Is pregnancy in America deadlier than in other rich countries?

The question is harder to answer than you might think

Few things are more tragic than the death of a woman in pregnancy or childbirth. In America, as in other rich countries, such deaths are extremely rare. An American woman is more likely to be struck by lightning than to die in childbirth. Nonetheless, 700–800 pregnant women and new mothers die each year. By some measures, America’s maternal mortality is several times higher than in rich European countries. By other measures, however, America has the same rate as Britain.

One bit of the puzzle is what counts as a maternal death. The standard definition used in international comparisons, such as those published by the World Health Organisation, is a death from complications of pregnancy if the death occurs between the time a woman becomes pregnant and six weeks after her pregnancy ends.

In rich countries, these deaths are tallied from vital-registration systems which in turn compile data from death certificates. These, however, are known to undercount maternal deaths, partly because doctors must select a cause of death from thousands of codes. They are more likely to consider the subset reserved for medical problems caused by pregnancy when the form has a checkbox asking whether the woman had been pregnant.

America added this checkbox to its standard death certificate in 2003, though it took more than a decade for all states to adopt it. It has been a mixed blessing, says Andreea Creanga of Johns Hopkins University. A recent study found that its growing use accounted for 80% of the steep rise in maternal mortality recorded in 2000–14. Although many maternal deaths that would otherwise go unrecorded are now tallied thanks to the checkbox, it is also often marked erroneously — showing recent pregnancy on the death certificates of women who died in their 50s, for example.

According to data from death certificates, America’s rate is 21 maternal deaths per 100,000 live births. In Britain, which does not use the pregnancy checkbox, the rate is four to five times lower. It is a rate that British health authorities do not consider reliable.

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