Rural-urban differences in maternal mortality trends in the US, 1999-2017: Accounting for the impact of the pregnancy status checkbox

Document Type


Publication Date



MRHRC, health data, death certificate, pregnancy, maternal death, misclassification, National Vital Statistics System, rural

Publication Title

American Journal of Epidemiology


Rural-urban differences in maternal mortality ratios (MMR) in the United States have been difficult to measure in recent years due to the incremental adoption of a pregnancy status checkbox on death certificates. Using 1999-2017 mortality and birth data, researchers statistically examined the impact of the pregnancy checkbox on MMRs by rural-urban residence (large urban, medium/small urban, rural) to predict trends as if all states had adopted the checkbox as of 1999. Implementation of the checkbox resulted in an average estimated increase of maternal deaths per 100,000 live births in all rural-urban areas compared with MMRs prior to the checkbox. However, when analyses were limited to direct/specific causes of maternal death, which are likely subject to less misclassification, trends and urban-rural differences were substantially attenuated. The authors conclude that accurate ascertainment of maternal deaths, particularly in rural areas, is important for reducing disparities in maternal mortality.


This pre-publication is written by (a) US Government employee(s) and is in the public domain in the US.