Limitations in the recording of maternal mortality in Germany: An analysis of statistical challenges.

Background: The World Health Organization (WHO) defines maternal mortality as the death of a woman during pregnancy or up to 42 days after delivery. The maternal mortality ratio (MMR) serves as an indicator of the quality of health care. In Germany, recording is based on the death certificate (ICD-10 code), with variations in documentation leading to underreporting. Studies indicate insufficient data in Berlin and queries in Germany. Method: 2,316 death certificates of women (aged 15 - 50) from the Berlin Central Archive (2019 - 2022) were analysed to identify maternal deaths and the quality of the information provided was assessed. In addition, the recording of pregnancy status on death certificates was examined nationwide. Results: Fourteen maternal deaths (excluding late cases according to the WHO) were identified. Only four cases were identifiable as maternal deaths solely on the basis of ICD-10 codes. The additional information 'Is or was the woman pregnant?' which is important for identification, was available in about a quarter of the death certificates reviewed. In 73.2 % of cases, the question 'Is or was the woman pregnant?' remained unanswered. A nationwide comparison of death certificates revealed considerable differences: only Bavaria and Bremen followed the WHO definition. Saxony-Anhalt does not record pregnancy status at all. Conclusion: The recording of maternal mortality in Germany is incomplete. Death certificates are often deficient. Many federal states record periods outside the WHO definition (3 - 12 months after birth). A standardized national system for registering maternal deaths is required to improve data collection and enable better prevention.