Abstract : CONTEXT: Deaths occurring among women who are pregnant or who have had a recent pregnancy have a devastating impact on the family and community. It is important to understand the magnitude and causes of pregnancy-associated mortality so that comprehensive strategies can be formulated to prevent such deaths. OBJECTIVE: To ascertain the number and causes of pregnancy-associated deaths using enhanced surveillance techniques. DESIGN, SETTING, AND SUBJECTS: Retrospective, cross-sectional analysis of death certificate data of reproductive-age women, live birth and fetal death records, and medical examiner records in Maryland during 1993-1998. MAIN OUTCOME MEASURE: Number of pregnancy-associated deaths, defined as death from any cause during pregnancy or within 1 year of delivery or pregnancy termination, by source of data and cause of death. RESULTS: A total of 247 pregnancy-associated deaths were ascertained. Twenty-seven percent (n = 67) were identified through cause-of-death information obtained from death certificates, 70% (n = 174) through linkage of death records with birth and fetal death records, and 47% (n = 116) through review of medical examiner records. Homicide was the leading cause of pregnancy-associated death (n = 50; 20%), and cardiovascular disorders were the second-leading cause (n = 48; 19%). CONCLUSIONS: In this Maryland sample, comprehensive identification of pregnancy-associated deaths was accomplished only after collecting information from multiple sources and including all deaths occurring up to 1 year after delivery or pregnancy termination. This enhanced pregnancy mortality surveillance led to the disturbing finding that a pregnant or recently pregnant woman is more likely to be a victim of homicide than to die of any other cause. By broadening pregnancy mortality to include all possible causes, previously neglected factors may assume increased importance in prenatal and postpartum care.