Assigning cause of maternal death: a comparison of findings by a facility-based review team, an expert panel using the new ICD-MM cause classification and a computer-based program (InterVA-4)

BJOG. 2016 Sep;123(10):1647-53. doi: 10.1111/1471-0528.13969. Epub 2016 Mar 9.


Objective: To compare methodology used to assign cause of and factors contributing to maternal death.

Design: Reproductive Age Mortality Study.

Setting: Malawi.

Population: Maternal deaths among women of reproductive age.

Methods: We compared cause of death as assigned by a facility-based maternal death review team, an expert panel using the International Classification of Disease, 10th revision (ICD-10) cause classification for deaths during pregnancy, childbirth and the puerperium (ICD-MM) and a computer-based probabilistic program (InterVA-4).

Main outcome measures: Number and cause of maternal deaths.

Results: The majority of maternal deaths occurred at a health facility (94/151; 62.3%). The estimated maternal mortality ratio was 363 per 100 000 live births (95% CI 307-425). There was poor agreement between cause of death assigned by a facility-based maternal death review team and an expert panel (κ = 0.37, 86 maternal deaths). The review team considered 36% of maternal deaths to be indirect and caused by non-obstetric complications (ICD-MM Group 7) whereas the expert panel considered only 17.4% to be indirect maternal deaths with 33.7% due to obstetric haemorrhage (ICD-MM Group 3). The review team incorrectly assigned a contributing condition rather than cause of death in up to 15.1% of cases. Agreement between the expert panel and InterVA-4 regarding cause of death was good (κ = 0.66, 151 maternal deaths). However, contributing conditions are not identified by InterVA-4.

Conclusions: Training in the use of ICD-MM is needed for healthcare providers conducting maternal death reviews to be able to correctly assign underlying cause of death and contributing factors. Such information can help to identify what improvements in quality of care are needed.

Tweetable abstract: For maternal deaths assigning cause of death is best done by an expert panel and helps to identify where quality of care needs to be improved.

Keywords: Cause of death classification; ICD-MM; InterVA-4; expert panel; maternal death review.

Publication types

  • Comparative Study
  • Multicenter Study

MeSH terms

  • Adult
  • Cause of Death*
  • Consensus*
  • Female
  • Humans
  • International Classification of Diseases*
  • Malawi / epidemiology
  • Maternal Death / classification*
  • Maternal Mortality
  • Middle Aged
  • Parturition*
  • Pregnancy
  • Pregnancy Complications / classification*
  • Pregnancy Complications / mortality
  • Retrospective Studies
  • Risk Factors
  • Software*
  • Uterine Hemorrhage / epidemiology