The association between Afghan Women's autonomy and experience of domestic violence, moderated by education status.

This study examines the association between Afghan women's autonomy (WA) and experience of domestic violence (physical, sexual, and emotional) in the previous 12 months, and whether this association is moderated by education status. We used data from 19,098 married women aged 15-49, who completed the 2015 Afghanistan Demographic and Health Survey- the first and only national survey administered in the country. WA was measured across 5 domains (healthcare, visiting family, household purchases, spending, and contraceptive use). Adjusted odds ratios and 95% confidence intervals for the association between domestic violence in the past 12 months (any vs. none) and WA were estimated using multiple logistic regression and adjusted for covariates. Interaction terms between education status and WA were also assessed. We found that the experience of physical, emotional, and sexual violence was 45% 30%, and 7%, and at least 1 in 2 had no autonomy. After adjustment, compared to women without autonomy, WA in healthcare decisions, spending, visiting families, and household purchases significantly decreased the odds of physical violence. Similarly, WA in healthcare decisions and spending significantly decreased the odds of sexual violence. Lastly, WA in spending and not using contraception was associated with reduced odds of emotional violence. We also found a greater protective effect of WA in visiting family among women with any education across each domestic violence outcome. These findings provide insights into areas for intervention to address gender inequalities (Sustainable Development Goal 3) and mitigate adverse health outcomes for mothers and their children (Goal 5).

The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2, 2008-2015.

Background: In the United States, 11.1% of households experience food insecurity; however, pregnant women are disproportionately affected. Maternal food insecurity may affect infant feeding practices, for example, through being a source of chronic stress that may alter the decision to initiate and continue breastfeeding. Thus, we sought to determine whether prenatal food insecurity was associated with breastfeeding (versus not) and exclusive breastfeeding duration among Oregon women. Method: The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 2008 to 2015 and the Oregon PRAMS-2 follow-up survey were used (n = 3,624) in this study. Associations with breastfeeding initiation and duration were modeled with multivariable logistic regression and accelerated failure time (AFT), respectively. Models were adjusted for maternal sociodemographic and pre-pregnancy health characteristics. Results: Nearly 10% of women experienced prenatal food insecurity. For breastfeeding initiation, unadjusted models suggested non-significant decreased odds (odds ratio (OR) 0.88 [confidence intervals (CI): 0.39, 1.99]), whereas adjusted models revealed a non-significant increased odds (OR 1.41 [CI: 0.58, 3.47]). Unadjusted AFT models suggested that food-insecure mothers had a non-significant decrease in exclusive breastfeeding duration (OR 0.76 [CI: 0.50, 1.17]), but adjustment for covariates attenuated results (OR 0.89 [CI: 0.57, 1.39]). Conclusions: Findings suggest minimal differences in breastfeeding practices when exploring food security status in the prenatal period, though the persistence of food insecurity may affect exclusive breastfeeding duration. Lower breastfeeding initiation may be due to other explanatory factors correlated with food insecurity and breastfeeding, such as education and marital status.

Breastfeeding Initiation by WIC Receipt After Formula Shortages in 2022.

This study assesses differences in breastfeeding initiation trends between Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants and WIC-eligible nonparticipants before, during, and after the 2022 infant formula disruption.

Functional data analysis to characterize disease patterns in frequent longitudinal data: application to bacterial vaginal microbiota patterns using weekly Nugent scores and identification of pattern-specific risk factors.

BACKGROUND: Technology advancement has allowed more frequent monitoring of biomarkers. The resulting data structure entails more frequent follow-ups compared to traditional longitudinal studies where the number of follow-up is often small. Such data allow explorations of the role of intra-person variability in understanding disease etiology and characterizing disease processes. A specific example was to characterize pathogenesis of bacterial vaginosis (BV) using weekly vaginal microbiota Nugent assay scores collected over 2 years in post-menarcheeal women from Rakai, Uganda, and to identify risk factors for each vaginal microbiota pattern to inform epidemiological and etiological understanding of the pathogenesis of BV. METHODS: We use a fully data-driven approach to characterize the longitudinal patters of vaginal microbiota by considering the densely sampled Nugent scores to be random functions over time and performing dimension reduction by functional principal components. Extending a current functional data clustering method, we use a hierarchical functional clustering framework considering multiple data features to help identify clinically meaningful patterns of vaginal microbiota fluctuations. Additionally, multinomial logistic regression was used to identify risk factors for each vaginal microbiota pattern to inform epidemiological and etiological understanding of the pathogenesis of BV. RESULTS: Using weekly Nugent scores over 2 years of 211 sexually active and post-menarcheal women in Rakai, four patterns of vaginal microbiota variation were identified: persistent with a BV state (high Nugent scores), persistent with normal ranged Nugent scores, large fluctuation of Nugent scores which however are predominantly in the BV state; large fluctuation of Nugent scores but predominantly the scores are in the normal state. Higher Nugent score at the start of an interval, younger age group of less than 20 years, unprotected source for bathing water, a woman's partner's being not circumcised, use of injectable/Norplant hormonal contraceptives for family planning were associated with higher odds of persistent BV in women. CONCLUSION: The hierarchical functional data clustering method can be used for fully data driven unsupervised clustering of densely sampled longitudinal data to identify clinically informative clusters and risk-factors associated with each cluster.

Measuring US Maternal Mortality.

This Viewpoint discusses the importance of collaboration among the agencies responsible for documenting rates of maternal mortality to ensure more accurate, reliable, and timely estimates.

Differences in Use of Fertility Treatment Between People With Medicaid and Private Health Insurance Coverage in the United States.

OBJECTIVES: We aimed to compare differences in receipt of any and specific types of fertility services between people with Medicaid and private insurance. METHODS: We used National Survey of Family Growth (2002-2019) data and linear probability regression models to examine the association between insurance type (Medicaid or private) and fertility service use. The primary outcome was use of fertility services in the past 12 months, and secondary outcomes were use of specific types of fertility services at any time: 1) testing, 2) common medical treatment, and 3) use of any fertility treatment type (testing, medical treatment, or surgical treatment of infertility). We additionally calculated time-to-pregnancy using a method that estimates the unobserved total amount of time the respondent spent trying to become pregnant using their current duration of pregnancy attempt at the time of the survey. We calculated time-to-pregnancy ratios across respondent characteristics to examine if insurance type was associated with differential time-to-pregnancy. RESULTS: In adjusted models, Medicaid coverage was associated with an 11.2-percentage point (95% confidence interval: -22.3 to -0.0) lower use of fertility services in the past 12 months compared with private coverage. Relative to private coverage, Medicaid insurance was also associated with large and statistically significantly lower rates of ever having used infertility testing or any fertility services. Insurance type was not associated with differences in time-to-pregnancy. CONCLUSIONS: People covered by Medicaid were less likely to have used fertility services compared with people with private insurance. Differences in coverage of fertility services between Medicaid and private payers may represent a barrier to fertility treatment for Medicaid recipients.

Changes in Pregnancy-Related Mortality Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic in the United States.

OBJECTIVE: To examine pregnancy-related mortality ratios before (January 2019-March 2020) and during (April 2020-December 2020 and 2021) the coronavirus disease 2019 (COVID-19) pandemic overall, by race and ethnicity, and by rural-urban classifications using vital records data. METHODS: Mortality and natality data (2019-2021) were obtained from the Centers for Disease Control and Prevention's WONDER database to estimate pregnancy-related mortality ratios, which correspond to any death during pregnancy or up to 1 year after the end of a pregnancy from causes related to the pregnancy per 100,000 live births. Pregnancy-related mortality ratios were determined from International Classification of Diseases, Tenth Revision codes A34, O00-O96, and O98-O99. Overall pregnancy-related mortality ratios were partitioned by whether COVID-19 was listed as a contributory cause, and quarterly estimates were compared between 2019 and 2021. Pregnancy-related mortality ratios were compared by race and ethnicity and rural-urban residence before (2019-March 2020) and during (April 2020-December 2020 and 2021) the COVID-19 pandemic. RESULTS: Pregnancy-related mortality was significantly higher in 2021 (45.5/100,000 live births) compared with during the pandemic in 2020 (36.7/100,000 live births) and before the pandemic (29.0/100,000 live births). Pregnancy-related mortality ratios increased across all race and ethnicity and rural-urban residence categories in 2021. The largest increase occurred among American Indian/Alaska Native people during 2021 compared with April-December of 2020 (pregnancy-related mortality ratio 160.8 vs 79.0/100,000 live births, 104% relative change, P =.017). Medium-small metropolitan (52.4 vs 37.7/100,000 live births, 39.0% relative change, P <.001) and rural (56.2 vs 46.5/100,000 live births, 21.0% relative change, P =.05) areas had a larger increase in 2021 compared with April-December 2020 compared with large urban areas (39.1 vs 33.7/100,000 live births, 15.9% relative change, P =.009). CONCLUSION: Pregnancy-related mortality ratios increased more rapidly in 2021 than in 2020, consistent with rising rates of COVID-19-associated mortality among women of reproductive age. This further exacerbated racial and ethnic disparities, especially among American Indian/Alaska Native birthing people.

Breastfeeding Initiation Trends by Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Race/Ethnicity Among Medicaid Births.

OBJECTIVE: Describe long-term breastfeeding initiation trends by prenatal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and race/ethnicity. DESIGN: Cross-sectional study of birth certificate data from 2009 to 2017 in 24 states that adopted the 2003 birth certificate revision by 2009. PARTICIPANTS: Term births with hospital costs covered by Medicaid (N = 6,402,704). MAIN OUTCOME MEASURES: Breastfeeding initiation. ANALYSIS: The descriptive characteristics of WIC participants and WIC-eligible nonparticipants were compared by year and race/ethnicity using the chi-square test of independence or t tests. Adjusted breastfeeding initiation prevalence was estimated using linear regression models with county fixed effects, controlling for sociodemographic and obstetric/health factors. Trends were compared by WIC status overall and within racial/ethnic groups. Differences and P values were assessed using interaction terms between WIC and year. RESULTS: Breastfeeding initiation increased for WIC participants and nonparticipants. Special Supplemental Nutrition Program for Women, Infants, and Children participants had lower adjusted breastfeeding initiation (2009: 69.0%; 2017: 78.5%) than nonparticipants (2009: 70.8%; 2017: 80.1%) (P < 0.001 per year). Breastfeeding initiation increased more rapidly in WIC participants than in nonparticipants for non-Hispanic Asian/Pacific Islander (21.4% and 8.6%, respectively; P < 0.001) and American Indian/Alaskan Native (13.6% and 8.1%, respectively; P = 0.02)-narrowing the gap between WIC participants and nonparticipants over time. CONCLUSIONS AND IMPLICATIONS: Annual birth certificate data provide detailed information for monitoring trends and disparities in breastfeeding initiation by prenatal WIC status. These findings can inform WIC and maternal child health program efforts to improve breastfeeding promotion for populations with low-income and racial/ethnic groups.

The role of doulas in respectful care for communities of color and Medicaid recipients.

BACKGROUND: Despite the tenets of rights-based, person-centered maternity care, racialized groups, low-income people, and people who receive Medicaid insurance in the United States experience mistreatment, discrimination, and disrespectful care more often than people with higher income or who identify as white. This study aimed to explore the relationship between the presence of a doula (a person who provides continuous support during childbirth) and respectful care during birth, especially for groups made vulnerable by systemic inequality. METHODS: We used data from 1977 women interviewed in the Listening to Mothers in California survey (2018). Respondents who reported high levels of decision making, support, and communication during childbirth were classified as having "high" respectful care. To examine associations between respectful care and self-reported doula support, we conducted multivariable logistic regressions. Interactions by race/ethnicity and private or Medi-Cal (Medicaid) insurance status were assessed. RESULTS: Overall, we found higher odds of respectful care among women supported by a doula than those without such support (odds ratios [OR]: 1.4, 95% CI: 1.0-1.8). By race/ethnicity, the association was largest for non-Hispanic Black women (2.7 [1.1-6.7]) and Asian/Pacific Islander women (2.3 [0.9-5.6]). Doula support predicts higher odds of respectful care among women with Medi-Cal (1.8 [1.3-2.5]), but not private insurance. CONCLUSIONS: Doula support was associated with high respectful care, particularly for low-income and certain racial/ethnic groups in California. Policies supporting the expansion of doulas for low-income and marginalized groups are consistent with the right to respectful care and may address disparities in maternal experiences.

The relationship between obstetrical interventions and the increase in U.S. preterm births, 2014-2019.

We examined the relationship between obstetrical intervention and preterm birth in the United States between 2014 and 2019. This observational study analyzed 2014-2019 US birth data to assess changes in preterm birth, cesarean delivery, induction of labor, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention (no labor cesarean or induction) after risk adjustment. The percentage of singleton preterm births in the United States increased by 9.4% from 2014-2019. The percent of singleton, preterm births delivered by cesarean increased by 6.0%, while the percent with induction of labor increased by 39.1%. The percentage of singleton preterm births where obstetrical intervention (no labor cesarean or induction) potentially impacted the gestational age at delivery increased from 47.6% in 2014 to 54.9% in 2019. Preterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Compared to non-Hispanic White women, Non-Hispanic Black women had a higher risk of preterm obstetric interventions. Preterm infants have higher morbidity and mortality rates than term infants, thus any increase in the preterm birth rate is concerning. A renewed effort to understand the trends in preterm interventions is needed to ensure that obstetrical interventions are evidence-based and are limited to those cases where they optimize outcomes for both mothers and babies.

Infant Sex-Specific Associations between Prenatal Food Insecurity and Low Birthweight: A Multistate Analysis.

BACKGROUND: Low birthweight is associated with increased risk of neonatal mortality and adverse outcomes among survivors. As maternal sociodemographic factors do not explain all of the risk in low birthweight, exploring exposures occurring during critical periods, such as maternal food insecurity, should be considered from a life course perspective. OBJECTIVES: To explore the association between prenatal food insecurity and low birthweight, as well as whether or not there may be a sex-specific response using a multistate survey. METHODS: Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 11 states during 2009-2017 were used, restricting to women with a singleton birth. Food insecurity was determined by a single question in PRAMS, and low birthweight was defined as a birth <2500 g. Multivariable logistic regression was used, stratified by infant sex and adjusted for maternal sociodemographic and prepregnancy health characteristics. RESULTS: There were n = 50,915 women from 2009 to 2017, with 9.1% experiencing food insecurity. Unadjusted results revealed that food-insecure mothers had an increased odds ratio of delivering a low-birthweight baby (OR: 1.38; 95% CI: 1.25, 1.53). Adjustment for covariates appeared to explain the association among male infants, whereas magnitudes remained greater among female infants (adjusted OR: 1.13; 95% CI: 0.94, 1.35). CONCLUSIONS: Findings suggest a sex-specific response to prenatal food insecurity, particularly among female offspring. Future studies are warranted with more precise measures of food insecurity and to understand the difference by infant sex.

Endometriosis and Uterine Fibroids and Their Associations with Elevated C-Reactive Protein and Leukocyte Telomere Length Among a Representative Sample of U.S. Women: Data from the National Health and Nutrition Examination Survey, 1999-2002.

Background: Recent studies have suggested a link between reproductive health and later-life chronic conditions, yet the mechanism remains unclear. One proposed mechanism is through chronic inflammation. The objective of this study was to examine the association between endometriosis and uterine fibroids and biomarkers of inflammation and cellular aging. Materials and Methods: We used data from the National Health and Nutrition Examination Survey (N = 2342; 1999-2002). Adjusted logistic and linear regression were used to examine the association between these two reproductive conditions and elevated C-reactive protein (CRP; >3.0 mg/L) and leukocyte telomere length (T/S ratio), respectively. Given that a greater length of time spent with a condition may represent persistence of an inflammatory process, we further examined the association between time since disease diagnosis on telomere length among the subset of women with diagnosed endometriosis and fibroids. Results: Women with endometriosis had greater odds of having elevated CRP than those without endometriosis (OR = 1.60; 95% CI: 1.05 to 2.45). Women with endometriosis had a shorter telomere length than women without endometriosis (-3.4, 95% CI: -7.3 to -0.3 in age-adjusted models and -2.9, 95% CI: -8.8 to 3.5 in fully adjusted models). Telomeres were 1% (95% CI: -1.2 to -0.6) shorter for every elapsed year since endometriosis diagnosis. No substantive patterns emerged between uterine fibroids and CRP or telomere length. Conclusions: Women with endometriosis (or a longer duration of time spent with endometriosis) had higher inflammatory markers and shorter mean telomere length. These results provide further insights into potential mechanisms linking endometriosis to chronic disease and later-life health.

Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017.

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable.

Causes contributing to the excess maternal mortality risk for women 35 and over, United States, 2016-2017.

To better understand age-related disparities in US maternal mortality, we analyzed 2016-2017 vital statistics mortality data with cause-of-death literal text (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths which had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. Age-related disparities were examined both overall and by primary cause. Compared to women <35, the 2016-2017 US maternal mortality rate was twice as high for women aged 35-39, four times higher for women aged 40-44, and 11 times higher for women aged 45-54 years. Obstetric hemorrhage was the leading cause of death for women aged 35+ with rates 4 times higher than for women <35, followed by postpartum cardiomyopathy with a 3-fold greater risk. Obstetric embolism, eclampsia/preeclampsia, and Other complications of obstetric surgery and procedures each had a two-fold greater risk of death for women aged 35+. Together these 5 causes of death accounted for 70.9% of the elevated maternal mortality risk for women aged 35+. The excess maternal mortality risk for women aged 35+ was focused among a few causes of death and much of this excess mortality is preventable. Early detection and treatment, as well as continued care during the postpartum year is critical to preventing these deaths. The Alliance for Innovation on Maternal Health has promulgated patient safety bundles with specific interventions that health care systems can adopt in an effort to prevent these deaths.

Trends in time-to-pregnancy in the USA: 2002 to 2017.

STUDY QUESTION: Has there been there a temporal change in time-to-pregnancy (TTP) in the USA. SUMMARY ANSWER: Overall, TTP was stable over time, but a longer TTP for women over 30 and parous women was identified. WHAT IS KNOWN ALREADY: Fertility rates in the USA have declined over the past several years. Although these trends have been attributed to changing reproductive intentions, it is unclear whether declining fecundity (the biologic ability to reproduce measured by TTP in the current report) may also play a role. Indeed, trends based on declining sperm quality and higher utilisation of infertility treatment suggest fecundity may be falling. STUDY DESIGN, SIZE, DURATION: This cross-sectional survey data from the National Survey of Family Growth was administered from 2002 to 2017. The surveys are based on nationally representative samples of reproductive-aged women in the USA. Interviews were conducted in person or through computer-assisted self-administration of sensitive questions. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included women who self-reported time spent trying to become pregnant allowing utilisation of the current duration approach to estimate the total duration of pregnancy attempt (i.e. TTP). In all, 1202 participants were analysed over each study period. To estimate a TTP distribution overall and by parity, we used a piecewise constant proportional hazards model that accounts for digit preference. Accelerated-failure-time regression models, which were weighted to account for the sampling design, were used to estimate time ratios (TRs). Models were adjusted for age, BMI, race, education, relationship status, parity, pelvic inflammatory disease treatment and any reproductive problems. MAIN RESULTS AND THE ROLE OF CHANCE: Of the participants analysed, the average age was 31.8 and BMI was 28.6, which was similar across the survey periods. Relationship status was the only demographic characteristic that changed over time. All other variables remained constant across the study periods. Overall, TRs comparing TTP between 2002 and 2017 increased slightly (TR: 1.02, 95% CI: 0.99, 1.04). When stratified by parity, parous women had a longer TTP over the later years of the study (TR: 1.04, 95% CI: 1.01, 1.06). TTP remained constant for nulliparous women. Similarly, TTP also increased over time for women over age thirty (TR: 1.02, 1.00, 1.05) but not for women under age thirty. LIMITATIONS, REASONS FOR CAUTION: Small changes in data collection over time may have impacted the findings. We accounted for this in sensitivity analyses using imputed data. Overall, TRs were slightly attenuated using the imputed data, but represented similar patterns to the original data. Results for parous women and women over 30 remained consistent in the sensitivity analyses. WIDER IMPLICATIONS OF THE FINDINGS: Consistent with reports of falling fertility rates and sperm counts, this study suggests parous and older couples in the USA may be taking longer to become pregnant. Although trends were suggestive of a small overall increase in TTP, particularly for parous women and women over age thirty, additional data are needed to attempt to understand these trends given the societal, economic and public health implications related to fecundity. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by National Institutes of Health grant R03HD097287 to A.C.M. There are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Stressful life events, the incidence of infertility, and the moderating effect of maternal responsiveness: a longitudinal study.

Although the association between stress and poor reproductive health is well established, this association has not been examined from a life course perspective. Using data from the National Longitudinal Survey of Youth 1997 cohort (N = 1652), we fit logistic regression models to test the association between stressful life events (SLEs) (e.g., death of a close relative, victim of a violent crime) during childhood, adolescence, and early adulthood and later experiences of infertility (inability to achieve pregnancy after 12 months of intercourse without contraception) reported by female respondents. Because reactions to SLEs may be moderated by different family life experiences, we stratified responses by maternal responsiveness (based on the Conger and Elder Parent-Youth Relationship scale) in adolescence. After adjusting for demographic and environmental factors, in comparison to respondents with one or zero SLEs, those with 3 SLEs and ≥ 4 SLEs had 1.68 (1.16, 2.42) and 1.88 (1.38, 2.57) times higher odds of infertility, respectively. Respondents with low maternal responsiveness had higher odds of infertility that increased in a dose-response manner. Among respondents with high maternal responsiveness, only those experiencing four or more SLEs had an elevated risk of infertility (aOR = 1.53; 1.05, 2.25). In this novel investigation, we demonstrate a temporal association between the experience of SLEs and self-reported infertility. This association varies by maternal responsiveness in adolescence, highlighting the importance of maternal behavior toward children in mitigating harms associated with stress over the life course.

Improving US maternal mortality reporting by analyzing literal text on death certificates, United States, 2016-2017.

Changes in data collection and processing of US maternal mortality data across states over time have led to inconsistencies in maternal death reporting. Our purpose was to identify possible misclassification of maternal deaths and to apply alternative coding methods to improve specificity of maternal causes. We analyzed 2016-2017 US vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We developed an alternative coding strategy to code the "primary cause of death" defined as the most likely cause that led to death. We recoded deaths with or without literal pregnancy mentions to maternal and non-maternal causes, respectively. Originally coded and recoded data were compared for overall maternal deaths and for a subset of deaths originally coded to ill-defined causes. Among 1691 originally coded maternal deaths, 597 (35.3%) remained a maternal death upon recoding and 1094 (64.7%) were recoded to non-maternal causes. The most common maternal causes were eclampsia and preeclampsia, obstetric embolism, postpartum cardiomyopathy, and obstetric hemorrhage. The most common non-maternal causes were diseases of the circulatory system and cancer, similar to the leading causes of death among all reproductive-age women (excluding injuries). Among 735 records originally coded to ill-defined causes, 94% were recoded to more specific, informative causes from literal text. Eighteen deaths originally coded as non-maternal mentioned pregnancy in the literals and were recoded as maternal deaths. Literal text provides more detailed information on cause of death which is often lost during coding. We found evidence of both underreporting and overreporting of maternal deaths, with possible overreporting predominant. Accurate data is essential for measuring the effectiveness of maternal mortality reduction programs.