How to report pregnancy-related cause of death in the death certificate, specifically which column to enter it in and what details to include according to Indian standard (International Classification of Diseases - ICD) guidelines?

Reporting Pregnancy-Related Deaths on Death Certificates in India

Pregnancy-related deaths should be documented in Part II of the death certificate (for contributory conditions), not Part I (immediate cause sequence), unless pregnancy complications directly caused death through a clear causal pathway. According to ICD-10 definitions, pregnancy-related death encompasses any death occurring while pregnant or within 42 days of termination of pregnancy, irrespective of cause 1.

Understanding the Classification System

Key Definitions for Death Certificate Completion

• Maternal death: Death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes 1

• Pregnancy-related death: Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death 1

• Late maternal death: Death from direct or indirect obstetric causes occurring more than 42 days but less than one year after termination of pregnancy 1

Where to Document Pregnancy on the Death Certificate

Part I: Immediate Cause of Death Sequence

Enter pregnancy-related conditions in Part I only when they are part of the direct causal chain leading to death 2. This applies to:

• Direct obstetric causes that led to death through a clear sequence:
  • Eclampsia/pre-eclampsia leading to cerebral hemorrhage 2
  • Obstetric embolism causing cardiopulmonary arrest 2
  • Postpartum hemorrhage leading to hypovolemic shock 3
  • Ruptured ectopic pregnancy causing hemorrhagic shock 3
  • Postpartum cardiomyopathy causing heart failure 2

Example for Part I:

• Line (a): Hypovolemic shock
• Line (b): Postpartum hemorrhage
• Line (c): Vaginal delivery

Part II: Other Significant Conditions

Enter pregnancy status in Part II when pregnancy contributed to death but was not part of the direct causal sequence 2, 1. This includes:

• Deaths from pre-existing conditions aggravated by pregnancy (indirect maternal deaths)
• Deaths where pregnancy was present but the primary cause was unrelated (e.g., cancer, cardiovascular disease in a pregnant woman) 2
• Any death occurring during pregnancy or within 42 days postpartum where pregnancy may have contributed but was not the direct cause 1

Write in Part II:

• "Pregnant, [X] weeks gestation" or
• "[X] days/weeks postpartum" or
• "Recent pregnancy termination"

What Specific Information to Include

Essential Details to Document

When pregnancy is relevant to the death, always include 4, 5:

1. Gestational age: Specify weeks of gestation at time of death
2. Pregnancy outcome: Live birth, stillbirth (≥20 weeks), miscarriage (<20 weeks), ectopic pregnancy, or termination 6, 4
3. Timing relative to pregnancy: During pregnancy, within 42 days postpartum, or 43 days to 1 year postpartum 1
4. Specific pregnancy complications: Pre-eclampsia, gestational diabetes, placental complications, etc. 4, 5

For Fetal Deaths (Stillbirths)

Stillbirth is defined as fetal death at ≥20 completed weeks of gestation 7, 6. Document:

• Gestational age in weeks 4, 5
• Specific cause if known: placental complications, cord complications, maternal complications, congenital malformations, or unspecified cause 4, 5
• Birthweight if available 4

Common Pitfalls to Avoid

Critical Documentation Errors

Do not automatically place pregnancy in Part I simply because the woman was pregnant 2. Analysis of US death certificates found that 64.7% of deaths originally coded as maternal were actually non-maternal causes upon review of literal text 2. This represents significant overreporting of maternal deaths when pregnancy is incorrectly assumed to be causal 2.

Do not omit pregnancy information entirely 2. The same study identified 18 deaths originally coded as non-maternal that mentioned pregnancy in the literal text and should have been classified as maternal deaths, demonstrating underreporting as well 2.

Be specific about the causal relationship 2. Use literal text to clearly describe how pregnancy contributed to or caused death, rather than simply noting pregnancy status 2.

Accurate Cause Specification

Avoid using "Fetal death of unspecified cause" when more specific information is available 4, 5. The five most common specific causes of fetal death are 4, 5:

1. Complications of placenta, cord, and membranes
2. Maternal complications of pregnancy
3. Congenital malformations and chromosomal abnormalities
4. Maternal conditions unrelated to present pregnancy
5. Unspecified cause (use only when truly unknown)

Algorithm for Decision-Making

Step-by-Step Approach

Step 1: Determine if pregnancy/postpartum status is within the relevant timeframe 1:

• Currently pregnant, OR
• Within 42 days of pregnancy termination (maternal death), OR
• 43 days to 1 year after pregnancy termination (late maternal death)

Step 2: Establish the causal relationship 2:

• Direct causal chain: Pregnancy complication → intermediate condition → death (use Part I)
• Contributory but not direct: Pregnancy aggravated pre-existing condition or was present but not causal (use Part II)

Step 3: Document specific details 4, 5:

• Gestational age
• Pregnancy outcome
• Specific complications
• Timing relative to delivery/termination

Step 4: For hemorrhage deaths, specify the subtype 3:

• Ruptured ectopic pregnancy (most common, 22.9%)
• Postpartum hemorrhage (21.2%)
• Other hemorrhage subtypes

This systematic approach ensures accurate classification that enables proper surveillance and targeted interventions for maternal mortality reduction 2.