death (obstetric and non-obstetric).
Pregnancy-related death
is the death of a woman while pregnant or
within the 42 days of termination of the
pregnancy (puerperium), irrespective of the
cause of death (obstetric and non-obstetric),
or when it occurs after the puerperium but is
from complications or sequelae of direct or
indirect obstetric causes.
Torres LM, Rhenals AL, Jiménez A, Ramírez-Villalobos D, Urióstegui R, Piña M, Rocha H. Búsqueda intencionada y
reclasificación de muertes maternas en México: el efecto en la distribución de las causas. Salud Pública Mex 2014;
56:333-347.
13 Hogan M C, Saavedra-Avendano B, Darney BG, Torres-Palacios LM, Rhenals-Osorio A L, Vázquez Sierra B L, et al.
Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study. Distribution of Time after Delivery of
Maternal Deaths in Mexico, 2010-2013. Bull World Health Organ 2016; 94: 362–369B.
14 Lamadrid-Figueroa H, Montoya A, Fritz J, Olvera M, Torres LM, Lozano R. Towards an inclusive and evidence-based
definition of the Maternal Mortality Ratio: an analysis of the distribution of time after delivery of maternal deaths in
Mexico, 2010-2013. PLoS ONE. 2016;11(6): e0157495.
15 De Cosio FG, Jiwani SS, Sanhueza A, Soliz PN, Becerra-Posada F, Espinal MA. (2016) Late Maternal Deaths and
Deaths from Sequelae Of Obstetric Causes in the Americas form 1999-2013: A Trend Analysis. PLOS ONE. 2016:11 (9);
e0160642.
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Rationale:

Unlike the current definition, this proposed definition encompasses all definitions and deaths
that are related to maternal deaths, because it takes into account late obstetric deaths and
those from sequelae of obstetric complications.

All pregnancy-related deaths should be cause for surveillance and analysis, in order to
determine their magnitude and establish preventive measures.

In some cases, deaths occurring during pregnancy, childbirth, or puerperium are mistakenly
classified as non-maternal and are omitted from analysis, leading to a lack of information on
their magnitude and behavior.

In order to provide a standardized definition of puerperium for the purposes of the ICD, it is
defined as the 42-day period following the termination of pregnancy.
2. Definitions derived from the comprehensive definition maternal death
Current definition
Proposed definition
A maternal death is the death of a woman
A maternal death is the death of a woman
while pregnant or within 42 days of
while pregnant or within 42 days of
termination of pregnancy, irrespective of the
termination of pregnancy, irrespective of the
duration and the site of the pregnancy, from
duration, site and form of ending, from any
any cause related to or aggravated by the
cause related to or aggravated by the
pregnancy or its management, but not from
pregnancy or its management, but not from
accidental or incidental causes.
external causes (V01-Y36, Y85-Y98), except
for complications of medical and surgical care
(Y40-Y84) of direct and indirect obstetric
causes.
Rationale:

This is equivalent to the current definition and will make it possible to monitor the traditional
Maternal Mortality Ratio (MMR per 100 000 live birth) indicator.

The terms accidental and incidental, whose interpretation causes confusion and leads to the
exclusion of a proportion of maternal deaths, are eliminated.

Some, but not all, external causes are excluded, since complications of medical and surgical
care related to direct and indirect obstetric causes are part of the chain of events leading to
death.
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
Chapter XV currently contains only some of the complications of procedures, but not all those
deriving from treatment related to direct and indirect obstetric causes (e.g., adverse effects of
other drugs, blood and blood derivatives; errors or omissions in surgical procedures; foreign
bodies left in the body cavity; etc.) that are sometimes responsible for erroneously classifying
deaths as non-maternal. These should be classified as direct or indirect obstetric deaths,
depending on the underlying cause being treated when the medical error or adverse reaction
occurred.

The term “incidental” is excluded because it refers to any event or cause that interrupts a
process, and thus is inconsistent with the definition of death due to indirect obstetric causes,
since many diseases that appear suddenly during pregnancy, childbirth, or puerperium are
“incidental.”
I. Direct obstetric deaths
Current definition
Proposed definition
Those resulting from obstetric complications
of the pregnant state (pregnancy, labour and
puerperium), from interventions, omissions
or incorrect treatment, or from a chain of
events resulting from any of the above.
Those resulting from obstetric complications of
the pregnant state (pregnancy, labour and
puerperium), from medical and surgical
interventions to treat these complications,
from omissions in treatment, from incorrect
treatment, or from a chain of events resulting
from any of the above.
Rationale:

The added phrase referring to medical and surgical interventions provides precision, ensuring
that deaths from these types of complications are not excluded from maternal deaths, since
they are part of the chain of events, as it was explained in the definition of maternal death.
II. Indirect obstetric deaths
Current definition
Proposed definition
Those resulting from previous existing
disease or disease that developed during
pregnancy and that was not due to direct
obstetric causes, but that was aggravated by
physiologic effects of pregnancy.
Those resulting from previous existing disease
or disease that developed during pregnancy
and that was not due to direct obstetric causes,
but that was aggravated by physiological
effects of pregnancy, childbirth or puerperium;
these diseases may also affect the course of
pregnancy, childbirth or puerperium.
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Rationale:

The inclusion notes in categories O98 and O99 refer to diseases that affect or may be affected
by pregnancy, childbirth, or puerperium; thus, these categories should be included in the
definition.

The effect of a disease on pregnancy, childbirth, or puerperium is not always evident through a
direct obstetric complication (for example, acute fetal disstress, preterm delivery, or abruptio
placentae, among others); thus, the absence of these complications is not a reason to rule out
a death as indirect obstetric death.
III. Late maternal death
Current definition
Proposed definition
This definition does not require changes.
IV. Maternal death from sequelae of obstetric causes
Current definition
Proposed definition
There is no definition.
Is the death of a woman from the residual
effects of direct or indirect obstetric causes
occurring a year or more after the
termination of pregnancy.
Rationale:
 This definition does not currently exist in the ICD-10; it is supplementary to the derived
definitions.
 There is a specific category in the ICD-10 for these deaths, as well as for late maternal
deaths.
 Their frequency has been increasing, along with the frequency of late maternal deaths;
these sequelae must be addressed in a timely fashion and their effects on the quality of life
evaluated.
 The absence of this definition leads to such deaths not being included in maternal death
statistics.
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V. Pregnancy-related death not classified as maternal death
Current definition
Proposed definition
There is no definition.
Is the death during pregnancy, childbirth, or
puerperium not due to external causes or
the interaction between pregnancy and the
condition; such that the death is not
classified as an indirect obstetric cause.
Rationale:
 This expands the spectrum of mortality related to pregnancy, childbirth, or puerperium
where a cause could not be determined, or where indirect obstetric complications were
identified as the cause.
 Pregnancy, childbirth, and puerperium may be factors associated with certain diseases, and
should be evaluated.
VI. Pregnancy-related death due to external causes
Current definition
Proposed definition
There is no definition.
Is the death during pregnancy, childbirth, or
puerperium due to external causes, except
for complications of medical and surgical care
(Y40-Y84) of direct and indirect obstetric
causes.
Rationale:
 This expands the spectrum of mortality related to pregnancy, childbirth, or puerperium
where the death is due to external causes.
 Information would be provided to gauge magnitude, frequency, and trends, and particularly
to expand preventive measures for causes of this type.
 Pregnancy, childbirth, and puerperium may be factors associated with certain external
causes, and should be evaluated.
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International reporting (Volume 2 of ICD-10)
Current note
Proposed note
For the purpose of the international reporting
of maternal mortality, only those maternal
deaths occurring before the end of the 42-day
reference period should be included in the
calculation of the various ratios and rates,
although the recording of later deaths is
useful for national analytical purposes.
For the purpose of the international reporting
of maternal mortality, in calculating of the
various rates and ratios should separately
include: (a) direct and indirect obstetric deaths
occurring before the end of the 42-day
reference period; and (b) late obstetric deaths
and deaths from sequelae, so that the nature
of these phenomena can be studied.
For purposes of national analysis, it is
recommended that records of pregnancyrelated deaths not classified as maternal
deaths be maintained, as well as records of
pregnancy-related deaths due to external
causes.
Rationale:
 It is specified that indirect obstetric causes should not be omitted.
 The separate study, evaluation, and monitoring of late obstetric deaths and deaths from
sequelae is also encouraged.
 The study of related deaths not classified as maternal is also encouraged.
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