Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by physicians, national and international maternal death review committees

Abstract Background: Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework for uniform classifications which enables comparison within and between countries and over time. However, despite using the guidelines, differences in classifying pregnancy-related deaths within and among countries remain. We evaluated consensus on maternal death classification using ICD-MM.Methods: Classification of the 2010-2014 pregnancy-related deaths in Suriname were compared (1) between the attending physician (death certificate/medical record) and the national maternal death review (MDR) committee; and (2) between MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied ICD-MM. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.Results: Nearly half (n=42) of the 89 cases reviewed by the Surinamese MDR committee were classified differently by the attending physicians. There was consensus among the three committees that 16 (18%) possible pregnancy-related deaths were not maternal, with opinions differing on 11 (15%, n=73) maternal deaths. Classification agreement into direct, indirect or unspecified (κ=0.53) and underlying cause attribution (κ=0.52) was moderate. The Dutch committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese MDR committees (4%). The Surinamese and Jamaican committees achieved better mutual agreement (κ=0.69) than Surinamese and the Dutch committees (κ=0.48). Agreement on the underlying cause category was best for abortive outcomes (κ=0.85) and obstetric hemorrhage (κ=0.74) and worst for unspecified (κ=0.29) and other direct causes (κ=0.32). Conclusions: Maternal death classification differs within Suriname and among MDR committees from different countries. Specific challenges applying ICD-MM included attribution of underlying cause when co-morbidities occur, inclusion of suicides, and maternal deaths occurring outside the country of residence.