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 to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. Methods The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement.Results Out of the 89 cases certified by attending physicians, 47% (n=42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n=16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n=11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ=0.53) and underlying cause group (κ=0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ=0.69 vs κ=0.63) was better than between the Surinamese and the Netherlands MDR committees (κ=0.48 vs κ=0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ=0.85) and obstetric hemorrhage (κ=0.74) and fair for unspecified (κ=0.29) and other direct causes (κ=0.32). Conclusions Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

Maternal Mortality in Suriname

“…In complex cases, involving several comorbidities or the co-occurrence of direct and indirect conditions, determination of the initiating event leading eventually to death is challenging. 49 In both situations, post-mortem autopsy is the gold standard to clarify most of the uncertain causes. However, it is seldom performed in Suriname due to financial and cultural reasons.…”