Pregnancy-related mortality from preeclampsia and eclampsia.

OBJECTIVE: To examine the role of preeclampsia and eclampsia in pregnancy-related mortality. METHODS: We used data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to examine pregnancy-related deaths from preeclampsia and eclampsia from 1979 to 1992. The pregnancy-related mortality ratio for preeclampsia-eclampsia was defined as the number of deaths from preeclampsia and eclampsia per 100,000 live births. Case-fatality rates for 1988-1992 were calculated for preeclampsia and eclampsia deaths per 10,000 cases during the delivery hospitalization, using the National Hospital Discharge Survey. RESULTS: Of 4024 pregnancy-related deaths at 20 weeks' or more gestation in 1979-1992, 790 were due to preeclampsia or eclampsia (1.5 deaths/100,000 live births). Mortality from preeclampsia and eclampsia increased with increasing maternal age. The highest risk of death was at gestational age 20-28 weeks and after the first live birth. Black women were 3.1 times more likely to die from preeclampsia or eclampsia as white women. Women who had received no prenatal care had a higher risk of death from preeclampsia or eclampsia than women who had received any level of prenatal care. The overall preeclampsia-eclampsia case-fatality rate was 6.4 per 10,000 cases at delivery, and was twice as high for black women as for white women. CONCLUSION: The continuing racial disparity in mortality from preeclampsia and eclampsia emphasizes the need to identify those differences that contribute to excess mortality among black women, and to develop specific interventions to reduce mortality from preeclampsia and eclampsia among all women.

Racial disparity in pregnancy-related mortality associated with livebirth: can established risk factors explain it?

The authors conducted a nested case-control study to determine whether the fourfold increased risk of pregnancy-related mortality for US Black women compared with White women can be explained by racial differences in sociodemographic and reproductive factors. Cases were derived from a national surveillance database of pregnancy-related deaths and were restricted to White women (n = 840) and Black women (n = 448) whose pregnancies resulted in a livebirth and who died of a pregnancy-related cause between 1979 and 1986. Controls were derived from national natality data and were randomly selected White women and Black women who delivered live infants and did not die from a pregnancy-related cause (n = 5,437). Simultaneous adjustment for risk factors by using logistic regression did not explain the racial gap in pregnancy-related mortality. The largest racial disparity occurred among women with the lowest risk of pregnancy-related death: those of low to moderate parity who delivered normal-birth-weight babies (adjusted odds ratio = 3.53, 95% confidence interval: 2.9, 4.4). In contrast, no racial disparity was found among women with the highest risk of pregnancy-related death: high-parity women who delivered low-birth-weight babies. These findings indicate that reproductive health care professionals need to develop strategies to reduce pregnancy-related deaths among both high- and low-risk Black women.

Are interpregnancy intervals between consecutive live births among black women associated with infant birth weight?

OBJECTIVES: The purpose of this study was to determine whether the length of interpregnancy intervals between consecutive live births among Black women had any significant effect on mean birth weight as had previously been reported in another study. DESIGN: We examined a sample (1,048 women, 66% of study participants) from a study of non-Hispanic Black women whose infants were born at a large, inner-city, public hospital in Georgia from October 1988 through August 1990. Data were evaluated for the 494 women whose current and immediately previous pregnancies ended in the birth of a live infant weighing 500 grams or more. METHODS: Linear regression and analysis of covariance models were developed. RESULTS: The median interpregnancy interval was 15 months (range 1 to 207 months), with 19 (4%) of the women having intervals of less than 3 months. After adjustment for parity, gestational age (in weeks), and smoking status, the mean birth weight associated with an interpregnancy interval of three or more months was 3,106 grams, 215 grams greater than that for an interval of less than three months (P = .06). CONCLUSIONS: Although longer birth spacing has been associated with certain positive social and health effects, the population attributable effect on infant birth weight may not be very significant.

Family planning services and programmes in countries of the Eastern Mediterranean Region.

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves.

Maternal mortality surveillance and maternal death reviews in countries of the Eastern Mediterranean Region.

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on maternal mortality surveillance systems and death review activities in the Region. Data were collected by questionnaire completed by ministry of health personnel. The findings show that 13 countries require official reporting of deaths of women of reproductive age. Most of the countries conduct maternal death reviews although only 8 have surveillance systems. Other areas investigated were the sources of information on maternal deaths, types of data collected, how the data are analysed and how such data are used. There is a need to strengthen information systems on maternal mortality in the Region in order to guide decision-makers in the planning and evaluation of maternal health programmes.

Maternal mortality surveillance and maternal death reviews in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on maternal mortality surveillance systems and death review activities in the Region. Data were collected by questionnaire completed by ministry of health personnel. The findings show that 13 countries require official reporting of deaths of women of reproductive age. Most of the countries conduct maternal death reviews although only 8 have surveillance systems. Other areas investigated were the sources of information on maternal deaths, types of data collected, how the data are analysed and how such data are used. There is a need to strengthen information systems on maternal mortality in the Region in order to guide decision-makers in the planning and evaluation of maternal health programmes

Family planning services and programmes in countries of the Eastern Mediterranean Region

This paper presents the findings of a 1999 survey of 19 countries of the World Health Organization Eastern Mediterranean Region on the family planning services and programmes in the Region. Data were collected using a questionnaire which explored the following areas: the presence of population or family planning policies and family planning activities, the family planning services available, promotional and educational activities on family planning, quality assurance, family planning data collection, analysis and dissemination, and the use of such information. The results indicate that 13 of the countries have national policies on population and family planning but even in those that do not, family planning services are widely available. The scope of the services provided varied. There is still a need to implement or strengthen family planning programmes in the Region, a need which is recognized by the countries themselves

Pregnancy-related mortality in the United States due to hemorrhage: 1979-1992.

OBJECTIVE: To study trends and examine risk factors for pregnancy-related mortality due to hemorrhage. METHODS: We analyzed pregnancy-related deaths from 1979-1992 from the National Pregnancy Mortality Surveillance System of the Centers for Disease Control and Prevention. Live-birth data used to calculate mortality ratios were obtained from published vital statistics. Deaths due to ectopic pregnancies were excluded. RESULTS: There were 763 pregnancy-related deaths from hemorrhage associated with intrauterine pregnancies, a ratio of 1.4 deaths per 100,000 live births. The pregnancy-related mortality ratio was higher for black women and those of other races than white women. The risk of pregnancy-related mortality increased with age. Abruptio placentae was the overall leading cause of pregnancy-related death due to hemorrhage. Leading causes of death differed by race, age group, and pregnancy outcome. CONCLUSION: Hemorrhage is the leading cause of pregnancy-related death in the United States. Black women have three times the risk of death of white women. In-depth investigations are needed to ascertain the risk factors associated with those deaths.

Pregnancy-related mortality in Hispanic women in the United States.

OBJECTIVE: To examine pregnancy-related mortality among Hispanic women in the United States. METHODS: We used data from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System to examine all reported pregnancy-related deaths (deaths during or within 1 year of pregnancy that were caused by pregnancy, its complications, or treatment) in states that reported Hispanic origin for 1979-1992. The pregnancy-related mortality ratio was defined as the number of pregnancy-related deaths per 100,000 live births. RESULTS: For the 14-year period, the overall pregnancy-related mortality ratio was 10.3 deaths per 100,000 live births for Hispanic women, 6.0 for non-Hispanic white women, and 25.1 for black women. In Hispanic subgroups, the pregnancy-related mortality ratio was 9.7 for Mexican women and ranged from 7.8 for Cuban women to 13.4 for Puerto Rican women. Pregnancy-induced hypertension was the leading cause of pregnancy-related death for Hispanic women overall. CONCLUSION: Pregnancy-related mortality ratios for Hispanic women were higher than those for non-Hispanic white women, but markedly lower than those for black women. The similarity in socioeconomic status between Hispanic and black women was not an indicator of similar health outcomes. Prevention of pregnancy-related deaths in Hispanic women should include investigation of medical and nonmedical factors and consider the heterogeneity of the Hispanic population.

Spontaneous abortion-related deaths among women in the United States--1981-1991.

OBJECTIVE: To examine trends in spontaneous abortion-related mortality and risk factors for these deaths from 1981 through 1991. METHODS: We used national data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to identify deaths due to spontaneous abortion (less than 20 weeks' gestation). Case-fatality rates were defined as the number of spontaneous abortion-related deaths per 100,000 spontaneous abortions. We calculated annual case-fatality rates as well as risk ratios by maternal age, race, and gestational age. RESULTS: During 1981-1991, a total of 62 spontaneous abortion-related deaths were reported to the Pregnancy Mortality Surveillance System. The overall case fatality rate was 0.7 per 100,000 spontaneous abortions. Maternal age 35 years and older (risk ratio [RR] 1.7, 95% confidence interval [CI] 0.9-3.0), maternal race other than white (RR 3.8, 95% CI 2.2-5.9), and gestational age over 12 weeks (RR 8.0, 95% CI 4.2-11.9) were risk factors for death due to spontaneous abortion. Of the 62 deaths, 59% were caused by infection, 18% by hemorrhage, 13% by embolism, 5% from complications of anesthesia, and 5% by other causes. Disseminated intravascular coagulation (DIC) was an associated condition among half of those deaths for which it was not the primary cause of death. CONCLUSION: Women 35 years of age and older, of races other than white, and in the second trimester of pregnancy age are at increased risk of death from spontaneous abortion. In addition, DIC complicates many spontaneous abortion cases that end in death. Because spontaneous abortion is a common outcome of pregnancy, continued monitoring of spontaneous abortion-related deaths is recommended.

Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991.

The authors estimated the number of clinically recognized pregnancies that occurred annually from 1981 to 1991 in the United States by type of outcome and by race. Estimates of the numbers of livebirths, induced abortions, ectopic pregnancies, and fetal deaths were obtained by using data from the Centers for Disease Control and Prevention in Atlanta, Georgia. The number of spontaneous abortions was estimated by using previously published, age-specific rates. More than 67 million pregnancies occurred during the study period. Overall, 62.5% of these pregnancies resulted in livebirths, 21.9% in legal induced abortions, 13.8% in spontaneous abortions, 1.3% in ectopic pregnancies, and 0.5% in fetal deaths. These data can be used to provide denominators for the calculation of a variety of pregnancy outcome-specific rates.

Postneonatal mortality surveillance--United States, 1980-1994.

PROBLEM/CONDITION: This report contains public health surveillance data that describe trends in postneonatal mortality (PNM) and that update information published in 1991. REPORTING PERIOD COVERED: 1980-1994. DESCRIPTION OF SYSTEM: National death certificate data characterizing PNM were reported by hospital physicians, coroners, and medical examiners. Data for 1980-1994 were compiled by the National Center for Health Statistics (NCHS) and obtained from NCHS public-use mortality tapes. RESULTS: The PNM rate per 1,000 live births declined 29.8% from 4.1 in 1980 to 2.9 in 1994 (31.7% decline among white infants and 25.8% among black). Most of the decline resulted from reduced mortality from infections and sudden infant death syndrome (SIDS). The PNM ratio between blacks and whites remained steady at approximately 2.1 during 1982-1988 and gradually increased to 2.4 by 1994 [corrected]. Autopsy rates for cases of SIDS increased from 82% to approximately 95% and did not differ among black infants and white infants. The decline of PNM rates for birth defects was greater for white infants than for black infants. The racial gap in PNM rates widened regionally during the study period, except in the South and the Northeast where ratios remained stable. In 1994, the largest gap persisted in the north-central region followed by the West and Northeast. INTERPRETATION: In 1994 as in 1980, PNM remained an important contributor to infant mortality, but nearly half of these deaths are caused by potentially preventable causes such as SIDS, infections, and injuries. The use of interventions for SIDS, birth defects, infections, and injuries can help reduce PNM and narrow the associated racial gap. ACTIONS TAKEN: This surveillance information, which will be distributed to administrators of state maternal and child health programs and to community-based organizations nationwide, will be useful in planning infant mortality reduction programs and to target PNM prevention efforts.

Cigarette smoking as a risk factor for ectopic pregnancy.

OBJECTIVE: Our purpose was to assess the risk of ectopic pregnancy among women who smoke cigarettes. STUDY DESIGN: We used data from a case-control study of ectopic pregnancy conducted from October 1988 to August 1990 at an inner-city hospital in Georgia. Cases were 196 non-Hispanic black women with a surgically confirmed ectopic pregnancy. Controls were non-Hispanic black women who had delivered either a live or a stillborn infant weighing at least 500 gm (n = 882) or who were pregnant and seeking an induced abortion (n = 237). RESULTS: After we adjusted for parity, douching history, history of infertility, and age, the odds ratio for ectopic pregnancy was 1.9 (95% confidence interval 1.4 to 2.7) for women who smoked during the periconception period compared with women who did not smoke at that time. After stratification by the amount of daily smoking during the periconception period, the odds ratio rose from 1.6 (95% confidence interval 0.9 to 2.9) for women who smoked 1 to 5 cigarettes to 1.7 (95% confidence interval 1.1 to 2.8) for women who smoked 6 to 10 cigarettes to 2.3 (95% confidence interval 1.3 to 4.0) for women who smoked 11 to 20 cigarettes, and to 3.5 (95% confidence interval 1.4 to 8.6) for women who smoked >20 cigarettes per day. CONCLUSION: In this inner-city population, cigarette smoking was an independent, dose-related risk factor for ectopic pregnancy among black women. The public health and medical care communities should inform the public of this additional risk associated with cigarette smoking and intensify intervention strategies to reduce cigarette smoking among women of reproductive age.

Hospitalizations for severe complications of pregnancy, 1987-1992.

OBJECTIVE: To compute ratios of severe pregnancy complications (the number of hospitalizations for pregnancy complications per 100 deliveries) and to examine factors associated with their prevalence. METHODS: Using population-based California hospital discharge data to estimate hospitalization ratios of pregnancy complications during 1987-1992, we defined cases by preselected pregnancy complication codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, excluding induced abortions and delivery-associated complications. All hospital deliveries of liveborn or stillborn infants were included in our denominator. We examined ratios by age, race-ethnicity, payment source, total hospitalization charges, and length of hospital stay. RESULTS: There were 833,264 hospitalizations for pregnancy complications in California (25 complications per 100 deliveries), which included admissions for preterm labor (33%), genitourinary infection (16%), and pregnancy-induced hypertension (15%). Age-specific ratios were highest for women 14 years old and younger (38 per 100 deliveries) and lowest for women 25-29 years old (23 per 100 deliveries). Ratios of complications varied by race-ethnicity; black women had the highest (42 per 100 deliveries), and Asian-Pacific Islander women had the lowest (21 per 100 deliveries). Ratios were unaffected by payment source. In 1987, Medicaid charges were $118 million for 33% of the number of total hospitalizations for complications. In 1992, such Medicaid hospitalizations accounted for $356 million (49%) of the $734 million in total charges and for 183,295 (45%) of the 409,000 total hospital days. CONCLUSION: Our results showed disparities in ratios of severe complications of pregnancy by age and race-ethnicity as well as a shift of financial burden to Medicaid. These findings suggest that such complications may be reduced by identifying risk factors and targeting high-risk groups.

Pregnancy-related mortality surveillance--United States, 1987-1990.

PROBLEM/CONDITION: The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 maternal deaths per 100,000 live births among black women; as of 1990, these goals had not been met. In addition, race-specific differences between black women and white women persist in the risk for pregnancy-related death. REPORTING PERIOD COVERED: This report summarizes surveillance data for pregnancy-related deaths in the United States for 1987-1990. DESCRIPTION OF SYSTEM: The National Pregnancy Mortality Surveillance System was initiated in 1988 by CDC in collaboration with the CDC/American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provided CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death records) of all identified pregnancy-related deaths. RESULTS: During 1987-1990, 1,459 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 9.2 deaths per 100,000 live births. The pregnancy-related mortality ratio for black women was consistently higher than for white women for every risk factor examined by race. The disparity between pregnancy-related mortality ratios for black women and white women increased from 3.4 times greater in 1987 to 4.1 times greater in 1990. Older women, particularly women aged > or =35 years, were at increased risk for pregnancy-related death. The gestational age-adjusted risk for pregnancy-related death was 7.7 times higher for women who received no prenatal care than for women who received "adequate" prenatal care. The distribution of the causes of death differed depending on the pregnancy outcome; for women who died following a live birth (i.e., 55% of the deaths), the leading causes of death were pregnancy-induced hypertension complications, pulmonary embolism, and hemorrhage. INTERPRETATION: Pregnancy-related mortality ratios for black women continued, as noted in previously published surveillance reports, to be three to four times higher than those for white women. The risk factors evaluated in this analysis confirmed the disparity in pregnancy-related mortality between white women and black women, but the reason(s) for this difference could not be determined from the available information. ACTIONS TAKEN: Continued surveillance and additional studies should be conducted to assess the magnitude of pregnancy-related mortality, to identify those differences that contribute to the continuing race-specific disparity in pregnancy-related mortality, and to provide information that policy makers can use to develop effective strategies to prevent pregnancy-related mortality for all women.

Vaginal douching and the risk of ectopic pregnancy among black women.

OBJECTIVE: Our goal was to determine whether vaginal douching was associated with ectopic pregnancy among black women and whether specific douching behaviors were associated with differences in risk. STUDY DESIGN: We analyzed data from a case-control study of ectopic pregnancy conducted between October 1988 and August 1990 at a major public hospital in Atlanta, Georgia. Case subjects were 197 black women with surgically confirmed ectopic pregnancies; the control group included 882 black women who were delivered of live or stillborn infants and 237 black women who were seeking to terminate a pregnancy. RESULTS: The adjusted odds ratio for ectopic pregnancy associated with ever having douched was 3.8 (95% confidence interval 1.6 to 8.9). The risk increased with increasing number of years of douching at least once per month. No douching behavior was found to be without risk; even women who douched for routine cleanliness were at increased risk of ectopic pregnancy. CONCLUSIONS: Vaginal douching is a modifiable behavior that may greatly increase a woman's risk of ectopic pregnancy.

The relation between induced abortion and ectopic pregnancy.

OBJECTIVE: To determine whether having had one or more induced abortions increases a woman's risk of having an ectopic pregnancy. METHODS: We conducted a case-control study of all women admitted to a major metropolitan hospital in Georgia with a surgical diagnosis of ectopic pregnancy during the period of October 1988 to August 1990. Controls were randomly selected from women seeking an induced abortion or delivering an infant at the same hospital. After exclusions, this analysis included 182 cases and 1056 controls. Stratified analysis and unconditional logistic regression were used to control for confounding and to estimate the relative risks. RESULTS: Approximately 90% of cases and controls were non-Hispanic, black women; 34% of the cases and 36% of the controls reported a history of induced abortion. The crude odds ratio for having an ectopic pregnancy associated with a history of induced abortion was 0.9 (95% confidence interval 0.6, 1.3). The odds ratio remained the same after adjusting for selected confounding variables and stratifying by the number of induced abortions, gestational age at the time of abortion, place where the abortion was performed, and the woman's report of medical complications of the abortion. CONCLUSION: We found no evidence that having one or more induced abortions increases a woman's risk of having an ectopic pregnancy.

Evaluation of induced abortion as a risk factor for ectopic pregnancy. A case-control study.

OBJECTIVE: To assess the risk of ectopic pregnancy after one or more induced abortions. DESIGN: Population-based case-control study. METHODS: We studied all women who had a histologically verified ectopic pregnancy in one Norwegian county between January 1, 1987, and December 31, 1990. We identified population-based control sets of women among participants in the second Norwegian fertility study (1988-1989). Gravida women 20-39 years of age, who were not using contraceptives and had become spontaneously pregnant, were eligible for analysis. The final analyses included 174 women with ectopic pregnancy, 115 pregnant control women and 227 nonpregnant control women. STATISTICAL METHODS: Chi-square test and unconditional logistic regression. RESULTS: Fifty-three (30.5%) of women with ectopic pregnancy, 18 (15.7%) of pregnant control women and 51 (22.5%) of nonpregnant control women had had one or more previous induced abortions. The adjusted odds ratio of ectopic pregnancy among women with one previous induced abortion was 1.3 (95% confidence interval; 0.9 to 1.8) and 1.2 (95% CI; 0.8 to 1.7) compared with pregnant and nonpregnant control women, respectively. Among women who had two or more induced abortions, the adjusted odds ratio of ectopic pregnancy was 0.2 (95% CI; 0.04 to 0.9) compared with pregnant control women and 1.8 (95% CI; 0.4 to 7.8) compared with nonpregnant control women. When we used the outcome of the most recent pregnancy, birth as reference, we found no association between an outcome of induced abortion and subsequent ectopic pregnancy regardless of whether the control women were pregnant. CONCLUSION: We found no association between induced abortion and subsequent ectopic pregnancy. Women who had induced abortions were characterized as having several other risk factors for ectopic pregnancy.

Increasing incidence of ectopic pregnancy in one Norwegian county--a population based study, 1970-1993.

OBJECTIVE: To estimate time trends related to ectopic pregnancy while considering the contribution of repeat ectopic pregnancy and changing treatment for infertile couples over the past 24 years. METHODS: Population based incidence data on ectopic pregnancy were collected from the only two hospitals in one Norwegian county from 1970 through 1993. Cases were identified through hospital discharge registries and all medical records were reviewed. Only females, aged 15-44 years, living permanently in the county and having a histologically verified ectopic pregnancy were eligible for the study. Data were analyzed in 5-year periods and 5-year age-groups. RESULTS: The incidence of ectopic pregnancy (per 1,000 woman-years) increased fourfold from the first to the last period. When we restricted the analyses to women with no previous ectopic pregnancy and no previous infertility surgery or treatment, we observed a linear threefold increase in the number of ectopic pregnancies. CONCLUSIONS: Repeat ectopic pregnancy and increased infertility treatment in the late 1970s and early 1980s might explain at most 25% of the increase in the incidence of ectopic pregnancy. After 1985, assisted reproduction might contribute to 4-5% of ectopic pregnancies diagnosed. The introduction of laparoscopy might explain some of this increase in the 1970s; however, we doubt that the introduction of more sensitive pregnancy tests or vaginal ultrasound in the 1980s contributed to the observed increase in ectopic pregnancy.

Pregnancy-related mortality in the United States, 1987-1990.

OBJECTIVE: To use data from the Centers for Disease Control and Prevention's (CDC) Pregnancy-Related Mortality Surveillance System to examine trends in pregnancy-related mortality and risk factors for pregnancy-related death. METHODS: In collaboration with ACOG and state health departments, the Pregnancy-Related Mortality Surveillance System has collected information on all deaths caused by pregnancy since 1979. Multiple data sources were used, including national death files, state health departments, maternal mortality review committees, individuals, and the media. As part of the initiation of the Pregnancy-Related Mortality Surveillance System in 1987, CDC staff contacted state health department personnel and encouraged them to identify and report pregnancy-related deaths. Data were reviewed and coded by experienced clinicians. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated. RESULTS: After decreasing annually after 1979, the reported pregnancy-related mortality ratio increased from 7.2 in 1987 to 10.0 in 1990. This increase occurred among women of all races. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live-birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy-related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. During the periods 1979-1986 and 1987-1990, the cause-specific pregnancy-related mortality ratios decreased for deaths due to hemorrhage and anesthesia, whereas pregnancy-related mortality ratios due to cardiomyopathy and infection increased. The leading causes of death varied according to the outcome of the pregnancy. CONCLUSION: Increased efforts to identify pregnancy-related deaths have contributed to an increase in the reported pregnancy-related mortality ratio. More than half of such deaths, however, are probably still unreported. Adequate surveillance of pregnancy-related mortality and morbidity is necessary for interpreting trends, identifying high-risk groups, and developing effective interventions.