Maternal Mortality in Germany: Data Gaps, Definitions, and Public Health Implications

Germany’s maternal mortality data underreport pregnancy-related deaths due to documentation gaps and varying practices across federal states.

Maternal mortality is a crucial global health indicator, measuring the risk of death associated with pregnancy and childbirth. According to the World Health Organization (WHO), it is defined as the death of a woman during pregnancy, childbirth, or within 42 days after termination of pregnancy if the cause is related to or worsened by pregnancy or its management, excluding incidental or accidental causes. The maternal mortality ratio (MMR) quantifies this risk per 100,000 live births and serves as a benchmark for the quality of obstetric and prenatal care.

In Germany, the recording of maternal mortality faces significant methodological challenges. The Robert Koch Institute’s (RKI) 2025 analysis highlights that national statistics currently depend primarily on the International Classification of Diseases (ICD-10) coding on death certificates combined with live birth numbers from population statistics. However, inconsistent documentation and incomplete reporting result in substantial undercounting of maternal deaths in official figures.

The RKI review of Berlin death certificates from 2019 to 2022 revealed that of 2,316 certificates for women aged 15–50, only a minority contained sufficient information to identify pregnancy status. Many certificates lacked explicit pregnancy-related data or included ambiguous entries that did not meet WHO criteria for maternal death. Only 14 pregnancy-related maternal deaths according to WHO definitions could be identified through comprehensive analysis—of which just four were recorded directly through relevant ICD-10 coding and thus entered into official statistics. The remaining cases required additional context from free text notes, specialized ‘In women’ fields, or confidential follow-up with certifying physicians.

This inconsistency is compounded by differences across federal states. Bavaria and Bremen are the only regions that align strictly with WHO recommendations by recording pregnancy status and postpartum periods up to 42 days. In contrast, many other states vary widely in how and whether they query pregnancy status, with some using a three-month window post-pregnancy or omitting additional questions altogether. This federal heterogeneity hampers nationwide comparability and obscures true maternal mortality trends.

Photo by Ante Samarzija 

Reliable recording is essential because maternal death, although rare in high-income countries like Germany, remains a significant marker of health system performance. According to international estimates, Germany’s maternal mortality ratio was around 4.2 maternal deaths per 100,000 live births in 2023, comparable to other high-income health systems but still subject to uncertainty due to underreporting.

The RKI and its collaborators argue that current reliance on ICD-10 codes alone is insufficient and that maternal deaths must be captured with additional pregnancy status information on all death certificates. Moreover, a standardized national registry for maternal deaths, with harmonized data collection across federal states, is imperative to improve completeness and accuracy. With better data, policymakers could identify systemic gaps in prenatal, intra-partum, and postpartum care and target interventions to reduce preventable deaths.

Challenges remain. Global efforts have reduced maternal mortality significantly over the past decades, but disparities persist across regions and within health systems. The WHO aims to reduce the global MMR to less than 70 per 100,000 live births by 2030 under Sustainable Development Goal 3.1.1, yet achieving this target demands consistent and high-quality data collection everywhere, including in high-income countries where maternal deaths are rare but critically informative about health system performance.

Germany’s maternal mortality statistics currently understate the true occurrence due to documentation gaps. Improved death certification practices, standardized nationwide reporting, and harmonized implementation of WHO criteria would strengthen the country’s capacity to monitor maternal health outcomes and guide policy. In a high-resource context where every maternal death is potentially preventable, robust data systems are a cornerstone of better care and accountability.

Source:  RKI